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Lee S, Neogi T, McGinley B, Wang N, Frey Law L, Torabian KA, Aoyagi K, Stefanik JJ, Carlesso LC, Hausdorff JM, Gazit E, Segal NA, Lewis CE, Nevitt MC, Kumar D. Associations of pain sensitivity and conditioned pain modulation with physical activity: findings from the Multicenter Osteoarthritis Study (MOST). Osteoarthritis Cartilage 2024; 32:982-989. [PMID: 38763431 PMCID: PMC11254545 DOI: 10.1016/j.joca.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Individuals with chronic pain due to knee osteoarthritis (OA) are insufficiently physically active, and alterations of facilitatory and inhibitory nociceptive signaling are common in this population. Our objective was to examine the association of these alterations in nociceptive signaling with objective accelerometer-based measures of physical activity in a large observational cohort. DESIGN We used data from the Multicenter Osteoarthritis Study. Measures of peripheral and central pain sensitivity included pressure pain threshold at the knee and mechanical temporal summation at the wrist, respectively. The presence of descending pain inhibition was assessed by conditioned pain modulation (CPM). Physical activity was quantitatively assessed over 7 days using a lower back-worn activity monitor. Summary metrics included steps/day, activity intensity, and sedentary time. Linear regression analyses were used to evaluate the association of pain sensitivity and the presence of descending pain inhibition with physical activity measures. RESULTS Data from 1873 participants was analyzed (55.9% female, age = 62.8 ± 10.0 years). People having greater peripheral and central sensitivity showed lower step counts. CPM was not significantly related to any of the physical activity measures, and none of the exposures were significantly related to sedentary time. CONCLUSIONS In this cohort, greater peripheral and central sensitivity were associated with reduced levels of objectively-assessed daily step counts. Further research may investigate ways to modify or treat heightened pain sensitivity as a means to increase physical activity in older adults with knee OA.
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Affiliation(s)
- Soyoung Lee
- Department of Physical Therapy, Boston University, Boston, MA, USA.
| | - Tuhina Neogi
- Division of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Brooke McGinley
- School of Public Health, Boston University, Boston, MA, USA.
| | - Na Wang
- School of Public Health, Boston University, Boston, MA, USA.
| | - Laura Frey Law
- Physical Therapy & Rehabilitation Science, University of Iowa, Iowa City, IA, USA.
| | - Kaveh A Torabian
- Department of Physical Therapy, Boston University, Boston, MA, USA.
| | - Kosaku Aoyagi
- Division of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Joshua J Stefanik
- Division of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; Department of Physical Therapy, Northeastern University, Boston, MA, USA.
| | - Lisa C Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
| | - Jeffrey M Hausdorff
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Rush University Medical Center, Chicago, IL, USA.
| | - Eran Gazit
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | - Neil A Segal
- Department of Rehabilitation Medicine, University of Kansas, Kansas City, KS, USA.
| | - Cora E Lewis
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Michael C Nevitt
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| | - Deepak Kumar
- Department of Physical Therapy, Boston University, Boston, MA, USA; Division of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Shah N, Borrelli B, Kumar D. Perceptions about smartphone-based interventions to promote physical activity in inactive adults with knee pain - A qualitative study. Disabil Rehabil Assist Technol 2024; 19:2221-2228. [PMID: 37873670 PMCID: PMC11039564 DOI: 10.1080/17483107.2023.2272854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/22/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE Smartphone-based interventions offer a promising approach to address inactivity in people with knee osteoarthritis (OA). We explored perceptions towards smartphone-based interventions to improve physical activity, pain, and depressed mood in inactive people with knee pain. METHODS This qualitative study included six focus groups at Boston University with inactive people with knee pain (n = 35). A smartphone app, developed by our team, using constructs of Social Cognitive Theory, was used to obtain participant feedback. RESULTS Participants discussed wanting to use smartphone-based interventions for personalized exercise advice, for motivation (e.g., customized voice messages, virtual incentives), and to make exercise "less boring" (e.g., music, virtual gaming). Preferred app features included video tutorials on how to use the app, the ability to select information that can be viewed on the home screen, and the ability to interact with clinicians. Features that received mixed responses included daily pain tracking, daily exercise reminders, peer-interaction for accountability, and peer-competition for motivation. All participants discussed privacy and health data security concerns while using the app. CONCLUSIONS Using a co-design approach, we report preferences and concerns related to using smartphone-based physical activity interventions in inactive people with knee pain. This information may help improve acceptability of such interventions in this population.
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Affiliation(s)
- Nirali Shah
- Department of Physical Therapy, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, 02215, USA
| | - Belinda Borrelli
- Center for Behavioral Science Research, Henry M. Goldman School of Dental Medicine, Boston University, 560 Harrison Ave, Boston, MA, 02118, USA
| | - Deepak Kumar
- Department of Physical Therapy, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, 02215, USA
- Section of Rheumatology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Latijnhouwers DAJM, Hoogendoorn KG, Nelissen RGHH, Putter H, Vliet Vlieland TPM, Gademan MGJ. Adherence to the Dutch recommendation for physical activity: prior to and after primary total hip and knee arthroplasty. Disabil Rehabil 2024; 46:2862-2870. [PMID: 37496462 DOI: 10.1080/09638288.2023.2237409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE To determine the course of adherence to physical activity (PA) recommendation in hip/knee osteoarthritis patients before and after hip/knee arthroplasty (THA/TKA). Moreover, we explored predictors for non-adherence 12 months postoperatively. MATERIALS AND METHODS Primary THA/TKA were included in a multicenter observational study. Preoperatively and 6/12 months postoperatively, patients reported engagement in moderate-intensity PA in days/week in the past 6 months (PA-recommendation (≥30 min of moderate-intensity ≥5 days/week)). We included predictors stratified by preoperative adherence: sex, age, BMI, comorbidities, smoking, living/working status, season, mental health, HOOS/KOOS subscales before and 6 months postoperatively, and 6-month adherence. RESULTS (1005 THA/972 TKA) Preoperatively, 50% of the population adhered. Adherence increased to 59% at 6 and 12 months. After 12 months, most patients remained at their preoperative PA level, 11% of the preoperative adherers decreased, while 20% of the preoperative non-adherers increased their PA level. In all different groups, adherence to the PA recommendation at 6 months was identified as a predictor (OR-range: 0.16-0.29). In addition, BMI was identified as predictor in the THA adherent (OR = 1.07; 95%CI [1.02-1.15]) and TKA non-adherent groups (OR = 1.08; 95%CI [1.03-1.12]). THA non-adherent group not having paid work (OR = 0.53; 95%CI [0.33-0.85]), and in the TKA adherent group, lower KOOS subscale symptoms (OR = 1.03; 95%CI [1.01-1.05]) were associated with non-adherence. CONCLUSIONS Majority of patients remained at their preoperative PA level. Non-adherence at 6 months was highly predictive for 12-month non-adherence.Implications for rehabilitationPhysical activity (PA) is crucial to decrease mortality risk, especially among patients suffering from osteoarthritis, as these patients have the potential to become more physically active after arthroplasty surgery.We found that physical function and pain improved, but 69% of the patients remained at their preoperative PA level, while 11% decreased and 20% increased their PA levels.Using this information shortly after surgery, orthopedic surgeons and other health care professionals can address patients at risk for decreased PA levels and provide PA advice.
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Affiliation(s)
| | | | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Thea P M Vliet Vlieland
- Department of Orthopedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Maaike G J Gademan
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Kumara MT, Cleveland RJ, Kostic AM, Weisner SE, Allen KD, Golightly YM, Welch H, Dale M, Messier SP, Hunter DJ, Katz JN, Callahan LF, Losina E. Budget impact of the Walk With Ease program for knee osteoarthritis. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100463. [PMID: 38562164 PMCID: PMC10982564 DOI: 10.1016/j.ocarto.2024.100463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Walk With Ease (WWE) is an effective low-cost walking program. We estimated the budget impact of implementing WWE in persons with knee osteoarthritis (OA) as a measure of affordability that can inform payers' funding decisions. Methods We estimated changes in two-year healthcare costs with and without WWE. We used the Osteoarthritis Policy (OAPol) Model to estimate per-person medical expenditures. We estimated total and per-member-per-month (PMPM) costs of funding WWE for a hypothetical insurance plan with 75,000 members under two conditions: 1) all individuals aged 45+ with knee OA eligible for WWE, and 2) inactive and insufficiently active individuals aged 45+ with knee OA eligible. In sensitivity analyses, we varied WWE cost and efficacy and considered productivity costs. Results With eligibility unrestricted by activity level, implementing WWE results in an additional $1,002,408 to the insurance plan over two years ($0.56 PMPM). With eligibility restricted to inactive and insufficiently active individuals, funding WWE results in an additional $571,931 over two years ($0.32 PMPM). In sensitivity analyses, when per-person costs of $10 to $1000 were added with 10-50% decreases in failure rate (enhanced sustainability of WWE benefits), two-year budget impact varied from $242,684 to $6,985,674 with unrestricted eligibility and from -$43,194 (cost-saving) to $4,484,122 with restricted eligibility. Conclusion Along with the cost-effectiveness of WWE at widely accepted willingness-to-pay thresholds, these results can inform payers in deciding to fund WWE. In the absence of accepted thresholds to define affordability, these results can assist in comparing the affordability of WWE with other behavioral interventions.
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Affiliation(s)
- Mahima T. Kumara
- Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca J. Cleveland
- Thurston Arthritis Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aleksandra M. Kostic
- Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Serena E. Weisner
- Thurston Arthritis Research Center, Osteoarthritis Action Alliance, University of North Carolina, Chapel Hill, NC, USA
| | - Kelli D. Allen
- Durham VA Health Care System, Durham, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yvonne M. Golightly
- College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, USA
- Thurston Arthritis Research Center and Osteoarthritis Action Alliance, University of North Carolina, Chapel Hill, NC, USA
| | - Heather Welch
- Montana Department of Public Health and Human Services, Helena, MT, USA
| | - Melissa Dale
- Montana Department of Public Health and Human Services, Helena, MT, USA
| | - Stephen P. Messier
- Department of Health and Exercise Science, Wake Forest University, Salem, NC, USA
| | - David J. Hunter
- Sydney Musculoskeletal Health, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
| | - Jeffrey N. Katz
- Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Leigh F. Callahan
- Thurston Arthritis Research Center, Departments of Medicine and Orthopaedics, Osteoarthritis Action Alliance, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Elena Losina
- Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Hoffman RM, Davis-Wilson HC, Hanlon S, Swink LA, Kline PW, Juarez-Colunga E, Melanson EL, Christiansen CL. Maximal daily stepping cadence partially explains functional capacity of individuals with end-stage knee osteoarthritis. PM R 2024; 16:532-542. [PMID: 37819260 PMCID: PMC11006829 DOI: 10.1002/pmrj.13082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/01/2023] [Accepted: 09/16/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Individuals with end-stage knee osteoarthritis (OA) walk at a lower intensity (ie, slower step cadence) contributing to worse physical function. Previous literature reports daily step counts and sedentary time, with little information regarding stepping bouts or cadence. Determining relationships between daily higher stepping cadence duration and clinical outcomes can move the field toward optimal daily stepping prescription. OBJECTIVE To quantify daily physical activity patterns of individuals with end-stage knee OA and determine the contribution of high stepping cadence to explain functional capacity variability. DESIGN Cross-sectional analysis. SETTING Veterans Administration medical center. PARTICIPANTS U.S. military veterans (n = 104; age: 67.1 years [7.2]; mean [SD]; male [89.3%]) with end-stage knee OA were enrolled. INTERVENTION Not applicable. MAIN OUTCOME MEASURE Functional capacity (6-Minute Walk Test [6MWT]). Physical activity (activPAL wearable sensor; cadence and time sitting, standing, and stepping), pain (Western Ontario and McMaster Universities Osteoarthritis Index-pain subscale) sociodemographic variables, and comorbidities (body mass index and Functional Comorbidity Index) are the main explanatory variables. RESULTS Participants' wake time was mainly sitting (11.0 h/day) in ≥60-minute bouts (29.7% ± 12.7 of sitting time). Standing (3.4 hours/day) and stepping (1.4 h/day) primarily occurred in 0-5 minute bouts (standing: 87.7% ± 14.4 of standing time, stepping: 98.7% ± 12.7 of stepping time) and stepping cadence was predominantly incidental (1-19 spm; 52.9% ± 9.6 of total stepping time). Backward elimination model results indicated shorter medium-to-brisk cadence bout duration, older age, and higher pain significantly explained shorter 6MWT distance (AdjR2=0.24, p < .01). CONCLUSIONS Individuals with knee OA spend most of their waking hours sitting, while standing and stepping occurs in short bouts at very low stepping cadence. Decreased time in high stepping cadence is associated with lower functional capacity. Future studies should explore if increasing the daily time spent in higher step cadence can improve functional capacity in this population.
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Affiliation(s)
- Rashelle M Hoffman
- Department of Physical Therapy, School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, USA
| | - Hope C Davis-Wilson
- RTI International, Technology Advancement and Commercialization, Research Triangle Park, North Carolina, USA
| | - Shawn Hanlon
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
| | - Laura A Swink
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
| | - Paul W Kline
- Department of Physical Therapy, High Point University, High Point, North Carolina, USA
| | - Elizabeth Juarez-Colunga
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Edward L Melanson
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Cory L Christiansen
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
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Aydemir B, Muhammad LN, Song J, Chang AH, Dunlop DD, Chang RW, Lee YC. Modifiable physical and behavioural factors associated with widespread pain in older adults with radiographic evidence of knee osteoarthritis. Musculoskeletal Care 2023; 21:1090-1097. [PMID: 37271894 PMCID: PMC10714439 DOI: 10.1002/msc.1789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To identify modifiable physical and behavioural factors associated with widespread pain (WSP) in older adults with radiographic evidence of knee osteoarthritis (OA). METHODS Cross-sectional initial visit data of participants with radiographic knee OA (Kellgren-Lawrence grade of ≥2) from the Osteoarthritis Initiative Study were analysed. WSP was defined as pain on both sides of the body, above and below the waist, and in the axial skeleton. Time (hrs/d) spent participating in sitting and moderate-strenuous physical activities were calculated from the Physical Activity Scale for the Elderly questionnaire. Physical function was quantified using gait speed and the chair stand test. Restless sleep was assessed using an item on the CES-D Scale. Logistic regression models were constructed to examine the strength of the associations between primary exposures and WSP in unadjusted and adjusted analyses. RESULTS Among the 2637 participants (mean age 62.6 years, 58.6% female), 16.8% met the criteria for WSP. All primary measures of interest were related to WSP in unadjusted analyses. In adjusted multivariable analysis, slow gait speed (adjusted odds ratio [aOR] 1.43; 95% CI 1.01, 2.02), lower chair stand rate (aOR 0.98; 95% CI 0.97-0.99), and restless sleep (aOR 1.61; 95% CI 1.25-2.08) maintained significant associations with WSP. CONCLUSION Poor sleep behaviours and low physical function capacity are associated with WSP in adults with radiographic knee OA. These findings highlight the importance of assessing sleep, physical function, and pain distribution in this population. Interventions to improve physical function and sleep behaviours should be investigated as potential strategies to mitigate WSP.
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Affiliation(s)
- Burcu Aydemir
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lutfiyya N. Muhammad
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jing Song
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alison H. Chang
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dorothy D. Dunlop
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rowland W. Chang
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yvonne C. Lee
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Aydemir B, Huang CH, Foucher KC. Gait speed and kinesiophobia explain physical activity level in adults with osteoarthritis: A cross-sectional study. J Orthop Res 2023; 41:2629-2637. [PMID: 37254645 PMCID: PMC10926713 DOI: 10.1002/jor.25624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 03/16/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023]
Abstract
Identifying potential contributing factors for physical inactivity in people with knee osteoarthritis is vital for designing practical activity promoting interventions. Walking is a common activity, but it is unknown how gait characteristics may influence physical activity and if psychological factors, specifically fear of movement (kinesiophobia), contribute to this relationship. The aim of our study was to investigate the contributions of select gait parameters and kinesiophobia to activity levels. Cross-sectional data from 40 participants (F 24|M 16; age 57.6 ± 8.9 years; BMI 34.7 ± 7.0 kg/m2 ) with uni- or bilateral knee osteoarthritis were included. Physical activity and kinesiophobia were assessed by self-report using the University of California, Los Angeles activity rating scale, and Tampa scale for kinesiophobia, respectively. Gait parameters were collected with three-dimensional gait analysis while participants walked on an instrumented split-belt treadmill at a self-selected speed. Higher peak sagittal plane joint moments at the ankle (ρ = 0.418, p = 0.007), and hip (ρ = 0.348, p = 0.028), faster self-selected gait speed (ρ = 0.553, p < 0.001), and less kinesiophobia or fear of movement (ρ = -0.695, p < 0.001) were independently related to higher physical activity level in adults with knee osteoarthritis. In hierarchical regression models, after accounting for covariates, only self-selected gait speed, and kinesiophobia significantly contributed to explaining the variation in physical activity level. Statement of clinical significance: Interventions aimed at improving physical activity participation in those with lower limb osteoarthritis should consider assessing the contribution of pain-related fear of movement.
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Affiliation(s)
- Burcu Aydemir
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chun-Hao Huang
- Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, MA, USA
| | - Kharma C. Foucher
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL, USA
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Zimmerman ZE, Cleveland RJ, Kostic AM, Leifer VP, Weisner SE, Allen KD, Golightly YM, Welch H, Dale M, Messier SP, Hunter DJ, Katz JN, Callahan LF, Losina E. Walk with ease for knee osteoarthritis: A cost-effectiveness analysis. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100368. [PMID: 37234863 PMCID: PMC10206185 DOI: 10.1016/j.ocarto.2023.100368] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023] Open
Abstract
Objective The Walk With Ease (WWE) program was developed by the Arthritis Foundation to help people with arthritis learn to exercise safely and improve arthritis symptoms. We sought to establish the value of the WWE program. Methods We used the Osteoarthritis Policy (OAPol) Model, a widely published and validated computer simulation of knee osteoarthritis (OA), to assess the cost-effectiveness of WWE in knee OA. We derived model inputs using data from a workplace wellness initiative in Montana that offered WWE to state employees. Our primary outcomes were quality-adjusted life years (QALYs) and costs over a 2-year period, which we used to calculate the incremental cost-effectiveness ratio (ICER). The base case analysis was restricted to subjects who were inactive or insufficiently active (<180 min/week of PA) at baseline. We performed scenario and probabilistic sensitivity analyses to determine the impact of uncertainty in model parameters on our results. Results In the base case analysis, adding WWE to usual care resulted in an ICER of $47,900/QALY. When the program was offered without preselection by baseline activity level, the ICER for WWE + usual care was estimated at $83,400/QALY. Results of the probabilistic sensitivity analysis indicated that WWE offered to inactive or insufficiently active individuals has a 52% chance of having an ICER <$50,000/QALY. Conclusion The WWE program offers good value for inactive/insufficiently active individuals. Payers may consider including such a program to increase physical activity in individuals with knee OA.
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Affiliation(s)
- Zoe E. Zimmerman
- Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca J. Cleveland
- Thurston Arthritis Research Center; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aleksandra M. Kostic
- Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Valia P. Leifer
- Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Serena E. Weisner
- Thurston Arthritis Research Center; Osteoarthritis Action Alliance, University of North Carolina, Chapel Hill, NC, USA
| | - Kelli D. Allen
- Durham VA Health Care System, Durham, USA
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yvonne M. Golightly
- College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, USA
- Thurston Arthritis Research Center and Osteoarthritis Action Alliance, University of North Carolina, Chapel Hill, NC, USA
| | - Heather Welch
- Montana Department of Public Health and Human Services, Helena, MT, USA
| | - Melissa Dale
- Montana Department of Public Health and Human Services, Helena, MT, USA
| | - Stephen P. Messier
- J.B. Snow Biomechanics Laboratory, Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA
| | - David J. Hunter
- Sydney Musculoskeletal Health, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
| | - Jeffrey N. Katz
- Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Leigh F. Callahan
- Thurston Arthritis Research Center Departments of Medicine and Orthopaedics, Osteoarthritis Action Alliance, Dept. of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Elena Losina
- Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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9
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Hinman RS, Jones SE, Nelligan RK, Campbell PK, Hall M, Foster NE, Russell T, Bennell KL. Absence of Improvement With Exercise in Some Patients With Knee Osteoarthritis: A Qualitative Study of Responders and Nonresponders. Arthritis Care Res (Hoboken) 2023; 75:1925-1938. [PMID: 36594402 DOI: 10.1002/acr.25085] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/20/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To compare the perceptions of patients about why they did, or did not, respond to a physical therapist-supported exercise and physical activity program. METHODS This was a qualitative study within a randomized controlled trial. Twenty-six participants (of 40 invited) with knee osteoarthritis sampled according to response (n = 12 responders, and 14 nonresponders based on changes in both pain and physical function at 3 and 9 months after baseline) to an exercise and physical activity intervention. Semistructured individual interviews were conducted. Inductive thematic analysis was undertaken within each subgroup using grounded theory principles. A deductive approach compared themes and subthemes across subgroups. Findings were triangulated with quantitative data. RESULTS (Sub)themes common to responders and nonresponders included the intervention components that facilitated engagement, personal attitudes and expectations, beliefs about osteoarthritis and exercise role, importance of adherence, and perceived strength gains with exercise. In contrast to responders who felt empowered to self-manage, nonresponders accepted responsibility for lack of improvement in pain and function with exercise, acknowledging that their adherence to the intervention was suboptimal (confirmed by quantitative adherence data). Nonresponders believed that their excess body weight (supported by quantitative data) contributed to their outcomes, encountered exercise barriers (comorbidities, stressors, and life events), and perceived that the trial measurement tools did not adequately capture their response to exercise. CONCLUSION Responders and nonresponders shared some similar perceptions of exercise. However, along with perceived limitations in trial outcome measurements, nonresponders encountered challenges with excess weight, comorbidities, stressors, and life events that led to suboptimal adherence and collectively were perceived to contribute to nonresponse.
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Affiliation(s)
- Rana S Hinman
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Sarah E Jones
- The University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Michelle Hall
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Nadine E Foster
- The University of Queensland and Metro North Health, Brisbane, Queensland, Australia
| | - Trevor Russell
- The University of Queensland, Brisbane, Queensland, Australia
| | - Kim L Bennell
- The University of Melbourne, Melbourne, Victoria, Australia
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10
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Nemati D, Quintero D, Best TM, Kaushal N. Investigating the association between knee osteoarthritis symptoms with pain catastrophizing domains between Hispanics and non-Hispanic Whites. Rheumatol Int 2023:10.1007/s00296-023-05396-1. [PMID: 37597058 DOI: 10.1007/s00296-023-05396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/14/2023] [Indexed: 08/21/2023]
Abstract
Knee osteoarthritis (KOA) is a chronic disease accompanied by debilitating symptoms including pain, stiffness, and limited physical functionality, which have been shown to be associated with pain catastrophizing. Previous studies have revealed racial discrepancies in pain catastrophizing, notably between Hispanics and non-Hispanics while pointing to potential health disparities. Using a conceptual model, this study aimed to investigate racial differences in associations between KOA symptoms with specific pain catastrophizing domains (rumination, magnification, and helplessness). Patients with KOA (n = 253; 147 Hispanics, 106 non-Hispanic Whites) completed a survey that included measures of knee symptoms, pain catastrophizing, and demographic variables. Structural equation modeling revealed that among Hispanics, each pain catastrophizing domain (rumination, magnification, and helplessness) was associated with at least two symptomatic experiences, including pain severity and difficulty in physical function. Specifically, pain severity was associated with (a) rumination: β = 0.48, p < 0.001, (b) magnification: β = 0.31, p = 0.003; and (c) helplessness: β = 0.39, p < 0.001). Additionally, a lower score in physical function was associated with higher magnification (β = 0.26, p = 0.01), and helplessness (β = 0.25, p = 0.01). Among non-Hispanic White patients, pain severity was further associated with two domains of pain catastrophizing, including rumination (β = 0.39, p < 0.001) and helplessness (β = 0.35, p = 0.01). In addition, association pathways for demographic variables revealed that older Hispanics experienced greater challenges with higher pain severity (β = 0.26, p = 0.01) and greater difficulty with physical function (β = 0.31, p < 0.001) while Hispanics females experienced higher pain (β = 0.19, p = 0.03). These findings highlight the importance of designing tailored interventions that consider key demographic factors such as age, and gender, to improve physical function that might alleviate pain catastrophizing among Hispanics with KOA.
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Affiliation(s)
- Donya Nemati
- Center for Healthy Aging, Self-Management, & Complex Care, College of Nursing, The Ohio State University, 1585 Neil Avenue, Columbus, OH, 43210, USA.
| | - Daniel Quintero
- Department of Orthopedics, Miller School of Medicine, U Health Sports Medicine Institute, U of Miami, Coral Gables, FL, USA
| | - Thomas M Best
- Department of Orthopedics, Miller School of Medicine, U Health Sports Medicine Institute, U of Miami, Coral Gables, FL, USA
| | - Navin Kaushal
- Department of Health Sciences, Indiana University School of Health and Human Sciences, Indianapolis, IN, USA
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11
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Hinman RS, Hall M, Comensoli S, Bennell KL. Exercise & Sports Science Australia (ESSA) updated Position Statement on exercise and physical activity for people with hip/knee osteoarthritis. J Sci Med Sport 2023; 26:37-45. [PMID: 36463000 DOI: 10.1016/j.jsams.2022.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022]
Abstract
This Position Statement is an update to the existing statement. It is intended for all health practitioners who manage people with hip/knee osteoarthritis. It synthesises the most recent evidence (with a focus on clinical guidelines and systematic reviews) for exercise in people with hip/knee osteoarthritis, and provides guidance to practitioners about how best to implement exercise in clinical practice. Clinical practice guidelines for hip/knee osteoarthritis advocate physical activity and exercise as fundamental core components of evidence-based management. Research evidence indicates that exercise can reduce joint pain, increase physical function, and improve quality of life in hip/knee osteoarthritis, and that a range of exercise types (both supervised and unsupervised) may be beneficial. Exercise dosage should be guided by the principles of the American College of Sports Medicine. As people with osteoarthritis experience many barriers to exercise, practitioners should take an active role in monitoring and promoting adherence to exercise in order to optimise therapeutic benefits.
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Affiliation(s)
- Rana S Hinman
- Department of Physiotherapy, The University of Melbourne, Australia.
| | - Michelle Hall
- Department of Physiotherapy, The University of Melbourne, Australia
| | | | - Kim L Bennell
- Department of Physiotherapy, The University of Melbourne, Australia
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12
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Lamberti N, Manfredini F, Babjaková J, Gallè F, Medijainen K, Karatzaferi C, Pavlova I, Netz Y, López-Soto PJ. Effect of physical activity interventions on quality of life in older adults: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31801. [PMID: 36482570 PMCID: PMC9726368 DOI: 10.1097/md.0000000000031801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Quality of life (QoL) has been acknowledged as a fundamental concept in the field of health and is favorably improved by physical activity (PA). This systematic review aims to assess the benefits and harms of different types of PA to improve health-related QoL in both community-dwelling and diseased older adults to provide a recommendation for the minimum amount of PA needed to obtain measurable QoL benefits. METHODS AND ANALYSIS We will search MEDLINE, Cochrane Central Register of Controlled Trials, CINHAL, Epistemonikos, Web of Science and gray literature. Randomized controlled trials enrolling healthy or diseased older adults aged > 65 years, providing any kind of physical activity intervention and having quality of life as an outcome will be included. There will be no language restriction. Two independent reviewers will screen the papers, and a third reviewer will resolve the conflicts. The quality of the included studies will be assessed through the Risk of Bias 2.0 tool. Finally, data will be extracted to create proper meta-analyses of comparisons between the different kinds of physical activity interventions or to control groups. ETHICS AND DISSEMINATION This review does not require approval from the Ethics Committee. The results will be disseminated in peer-reviewed journals and at international conferences; moreover, the findings will be shared on social media using an accessible language.
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Affiliation(s)
- Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Fabio Manfredini
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Jana Babjaková
- Institute of Hygiene, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Francesca Gallè
- Department of Movement Sciences and Wellbeing, University of Naples Parthenope, Naples, Italy
| | - Kadri Medijainen
- Lead of Physiotherapy curriculums, University of Tartu, Tartu, Estonia
| | | | - Iuliia Pavlova
- Department of Theory and Methods of Physical Culture, Lviv State University of Physical Culture named after Ivan Boberskyj, Lviv, Ukraine
| | - Yael Netz
- The academic College at Wingate, Israel
| | - Pablo Jesús López-Soto
- Department of Nursing. Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Department of Nursing, Pharmacology and Physiotherapy. Universidad de Córdoba, Córdoba, Spain
- Department of Nursing, Hospital Universitario Reina Sofia de Córdoba, Córdoba, Spain
- * Correspondence: Pablo Jesús López-Soto, Department of Nursing. Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain. Avda. Menéndez Pidal s/n Córdoba 14004, Spain (e-mail: )
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13
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Okura K, Shibata K, Suda T, Kimoto M, Saito A, Wakasa M, Kimura Y, Okada K. Gait-related self-efficacy is directly associated with daily step counts in individuals with knee osteoarthritis. Knee 2022; 39:124-131. [PMID: 36191399 DOI: 10.1016/j.knee.2022.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/05/2022] [Accepted: 09/15/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In addition to physical factors, psychological factors such as self-efficacy (SE) reportedly affect physical activity (PA) levels in individuals with knee osteoarthritis (OA). However, the relationship between PA and SE for walking tasks in patients with knee OA remains unclear. The present study aimed to investigate the direct and indirect pathways of SE for walking tasks and the influence of previously reported factors on PA level in individuals with knee OA. METHODS A cross-sectional design was employed. Eighty-five individuals with knee OA were enrolled. The daily step count (Steps) was considered an objective level of PA. The SE for the walking task was assessed using a modified Gait Efficacy Scale (mGES). Data on gait speed (GS), the visual analog scale (VAS) score for knee pain, Kellgren-Lawrence (K-L) grade of radiographic severity of knee OA, age, and body mass index were collected. Path analysis was performed to investigate the direct and indirect effects of these variables on Steps. RESULTS After exclusion, 70 participants were included. The alternative model, which included Steps, mGES, GS, VAS, K-L grade, and age, showed a good fit. mGES and age had a direct effect on Steps (standardized path coefficients: 0.337 and -0.542, respectively), while the other variables had indirect effects. CONCLUSIONS The SE for walking tasks was directly associated with Steps representative of the PA level. This finding suggests that SE for the walking task may be important in improving PA levels in individuals with knee OA.
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Affiliation(s)
- Kazuki Okura
- Division of Rehabilitation, Akita University Hospital, Akita, Japan; Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan.
| | | | - Tomohiro Suda
- Division of Rehabilitation, Akita University Hospital, Akita, Japan; Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan
| | - Minoru Kimoto
- Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan
| | - Akira Saito
- Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan
| | - Masahiko Wakasa
- Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan
| | - Yoshiaki Kimura
- Department of Orthopedic Surgery, Akita City Hospital, Akita, Japan
| | - Kyoji Okada
- Department of Physical Therapy, Akita University Graduate School of Health Sciences, Akita, Japan
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14
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Impact of COVID-19 Pandemic on Physical Activity, Pain, Mood, and Sleep in Adults with Knee Osteoarthritis. JOURNAL FOR THE MEASUREMENT OF PHYSICAL BEHAVIOUR 2022; 5:294-298. [PMID: 36779003 PMCID: PMC9918033 DOI: 10.1123/jmpb.2022-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective To examine changes in physical activity, sleep, pain and mood in people with knee osteoarthritis (OA) during the ongoing COVID-19 pandemic by leveraging an ongoing randomized clinical trial (RCT). Methods Participants enrolled in a 12-month parallel two-arm RCT (NCT03064139) interrupted by the COVID-19 pandemic wore an activity monitor (Fitbit Charge 3) and filled out custom weekly surveys rating knee pain, mood, and sleep as part of the study. Data from 30 weeks of the parent study were used for this analysis. Daily step count and sleep duration were extracted from activity monitor data, and participants self-reported knee pain, positive mood, and negative mood via surveys. Metrics were averaged within each participant and then across all participants for pre-pandemic, stay-at-home, and reopening periods, reflecting the phased re-opening in the state of Massachusetts. Results Data from 28 participants showed small changes with inconclusive clinical significance during the stay-at-home and reopening periods compared to pre-pandemic for all outcomes. Summary statistics suggested substantial variability across participants with some participants showing persistent declines in physical activity during the observation period. Conclusion Effects of the COVID-19 pandemic on physical activity, sleep, pain, and mood were variable across individuals with OA. Specific reasons for this variability could not be determined. Identifying factors that could affect individuals with knee OA who may exhibit reduced physical activity and/or worse symptoms during major lifestyle changes (such as the ongoing pandemic) is important for providing targeted healthcare services and management advice towards those that could benefit from it the most.
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15
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Chang AH, Lee JJ, Almagor O, Chmiel JS, Hayes KW, Moisio KC, Sharma L. Knee Confidence Trajectories Over Eight Years and Factors Associated With Poor Trajectories in Individuals With or at Risk for Knee Osteoarthritis. Arthritis Care Res (Hoboken) 2022; 74:1857-1865. [PMID: 33973405 PMCID: PMC10266298 DOI: 10.1002/acr.24629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To identify distinct trajectories of lack of knee confidence over an 8-year follow-up period and to examine baseline factors associated with poor trajectories in individuals with or at risk for knee osteoarthritis (OA). METHODS The Osteoarthritis Initiative is a prospective cohort study of individuals with or at high risk for knee OA. Confidence in the knees was assessed within the Knee Injury and Osteoarthritis Outcome Score instrument querying how much the individual is troubled by lack of confidence in his/her knee(s), rated as not-at-all (score = 0), mildly (score = 1), moderately (score = 2), severely (score = 3), and extremely (score = 4) troubled, reported annually from baseline to 96 months. Lack of knee confidence was defined as a score of ≥2. We used latent class models to identify subgroups that share similar underlying knee confidence trajectories over an 8-year period and multivariable multinomial logistic regression models to examine baseline factors associated with poor trajectories. RESULTS Among 4,515 participants (mean ± SD age 61.2 ± 9.2 years, mean ± SD BMI 28.6 ± 4.8 kg/m2 ; 2,640 [58.5%] women), 4 distinct knee confidence trajectories were identified: persistently good (65.6%); declining (9.1%); poor, improving (13.9%); and persistently poor (11.4%). Baseline predictors associated with persistently poor confidence (reference: persistently good) were younger age, male sex, higher body mass index (BMI), depressive symptoms, more advanced radiographic disease, worse knee pain, weaker knee extensors, history of knee injury and surgery, and reported hip and/or ankle pain. CONCLUSION Findings suggest the dynamic nature of self-reported knee confidence and that addressing modifiable factors (e.g., BMI, knee strength, depressive symptoms, and lower extremity pain) may improve its long-term course.
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Affiliation(s)
- Alison H Chang
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jungwha Julia Lee
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Orit Almagor
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joan S Chmiel
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen W Hayes
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kirsten C Moisio
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leena Sharma
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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16
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Östlind E, Ekvall Hansson E, Eek F, Stigmar K. Experiences of activity monitoring and perceptions of digital support among working individuals with hip and knee osteoarthritis - a focus group study. BMC Public Health 2022; 22:1641. [PMID: 36042425 PMCID: PMC9426251 DOI: 10.1186/s12889-022-14065-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/23/2022] [Indexed: 11/11/2022] Open
Abstract
Background Mobile health (mHealth), wearable activity trackers (WATs) and other digital solutions could support physical activity (PA) in individuals with hip and knee osteoarthritis (OA), but little is described regarding experiences and perceptions of digital support and the use of WAT to self-monitor PA. Thus, the aim of this study was to explore the experiences of using a WAT to monitor PA and the general perceptions of mHealth and digital support in OA care among individuals of working age with hip and knee OA. Methods We conducted a focus group study where individuals with hip and knee OA (n = 18) were recruited from the intervention group in a cluster-randomized controlled trial (C-RCT). The intervention in the C-RCT comprised of 12-weeks use of a WAT with a mobile application to monitor PA in addition to participating in a supported OA self-management program. In this study, three focus group discussions were conducted. The discussions were transcribed and qualitative content analysis with an inductive approach was applied. Results The analysis resulted in two main categories: A WAT may aid in optimization of PA, but is not a panacea with subcategories WATs facilitate PA; Increased awareness of one’s limitations and WATs are not always encouraging, and the second main category was Digital support is an appreciated part of OA care with subcategories Individualized, early and continuous support; PT is essential but needs to be modernized and Easy, comprehensive, and reliable digital support. Conclusion WATs may facilitate PA but also aid individuals with OA to find the optimal level of activity to avoid increased pain. Digital support in OA care was appreciated, particularly as a part of traditional care with physical visits. The participants expressed that the digital support should be easy, comprehensive, early, and continuous. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14065-0.
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Affiliation(s)
- Elin Östlind
- Department of Health Sciences, Lund University, Lund, Sweden. .,Dalby Health Care Center, Region Skåne, Sweden.
| | - Eva Ekvall Hansson
- Department of Health Sciences, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
| | - Frida Eek
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Kjerstin Stigmar
- Department of Health Sciences, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
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17
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Beauchamp T, Arbeeva L, Cleveland RJ, Golightly YM, Hales DP, Hu DG, Allen KD. Accelerometer-Based Physical Activity Patterns and Associations With Outcomes Among Individuals With Osteoarthritis. J Clin Rheumatol 2022; 28:e415-e421. [PMID: 33902099 PMCID: PMC8542057 DOI: 10.1097/rhu.0000000000001750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study examined patterns of physical activity and associations with pain, function, fatigue, and sleep disturbance among individuals with knee or hip osteoarthritis. METHODS Participants (n = 54) were enrolled in a telephone-based physical activity coaching intervention trial; all data were collected at baseline. Self-reported measures of pain and function (WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index] subscales), fatigue (10-point numeric rating scale), and PROMIS (Patient-Reported Outcomes Information System) Sleep Disturbance were collected via telephone. Accelerometers were mailed to participants and were worn for at least 3 days. Proportion of time participants spent in sedentary behavior during the morning (from wake until 12:00 pm), afternoon (12:00 pm until 5:59 pm) and evening (6:00 pm until sleep) each day was averaged across all days of wear. Pearson correlations assessed associations between activity and self-reported measures. RESULTS Participants spent a large proportion of time in sedentary behavior: 65.6% of mornings, 70.0% of afternoons, and 76.6% of evenings. Associations between proportion of time spent in sedentary behavior and reported outcomes were generally strongest in the afternoon, strongest for WOMAC function, and lowest for PROMIS Sleep Disturbance. In the evening hours, sedentary time was most strongly associated with fatigue. CONCLUSIONS Overall, findings stress the importance of reducing sedentary behavior among adults with osteoarthritis and suggest behavioral interventions may be strengthened by considering patients' within-day variation in symptoms and activity.
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Affiliation(s)
- Tyler Beauchamp
- From the Medical College of Georgia at Augusta University, Augusta, GA
| | - Liubov Arbeeva
- Department of Medicine and Thurston Arthritis Research Center
| | | | - Yvonne M Golightly
- Division of Physical Therapy and Thurston Arthritis Research Center, Injury Prevention Research Center, Department of Epidemiology
| | - Derek P Hales
- Department of Nutrition Gillings School of Global Public Health and Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - David G Hu
- Department of Medicine and Thurston Arthritis Research Center
| | - Kelli D Allen
- Department of Medicine and Thurston Arthritis Research Center
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18
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Östlind E, Eek F, Stigmar K, Sant'Anna A, Hansson EE. Promoting work ability with a wearable activity tracker in working age individuals with hip and/or knee osteoarthritis: a randomized controlled trial. BMC Musculoskelet Disord 2022; 23:112. [PMID: 35114983 PMCID: PMC8812043 DOI: 10.1186/s12891-022-05041-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Physical activity (PA) may improve work ability and health in individuals with hip and/or knee osteoarthritis (OA). The use of wearable activity trackers (WATs) has been shown to increase PA and improve other health outcomes but little is known concerning their effect on work ability. The objectives of this study were to examine the effect of self-monitoring PA with a WAT on work ability, PA and work productivity among individuals of working age with hip and/or knee OA. Methods Individuals (n = 160) were included and cluster-randomized to a Supported Osteoarthritis Self-management Program (SOASP) with the addition of self-monitoring PA using a commercial WAT for 12 weeks (n = 86), or only the SOASP (n = 74). Primary outcome was self-reported work ability measured with the Work Ability Index (WAI) and secondary outcomes were self-reported PA measured with the International Physical Activity Questionnaire – Short Form (IPAQ-SF) and work productivity, measured with the Work Productivity and Activity Impairment scale: Osteoarthritis (WPAI:OA) at baseline and after 3, 6 and 12 months. Data was primarily analysed with linear mixed models. Results Participants with data from baseline and at least one follow-up were included in the analyses (n = 124). Linear mixed models showed no statistically significant difference between groups regarding pattern of change in work ability or PA, from baseline to follow-ups. Also, neither group had a statistically significant difference in work ability between baseline and each follow-up. Conclusion The SOASP together with self-monitoring PA with a WAT did not have any effect on the primary outcome variable work ability. Participants already at baseline had good work ability and were physically active, which could have reduced the possibility for improvements. Future interventions should target a population with lower work ability and PA-level. Trial registration ClinicalTrials.gov, NCT03354091. Registered 15/11/2017.
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Affiliation(s)
- Elin Östlind
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden. .,Dalby Healthcare Center, Region Skåne, Lund, Sweden.
| | - Frida Eek
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden
| | - Kjerstin Stigmar
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
| | | | - Eva Ekvall Hansson
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
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19
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Kanavaki AM, Rushton A, Klocke R, Abhishek A, Duda JL. Assessing moderate-to-vigorous physical activity in hip and knee osteoarthritis using accelerometers: Implications of different patterns and cut-points for health and well-being. J Sports Sci 2022; 40:156-163. [PMID: 35038969 DOI: 10.1080/02640414.2021.1981689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This cross-sectional study explored how using age-specific and non-age-specific cut-points to assess moderate-to-vigorous physical activity (MVPA) measured by GT3X accelerometers affected bouted and total volume MVPA associations with health and well-being. METHODS MVPA correlations with physical function, BMI, joint pain, quality of life, anxiety and depression were tested. Steiger's z compared the strength of these correlations for each pair of cut-points. RESULTS A total of 109 adults with hip/knee osteoarthritis [M= 63.8 years (±10.58), 63.3% women] participated. Applying age-specific cut-points resulted in significantly more time classified as MVPA (76/9.5min total volume/bouted) compared to non-age-specific (38.8/7min total volume/bouted). Only total volume MVPA correlations differed significantly as a function of cut-points for self-reported function, quality of life, anxiety and depression (p ≤ .05). For age-specific cut-points, more time spent in MVPA was associated with a worse psychological profile. DISCUSSION Applying age-specific cut-points for MVPA assessment in older adults with lower limb OA had implications for MVPA associations with health and well-being when total volume, but not bouted, MVPA was considered. Age-specific total volume MVPA needs further understanding regarding patterns and affective responses it comprises. Bouted MVPA is an important pattern for MVPA accrual, but probably not an applicable PA target for many patients.
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Affiliation(s)
- Archontissa M Kanavaki
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,University of Birmingham, MRC-Arthritis Research Centre for Musculoskeletal Ageing Research, Birmingham, UK
| | - Alison Rushton
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,University of Birmingham, MRC-Arthritis Research Centre for Musculoskeletal Ageing Research, Birmingham, UK
| | - Rainer Klocke
- Department of Rheumatology, Dudley Group Nhs Foundation Trust, Dudley, UK
| | - Abhishek Abhishek
- Academic Rheumatology Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Joan L Duda
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,University of Birmingham, MRC-Arthritis Research Centre for Musculoskeletal Ageing Research, Birmingham, UK
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Decreased physical activity in patients with ankle osteoarthritis. A case-control study comparing daily step counts. Foot Ankle Surg 2022; 28:66-71. [PMID: 33551322 DOI: 10.1016/j.fas.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/03/2020] [Accepted: 01/25/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to compare physical activity levels and the proportion of patients who met physical activity recommendations in patients with ankle osteoarthritis and controls. METHODS Ankle osteoarthritis patients (n = 50) and controls (n = 50) were recruited. physical activity was measured using an accelerometer-based monitor. Physical activity parameters, including the step count/day, the proportion of patients who met physical activity recommendations of ≥7000 steps/day, and moderate to vigorous physical activity minutes/day, were compared between the patient groups. RESULTS The patients with ankle osteoarthritis walked 3998 steps/day, while the controls walked 6531 steps/day (P < .001). Only 7 (14%) ankle osteoarthritis patients and 17 (34%) controls met the physical activity recommendations of ≥7000 steps/day (P = .01). Time spent performing moderate to vigorous physical activity was 58 and 78 min/day in the ankle osteoarthritis and controls, respectively. CONCLUSIONS The physical activity level of ankle osteoarthritis patients was lower than that of controls. Only a limited proportion of ankle osteoarthritis patients met the physical activity recommendation.
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Okura K, Shibata K, Suda T, Iwakura M, Wakasa M, Kimura Y, Okada K. Gait-related Self-efficacy is Low in Older Adults with Knee Osteoarthritis: A Preliminary Study. Phys Ther Res 2021; 25:31-34. [PMID: 35582119 PMCID: PMC9095421 DOI: 10.1298/ptr.e10128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/01/2021] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To investigate the differences in self-efficacy (SE) for walking tasks between older patients with knee osteoarthritis (OA) and older adults without knee OA. METHODS A cross-sectional design was employed. Older patients with radiographic knee OA and community-dwelling older adults without knee OA as controls were enrolled in the study. SE for the walking task was assessed using the modified gait efficacy scale (mGES). A Wilcoxon rank-sum test was used to compare the mGES between the groups of participants. A Tobit regression model was used to estimate the difference in mGES. The presence of radiographic knee OA was used as an independent variable. Sex (women), age, and body mass index were used as potential confounding variables in the model. RESULTS After exclusion, 78 participants (n=40 with knee OA, n=38 controls) were included. The mGES was lower in patients with knee OA than in controls. In the Tobit regression model adjusted for confounding factors, mGES in patients with knee OA was estimated to be 26.8 (95% confidence interval [CI]: 15.8-37.8) points lower than in controls. CONCLUSION This study demonstrated that mGES was lower in older patients with knee OA than in older adults without knee OA.
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Affiliation(s)
- Kazuki Okura
- Department of Rehabilitation, Akita University Hospital, Japan
| | | | - Tomohiro Suda
- Department of Rehabilitation, Akita University Hospital, Japan
| | | | - Masahiko Wakasa
- Department of Physical Therapy, Akita University Graduate School of Health Sciences, Japan
| | - Yoshiaki Kimura
- Department of Orthopedic Surgery, Akita City Hospital, Japan
| | - Kyoji Okada
- Department of Physical Therapy, Akita University Graduate School of Health Sciences, Japan
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22
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Arant KR, Zimmerman ZE, Bensen GP, Losina E, Katz JN. Perceptions of Physical Activity and the Use of Activity Monitors to Increase Activity Levels in Patients Undergoing Total Knee Replacement. ACR Open Rheumatol 2021; 3:771-778. [PMID: 34411466 PMCID: PMC8593770 DOI: 10.1002/acr2.11324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/21/2021] [Indexed: 12/04/2022] Open
Abstract
Objective Although most total knee replacement (TKR) recipients report less pain and improved function after TKR, many remain sedentary. We aimed to understand TKR recipients’ motivations for undergoing TKR, perceptions of and goals related to physical activity, and the role, if any, that activity monitors might play in their recovery. Methods We conducted a qualitative study, individually interviewing 27 participants who had recently undergone or were about to undergo TKR. We conducted a thematic analysis to better understand participants’ views of the benefits and barriers to physical activity after TKR. Results We identified nine themes and one subtheme that identify patients’ initial motivations for undergoing TKR and may help TKR recipients achieve increased activity levels and a perceived successful recovery. Some key messages that emerged from our work include the following: exercise is necessary for physical and mental health, pain and functional limitation interfere with daily life, tracking steps motivates individuals to increase activity levels, and different incentives (for engaging in physical exercise and using an activity monitor) are effective for different individuals. Conclusion Participants recognized the health benefits of physical activity, and many believed activity monitor use would help them become more active after surgery. Both external and internal factors played a role in motivating individuals to become more active and wear activity monitors.
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Affiliation(s)
| | | | | | - Elena Losina
- Brigham and Women's Hospital, Harvard Medical School and Boston University School of Public Health, Boston, Massachusetts
| | - Jeffrey N Katz
- Brigham and Women's Hospital, Harvard Medical School and Harvard Chan School of Public Health, Boston, Massachusetts
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Östlind E, Sant'Anna A, Eek F, Stigmar K, Ekvall Hansson E. Physical activity patterns, adherence to using a wearable activity tracker during a 12-week period and correlation between self-reported function and physical activity in working age individuals with hip and/or knee osteoarthritis. BMC Musculoskelet Disord 2021; 22:450. [PMID: 33992121 PMCID: PMC8126142 DOI: 10.1186/s12891-021-04338-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 05/06/2021] [Indexed: 04/16/2023] Open
Abstract
Background A majority of individuals with osteoarthritis (OA) are insufficiently physically active. Self-monitoring with wearable activity trackers (WAT) could promote physical activity (PA), and increased knowledge of PA patterns and adherence to using a WAT is needed. The aim of this study was to describe PA patterns and adherence to WAT-use during an intervention among participants of working age with hip and/or knee OA. The study further explores the correlation between self-reported joint function and PA. Methods Individuals of working age with hip and/or knee OA who used a WAT, Fitbit Flex 2, for 12 weeks were included. Participants monitored their PA in the Fitbit-app. An activity goal of 7,000 steps/day was set. Steps and minutes in light (L), moderate and vigorous (MV) PA were collected from the Fitbit. Self-reported joint function (HOOS/KOOS) was completed. Data was analyzed with linear mixed models and Spearman’s rank correlation. Results Seventy-five participants (45–66 years) walked on average 10 593 (SD 3431) steps/day, spent 248.5 (SD 42.2) minutes in LPA/day, 48.1 (SD 35.5) minutes in MVPA/day, 336.0 (SD 249.9) minutes in MVPA/week and used the Fitbit for an average of 88.4 % (SD 11.6) of the 12-week period. 86.7 % took > 7,000 steps/day and 77.3 % spent > 150 min in MVPA/week. Mean daily steps/week decreased significantly over the 12 weeks (β-coefficient − 117, 95 % CI -166 to -68, p = < 0.001) as well as mean daily minutes in LPA/week (β-coefficient − 2.3, 95 % CI -3.3 to -1.4, p = < 0.001), mean daily minutes in MVPA/week (β-coefficient − 0.58, 95 % CI -1.01 to -0.16, p = 0.008) and mean adherence to Fitbit-use per week (β-coefficient − 1.3, 95 % CI -1.8 to -0.8, p = < 0.001). There were no significant correlations between function (HOOS/KOOS) and PA. Conclusions The majority of participants reached 7,000 steps/day and the recommended 150 min in MVPA per week. However, PA decreased slightly but gradually over time. Adherence to using the Fitbit was high but also decreased during the intervention. Understanding PA patterns and the use of a Fitbit to promote PA could be beneficial in tailoring interventions for individuals with hip and/or knee OA.
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Affiliation(s)
- Elin Östlind
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden. .,Dalby healthcare center, Region Skåne, Lund, Sweden.
| | | | - Frida Eek
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden
| | - Kjerstin Stigmar
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
| | - Eva Ekvall Hansson
- Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
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Shah N, Kramer J, Borrelli B, Kumar D. Interrelations between factors related to physical activity in inactive adults with knee pain. Disabil Rehabil 2021; 44:3890-3896. [PMID: 33689528 DOI: 10.1080/09638288.2021.1891303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose was to explore interrelations between factors related to engagement in physical activity in inactive adults with knee pain. METHOD Inactive adults with knee pain (n = 35) participated in six focus groups designed to inquire about barriers and facilitators related with engagement in physical activity. Directed content analysis and inductive thematic analysis were used to identify factors related to physical activity and associated interrelations respectively. As an exploratory analysis, sex differences in barriers and facilitators to physical activity were assessed. RESULTS In this cohort (age = 60.9 ± 8.6 years; 22 females), self-reported physical activity was 26.3 ± 46.8 min/week. Factors related to physical activity were grouped into domains of physical status, psychological status, environment, knowledge, and resources. It was seen that the interrelations between a person and their environment, as well as, between impairments and everyday responsibilities influenced engagement in physical activity. Females were more likely to identify physical and psychological status, social expectations, and lack of knowledge as barriers. Males indicated a preference for using mobile technologies to overcome barriers. CONCLUSION Interplay of various barriers and facilitators is related to engagement in physical activity in inactive older adults with knee pain. Interventions to promote physical activity should address these interrelations and sex differences.Implications for rehabilitationInterrelations between individual factors related to engagement in physical activity and sex differences in these factors are present in inactive adults with knee pain.Interventions to improve physical activity should be implemented by addressing factors and interrelations between factors related to physical activity in inactive adults with knee pain.Interventions to address low levels of physical activity in adults with knee pain should take into account sex differences.
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Affiliation(s)
- Nirali Shah
- Department of Physical Therapy and Athletic Training, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
| | - Jessica Kramer
- Department of Occupational Therapy, College of Public Health and Health Professions, Occupational Therapy, University of Florida, Gainesville, FL, USA.,Department of Occupational Therapy, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA
| | - Belinda Borrelli
- Center for Behavioral Science Research, Department of Health Policy and Health Services Research, Henry M. Goldman School of Dental Medicine, Boston University, Boston, MA, USA
| | - Deepak Kumar
- Department of Physical Therapy and Athletic Training, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, MA, USA.,Department of Physical Therapy and Athletic Training, Sargent College, Boston University, Boston, MA, USA
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