Open Access Publications

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

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Impact of COVID-19 on patellar tendon properties over the first year after infection
(Scientific Reports, 2026-01-07) de Jesus Ferreira. Leandro Gomes; da Silva Almeida, Isabella; Costa, Rochelle Rocha; Roriz, Gabrielle Vieira; Farinha, Rebeca Carvalho Moreira; Grävare Silbernagel, Karin; Geremia, Jeam Marcel; Quagliotti Durigan. João Luiz; Rita de Cássia Marqueti
This study aimed to examine the impact of infection severity and associated inactivity on patellar tendon health following COVID-19. Seventy participants were divided into three groups: moderate COVID-19 (n = 22), severe COVID-19 (n = 18), and control (n = 30). Four assessments were conducted over one-year for the COVID groups - between the 21st and 30th days (A21−30), 31 and 90 days (A31−90), 91 and 180 days (A91−180), and 181 and 360 days (A181−360) after the onset of symptoms for moderate or hospital discharge for severe. Maximal voluntary isometric knee extension contractions were performed, with simultaneous ultrasound imaging of patellar tendon length to calculate material and mechanical properties. Morphological properties (length and cross-sectional area) were obtained at rest. During one year, the severe group consistently had lower state of load on tendon (p < 0.002) and stress (p < 0.001) compared to the moderate and control groups, while strain in the first three months post-infection was comparable to the other groups (p > 0.256). A reduction in stiffness (p < 0.009) and Young’s modulus (p < 0.015) was observed during the same assessment period. Severe infection cases were associated with prolonged reductions in tendon load and stress. These findings suggest that systemic effects of infection and reduced activity levels may contribute to tendon adaptations.
Stochastic resonance stimulation effect on stability during walking in people with Parkinson disease
(International Biomechanics, 2025-11-06) Alsaqabi, Eman; DiBianca, Stephen; Sansare, Ashwini; Verma, Khushboo; Reimann, Hendrik; Jeka, John
People with Parkinson disease (PwPD) often face challenges with maintaining balance while walking, which can stem from sensory dysfunction. Studies have identified different biomechanical strategies that aid in preserving upright balance control. Stochastic resonance (SR) stimulation delivers sub-threshold electrical noise to enhance the detection capabilities of dysfunctional sensory systems. Yet, the effectiveness of SR in enhancing gait stability in PwPD is undetermined. The purpose of this study was to investigate the effects of SR on balance control during visually perturbed walking in PwPD (NCT06829342). Fourteen individuals with PD completed the study. We established individualized sensory thresholds for SR stimulation and identified the optimal SR intensity. Following this, the participants walked within a virtually perturbed environment. Center of mass (CoM) excursion, foot placement, and ankle roll responses were assessed bilaterally. Peak CoM excursion showed a significant increase, indicating reduced stability, with the SR condition compared to no-SR at the more affected side. Outcome measures related to balance control mechanisms were insignificant. With SR, PwPD were driven by the induced fall with more sway and without significant alterations in balance strategies, which might be due to adding more noise to sensory processing and misidentifying the more affected side.
Research priorities for physical activity and exercise management of people with knee and hip osteoarthritis: A multi-stage international priority-setting study from the OARSI Rehabilitation Discussion Group
(Osteoarthritis and Cartilage, 2025-07-10) Bennell, Kim L.; Nelligan, Rachel K.; Pardo, Jesse J.; Stratulate, Sarah; Holden, Melanie A.; Lawford, Belinda J.; Thoma, Louise M.; White, Daniel K.; Wellsandt,Elizabeth; Master, Hiral; Larsen, Jesper Bie; Button, Kate; Collins, Natalie J.; Skou, Søren T.; Henrotin, Yves; Hinman, Rana S.
Objective: To identify research priorities for physical activity and exercise management of knee and hip osteoarthritis (OA). Design: We used a multi-stage process involving an international multi-disciplinary panel of 276 experts (150 consumers, 69 clinicians spanning 5 disciplines, 54 researchers, and 3 funder/consumer organisation Results: A list of 61 research questions was compiled from the literature and the panel generated an additional 346 questions. Following consolidation, 178 questions remained and were scored by 150 of the original panelists (54%), with mean priority scores from 5.0 to 8.4. 153 (55%) panelists completed the discrete choice experiment. The top three research priorities were: 1) investigating the impact of physical activity and exercise on delaying/avoiding joint replacement, 2) developing effective interventions to promote long-term exercise adherence, and 3) stratifying people to the most appropriate form of exercise support. Conclusion: We identified research priorities about physical activity and exercise management of knee and hip OA. These will guide the international research agenda with the aim of improving outcomes for people with OA.
Innovative Compact Vibrational System with Custom GUI for Modulating Trunk Proprioception Using Individualized Vibration Parameters
(Bioengineering, 2025-10-07) Mandal, Debdyuti; Gilliam, John R.; Silfies, Sheri P.; Banerjee, Sourav
Conventional vibrational systems associated with proprioception are mostly equipped with a single standard frequency and amplitude. This feature often fails to show kinesthetic illusion on different subjects, as different individuals respond to different frequencies and amplitudes. Additionally, different muscle groups may also require the flexibility of frequencies and amplitudes. We developed a custom vibrational system that is equipped with flexible frequency and amplitude, adapted to a custom graphical user interface (GUI). Based on the user’s criteria, the proposed vibrational system enables a wide range of frequencies and amplitudes that can be swept under a single platform. In addition, the system uses small linear actuators that are wearable and attach to the subject without the need for restrictive straps. The vibrational system was used to model trunk proprioceptive impairment associated with low back pain. Low back pain is the leading cause of disability worldwide. It is mostly associated with impaired postural control of the trunk. For postural control, the somatosensory system transmits proprioceptive (position sense) information from the sensors in the skin, joints, muscles, and tendons. Proprioceptive studies on trunk muscles have been conducted where the application of vibration at a set amplitude and frequency across all participants resulted in altered proprioception and a kinesthetic illusion, but not in all individuals. To assess the feasibility of the system, we manipulated the trunk proprioception of five subjects, demonstrating that the vibrational system is capable of modulating trunk proprioception and the value of customizing parameters of the system to obtain maximal deficits from individual subjects.
Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts
(British Journal of Sports Medicine, 2025-07-24) Demangeot, Yoann; O’Neill, Seth; Degache, Francis; Rapin, Amandine; Asgher, Umer; Chester, Rachel; Chimenti, Ruth L; Jan de Vos,Robert; Escriche-Escuder, Adrian; Farnqvist, Kenneth; Habets, Bas; Maffulli, Nicola; Magnusson, Stig Peter; Malliaras, Peter; Murphy, Myles C; Purdam, Craig R; Rees, Jonathan D; Ebonie K Rio- Igor Sancho; Scott, Alex; Gravare Silbernage, Karin; Gremeaux, Vincent; Boyer, François C; Taiar, Redha
To assess the level of agreement among experts on the heel raise exercise parameters that influence midportion and insertional Achilles tendinopathy (AT) rehabilitation outcomes. An international expert panel in AT rehabilitation was invited to complete a three-round Delphi survey. In the first two rounds, experts were asked to review a pregenerated list of exercise parameters (based on the heel raise exercise) and rate their perceived influence on rehabilitation outcome, using a 5-point Likert scale. For each parameter, consensus criteria for major influence on rehabilitation were (a) median≥4, (b) ≥75% of scoring 4 or 5 and (c) IQR≤1. The third round aimed to rank the exercise parameters according to importance (from most to least important) during rehabilitation. 17 experts participated in the entire Delphi process. A total of 16 exercise parameters were assessed, of which 4 (intensity of contraction, total time under tension, number of repetitions and sets, type of contraction) reached consensus as having a major influence on rehabilitation for midportion AT and 3 reached consensus for insertional AT (range of ankle dorsiflexion during the exercise, intensity of contraction, number of repetitions and sets). The rankings of parameters that reached consensus showed that contraction intensity was perceived as the most important variable for midportion AT rehabilitation, while range of ankle dorsiflexion was deemed the most important variable for insertional AT rehabilitation. This study identified key exercise parameters for mid-portion and insertional AT rehabilitation based on expert opinion. This information should assist practitioners in optimising their approach to deliver more effective, patient-specific exercises for AT rehabilitation.
Physical Activity in Pre-Ambulatory Children with Cerebral Palsy: An Exploratory Validation Study to Distinguish Active vs. Sedentary Time Using Wearable Sensors
(Sensors, 2025-02-19) Orlando, Julie M.; Smith, Beth A.; Hafer, Jocelyn F.; Paremski, Athylia; Amodeo, Matthew; Lobo, Michele A.; Prosser, Laura A.
Wearable inertial sensor technology affords opportunities to record the physical activity of young children in their natural environments. The interpretation of these data, however, requires validation. The purpose of this study was to develop and establish the criterion validity of a method of quantifying active and sedentary physical activity using an inertial sensor for pre-ambulatory children with cerebral palsy. Ten participants were video recorded during 30 min physical therapy sessions that encouraged gross motor play activities, and the video recording was behaviorally coded to identify active and sedentary time. A receiver operating characteristic curve identified the optimal threshold to maximize true positive and minimize false positive active time for eight participants in the development dataset. The threshold was 0.417 m/s2 and was then validated with the remaining two participants; the percent of true positives and true negatives was 92.2 and 89.7%, respectively. We conclude that there is potential for raw sensor data to be used to quantify active and sedentary time in pre-ambulatory children with physical disability, and raw acceleration data may be more generalizable than the sensor-specific activity counts commonly reported in the literature.
Health-related quality of life after major extremity trauma: qualitative research with military service members and clinicians to inform measurement of patient-reported outcomes
(Quality of Life Research, 2025-02-20) Tyner, Callie E.; Kisala, Pamela A.; Slotkin, Jerry; Cohen, Matthew L.; Cancio, Jill M.; Pruziner, Alison L.; Dearth, Christopher L.; Tulsky, David S.
Purpose The purpose of this study was to understand health-related quality of life (HRQOL) factors for adults who experience major extremity trauma, including limb preservation and amputation, to guide the selection and creation of patient-reported outcome (PRO) measures. Methods A thematic content qualitative analysis was used to study service members (SMs) with a history of major extremity trauma and clinical providers with expertise in limb trauma, limb loss, and limb preservation/reconstruction. Focus groups were conducted at three Military Treatment Facilities and one Department of Veterans Affairs Medical Center. Results Fifty-six SMs and 34 clinicians participated. Thirty-six percent of focus group comments were coded under Physical Health, 31% Emotional Health, and 28% Social Participation. These results were largely consistent across clinicians and SMs, and clinical subgroups, with a few exceptions such as the relevance of fine motor tasks and prosthetic devices for SMs with upper extremity injury/limb loss, and orthotic devices for SMs with limb preservation/reconstruction. Conclusion Many HRQOL topics identified are shared with existing general PRO measures—including pain, physical function, anxiety, depression, anger, positive affect and well-being, fatigue, social participation, and loneliness—as well as rehabilitation-focused PRO measures—such as resilience, grief/loss, stigma, self-esteem, mobility, fine motor functioning, self-care, and independence. This qualitative research can be used to inform domains of HRQOL in need of new PRO measures for this population, including satisfaction with orthosis/prosthesis, satisfaction with physical abilities/athleticism, body image, future outlook, and vocational impact.
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, Amir
Autism 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.
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.6
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.
Dominant Arm Internal and External Rotation Strength is Related to Arm Pain in Youth Baseball Players
(International Journal of Sports Physical Therapy, 2024-11-01) Paskewitz, Jeffrey; Breidenbach, Fred; Malloy, Philip; Eckrich, P. Michael; Zarzycki, Ryan
Background and Purpose The prevalence of arm pain in youth baseball players is high with approximately half reporting arm pain during the season, and the number of ulnar collateral ligament reconstructions in youth baseball players is increasing. Few studies have examined the relationship between shoulder strength and passive range of motion (ROM) with arm pain (either shoulder or elbow pain) during throwing, especially in athletes in early adolescence. The purpose of this study was to determine the relationship between shoulder ROM and strength and the presence of arm pain during throwing in youth baseball players. It was hypothesized that less internal rotation (IR) ROM, less total rotational ROM, and lower IR and external rotation (ER) strength would be associated with arm pain. Study Design Observational cohort study Methods Sixty-five youth male baseball players between the ages of 12-15 were enrolled. Shoulder strength (ER, IR, ER/IR strength ratio, scaption) and passive ROM (ER, IR, flexion, horizontal adduction) were collected prior to the start of the spring 2021 baseball season. Players self-reported their arm pain frequency during throwing as never, rarely, sometimes, often, or always. The relationship between reported arm pain frequency during throwing and shoulder ROM and strength measurements was examined. Results ER (ρ= -0.289, p=0.020) and IR strength (ρ= -0.262, p=0.035) were weakly and negatively correlated with reports of arm pain during throwing. No other clinical variables were associated with reports of arm pain (p ≥ 0.124) Conclusion In youth baseball players, greater IR and ER strength were associated with less arm pain frequency during throwing, while ROM was not associated with arm pain frequency. Future research should explore these variables prospectively to determine if changes in ROM and strength are related to the development of arm pain in youth baseball players. Level of Evidence 3
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.
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, Karin
Patellar 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.
Hop Distance Symmetry Moderately Reflects Knee Biomechanics Symmetry During Landing But Not For Controlled Propulsions
(International Journal of Sports Physical Therapy, 2024-08-01) Di Paolo, Stefano; Ito, Naoaki; Seymore, Kayla D.; Sigurðsson, Haraldur B.; Bragonzoni, Laura; Zaffagnini, Stefano; Snyder-Mackler, Lynn; Gravare Silbernagel, Karin
Background Landing with poor knee sagittal plane biomechanics has been identified as a risk factor for Anterior Cruciate Ligament (ACL) injury. However, it is unclear if the horizontal hop test battery reflects knee function and biomechanics. Hypothesis/Purpose To investigate the correlation between clinical limb symmetry index (LSI) and landing and propulsion knee biomechanics during the hop test battery using markerless motion capture. Study Design Cross-sectional biomechanics laboratory study Methods Forty-two participants with and without knee surgery (age 28.0 ± 8.0 years) performed the hop test battery which consisted of a single hop for distance, crossover hop, triple hop, and 6-m timed hop in the order listed. Eight high speed cameras were used to collect simultaneous 3D motion data and Theia 3D (Theia Markerless Inc.) was used to generate 3D body model files. Lower limb joint kinematics were calculated in Visual3D. Correlation (Spearman’s ρ) was computed between clinical LSI and symmetry in peak and initial contact (IC) knee flexion angle during propulsion and landing phases of each movement. Results In the single hop, clinical LSI showed positive correlation with kinematic LSI at peak landing (ρ= 0.39, p=0.011), but no correlation at peak propulsion (ρ= -0.03, p=0.851). In the crossover hop, non-significant correlations were found in both propulsion and landing. In the triple hop, positive correlation was found at peak propulsion (ρ= 0.38, p=0.027), peak landing (ρ= 0.48 – 0.66, p<0.001), and last landing IC (ρ= 0.45, p=0.009). In the timed hop, peak propulsion showed positive correlation (ρ= 0.51, p=0.003). Conclusions Single hop and triple hop distance symmetry reflected landing biomechanical symmetry better than propulsion symmetry. Poor scores on the hop test battery reflect asymmetrical knee landing biomechanics, emphasizing the importance of continuing to use the hop test battery as part of clinical decision making. Level of Evidence 3b
Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair
(Knee Surgery, Sports Traumatology, Arthroscopy, 2024-05-24) Aufwerber, Susanna; Svedman, Simon; Grävare Silbernagel, Karin; Ackermann, Paul W.
Purpose The aim of the study was to examine the impact of a deep venous thrombosis (DVT) on patient outcomes 3 years after Achilles tendon rupture (ATR) repair and if there were continued improvements between 1 and 3 years after surgery. A secondary aim was to determine risk factors associated with impaired patient outcomes in the long term. Methods This cohort study consisted of 181 ATR-repaired patients, from two large randomized clinical trials, who attended a 3-year follow-up evaluation. Patients were postoperatively randomized to two different weight-bearing interventions compared with immobilization in a below-knee plaster cast for 2 weeks. During immobilization, screening for DVT was performed with Doppler ultrasound. At 1 and 3 years postoperatively, functional- and patient-reported outcomes were evaluated by the validated heel-rise test and self-reported questionnaire, Achilles tendon Total Rupture Score (ATRS). Results In total, 76 out of 181 (42%) patients exhibited a DVT at the 2- or 6-week screening after ATR surgery. Suffering from a DVT during immobilization resulted at 3 years in a worse limb symmetry index (LSI) of heel-rise total work compared to patients without DVT, adjusted for age (DVT mean LSI 68% vs. no DVT 78%, p = 0.027). At 3 years, patients with a DVT during immobilization displayed lower ATRS (DVT median 88 vs. no DVT 93, p = 0.046), which was not significant after adjustment for age. However, patients with DVT exhibited an improvement in ATRS, LSI total work, and LSI maximum height between 1 and 3 years, which was not seen among patients without DVT. Independent risk factors for reduced patient functional outcomes at 3 years were older age, greater calf muscle hypotrophy, and suffering a DVT. Conclusions DVT during immobilization affects patients' long-term functional outcomes 3 years after ATR repair. Clinicians should adequately address risk factors contributing to impaired patient outcomes in the long term, including calf muscle hypotrophy, DVT, and older age. Level of Evidence Level Ⅲ. Abbreviations ATR Achilles tendon rupture ATRS Achilles tendon Total Rupture Score BMI body mass index CDU compression duplex ultrasound DVT deep venous thrombosis EFM early functional mobilization IPC intermittent pneumatic compression LMWH low-molecular-weight heparin LSI limb symmetry index PAS Physical Activity Scale RCT randomized controlled study
A Portable, Neurostimulation-Integrated, Force Measurement Platform for the Clinical Assessment of Plantarflexor Central Drive
(Bioengineering, 2024-01-30) Collimore, Ashley N.; Alvarez, Jonathan T.; Sherman, David A.; Gerez, Lucas F.; Barrow, Noah; Choe, Dabin K.; Binder-Macleod, Stuart; Walsh, Conor J.; Awad, Louis N.
Plantarflexor central drive is a promising biomarker of neuromotor impairment; however, routine clinical assessment is hindered by the unavailability of force measurement systems with integrated neurostimulation capabilities. In this study, we evaluate the accuracy of a portable, neurostimulation-integrated, plantarflexor force measurement system we developed to facilitate the assessment of plantarflexor neuromotor function in clinical settings. Two experiments were conducted with the Central Drive System (CEDRS). To evaluate accuracy, experiment #1 included 16 neurotypical adults and used intra-class correlation (ICC2,1) to test agreement of plantarflexor strength capacity measured with CEDRS versus a stationary dynamometer. To evaluate validity, experiment #2 added 26 individuals with post-stroke hemiparesis and used one-way ANOVAs to test for between-limb differences in CEDRS’ measurements of plantarflexor neuromotor function, comparing neurotypical, non-paretic, and paretic limb measurements. The association between paretic plantarflexor neuromotor function and walking function outcomes derived from the six-minute walk test (6MWT) were also evaluated. CEDRS’ measurements of plantarflexor neuromotor function showed high agreement with measurements made by the stationary dynamometer (ICC = 0.83, p < 0.001). CEDRS’ measurements also showed the expected between-limb differences (p’s < 0.001) in maximum voluntary strength (Neurotypical: 76.21 ± 13.84 ft-lbs., Non-paretic: 56.93 ± 17.75 ft-lbs., and Paretic: 31.51 ± 14.08 ft-lbs.), strength capacity (Neurotypical: 76.47 ± 13.59 ft-lbs., Non-paretic: 64.08 ± 14.50 ft-lbs., and Paretic: 44.55 ± 14.23 ft-lbs.), and central drive (Neurotypical: 88.73 ± 1.71%, Non-paretic: 73.66% ± 17.74%, and Paretic: 52.04% ± 20.22%). CEDRS-measured plantarflexor central drive was moderately correlated with 6MWT total distance (r = 0.69, p < 0.001) and distance-induced changes in speed (r = 0.61, p = 0.002). CEDRS is a clinician-operated, portable, neurostimulation-integrated force measurement platform that produces accurate measurements of plantarflexor neuromotor function that are associated with post-stroke walking ability.
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.
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.
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.
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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