Gregory E. Hicks

Interrater reliability of clinical examination measures for identification of lumbar segmental instability.

OBJECTIVE To determine the interrater reliability of common clinical examination procedures proposed to identify patients with lumbar segmental instability. DESIGN Single group repeated-measures interrater reliability study. SETTING Outpatient physical therapy (PT) clinic and university PT department. PARTICIPANTS A consecutive sample of 63 subjects (38 women, 25 men; 81% with previous episodes of low back pain [LBP]) with current LBP was examined by 3 pairs of raters. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Repeat measurements of clinical signs and tests proposed to identify lumbar segmental instability. RESULTS Kappa values for the trunk range of motion (ROM) findings varied (range,.00-.69). The prone instability test (kappa=.87) showed greater reliability than the posterior shear test (kappa=.22). The Beighton Ligamentous Laxity Scale (LLS) for generalized ligamentous laxity showed high reliability (intraclass correlation coefficient=.79). Judgments of pain provocation (kappa range,.25-.55) were generally more reliable than judgments of segmental mobility (kappa range, -.02 to.26) during passive intervertebral motion testing. CONCLUSIONS The results agree with previous studies suggesting that segmental mobility testing is not reliable. The prone instability test, generalized LLS, and aberrant motion with trunk ROM demonstrated higher levels of reliability.

Association of Low Vitamin D Levels With the Frailty Syndrome in Men and Women

BACKGROUND Although both vitamin D (25-hydroxyvitamin D [25(OH)D]) insufficiency and the frailty syndrome are more prevalent in women than men, sex-specific associations have not been explored. We estimated sex-specific associations of low 25(OH)D with frailty. Vitamin D insufficiency can result in hyperparathyroidism, and thus, parathyroid hormone (PTH) was explored as a potential mediator in the relationship between 25(OH)D levels and frailty. METHODS The sample included 444 male and 561 female participants aged 65 years and older from the InCHIANTI study for whom 25(OH)D levels and frailty information were available. Frailty was defined as the presence of at least three of the five following criteria: slowness, weakness, low energy expenditure, exhaustion, and weight loss. Logistic regression models estimated the association between serum levels of 25(OH)D and PTH with frailty, controlling for potential confounders. RESULTS Independent of covariates, men with 25(OH)D <50 nmol/L had greater odds of frailty than those with 25(OH)D > or =50 nmol/L (odds ratio [OR] = 4.94, 95% confidence interval [CI] = 1.80-13.61). In women, the adjusted OR for frailty (95% CI) was 1.43 (0.58-3.56). The 25(OH)D ORs differed between men and women (p = .041). ORs changed little after controlling for PTH. However, when low energy expenditure was excluded from the frailty definition, adjusted OR for frailty in men (95% CI) was 2.18 (0.59-8.04); controlling for PTH attenuated this OR by 32%. In women, the OR (95% CI) for frailty (low energy expenditure excluded) was 1.54 (0.31-7.58) and was attenuated by 6% after controlling for PTH. CONCLUSIONS Vitamin D insufficiency was associated with frailty in men, but not in women. Results suggest that PTH mediates the relationship between 25(OH)D and nonenergy expenditure aspects of frailty.

Degenerative Lumbar Disc and Facet Disease in Older Adults: Prevalence and Clinical Correlates

Study Design. A case-control study of older adults with and without chronic low back pain (CLBP). Objective. Compare and describe the radiographic severity of degenerative disc and facet disease in the lumbosacral spine of community-dwelling older adults with and without CLBP and to examine the relationship between spinal pathology and pain. Summary of Background Data. Degenerative spinal pathology is often implicated as the primary reason for CLBP in older adults. Despite evidence that spinal pathology may be ubiquitous in older adults regardless of pain status, radiography continues to be heavily used in the diagnostic process. Methods. Participants in this case-control study included 162 older adults (≥65) with CLBP and an age and gender matched pain-free group of 158 people. CLBP was characterized as pain of at least moderate intensity occurring daily or almost everyday for at least 3 months. Radiographic severity of disc and facet disease was graded using a reliable and valid system. Results. Results demonstrated that the presence of degenerative disc and facet pathology in older adults is ubiquitous, regardless of clinical status, with greater than 90% demonstrating some level of degeneration. Higher radiographic severity scores were associated with the presence of CLBP. In fact, presence of severe disc pathology was associated with 2-fold greater odds of having CLBP. But, radiographic severity of disc and facet disease was not associated with pain severity among those with CLBP. Conclusion. From a research perspective, radiographic evaluation of spinal pathology provides additional information about older adults with CLBP compared to pain-free individuals, but its clinical utility for diagnostic purposes is still in question.

Absolute Strength and Loss of Strength as Predictors of Mobility Decline in Older Adults: The InCHIANTI Study

BACKGROUND Theoretical definitions of sarcopenia traditionally emphasize age-related loss of muscle strength; however, most analyses of the association between strength and mobility examine strength at a single time point. This study sought to identify sex-specific cutpoints for muscle strength and power (at one time point) and 3-year changes in strength and power that would maximize prediction of 3-year mobility decline. METHODS Longitudinal analysis of 934 adults aged ≥65 years enrolled in the Invecchiare in Chianti study was conducted. Grip strength, knee extension strength, and lower extremity power were measured at baseline and 3 years postenrollment. Mobility function (gait speed and self-reported mobility disability) was measured at 3 and 6 years postenrollment. Classification and regression tree analysis was used to predict mobility decline from Years 3 to 6. RESULTS Men with knee extension strength <19.2 kg and grip strength <39.0 kg had clinically meaningful declines in gait speed of .24 m/s. Furthermore, men with power <105 W were nearly nine times more likely to develop incident mobility disability (likelihood ratio = 8.68; 95% confidence interval = 3.91, 19.44). Among women, knee extension strength <18.0 kg was associated with a minimal gait speed decline of 0.06 m/s, and women with leg power <64 W were three times more likely to develop incident mobility disability (likelihood ratio = 3.01; 95% confidence interval = 1.79, 5.08). Three-year changes in strength and power did not predict mobility decline in either sex. CONCLUSIONS Findings suggest that strength and power measured at one time point are more predictive of mobility decline than 3-year changes and that low strength and power are particularly powerful risk factors in men.

Epidemiology of back pain in a representative cohort of italian persons 65 years of age and older : The InCHIANTI study

Study Design. Clinico-epidemiologic study in the Chianti area (Tuscany, Italy). Objectives. To describe prevalence and correlates of back pain in a representative sample of the population. Summary of Background Data. Back pain is common in old age and is related to functional limitations, but back pain characteristics and correlates in older adults, which may be targeted by specific interventions, are still underinvestigated. Methods. A total of 1,299 persons aged 65 or older were selected from the city registry of Greve in Chianti and Bagno a Ripoli; 1,008 (565 women; 443 men) were included in this analysis. Back pain in the past 12 months was ascertained using a questionnaire. Potential correlates of back pain were identified in age- and sex-adjusted regression analyses, and their independent association with back pain was tested in a multivariate model. Results. The prevalence of frequent back pain was 31.5%. Back pain was reported less often by men and the very old, was primarily located in the dorsolumbar and lumbar spine, was moderate in intensity and mainly elicited by carrying, lifting, and pushing heavy objects. Among participants who reported frequent back pain, 76.3% had no back pain-related impairments; 7.4% of the overall study population had back pain-related functional limitation. Back pain participants were significantly more likely to report difficulty in heavy household chores, carrying a shopping bag, cutting toenails, and using public transportation. Limited trunk extension, depression, low levels of prior-year physical activity, and hip, knee, and foot pain were independent correlates of back pain. Conclusions. Frequent back pain is highly prevalent in the older population and is often associated with conditions that are potentially reversible.

Associations of back and leg pain with health status and functional capacity of older adults: Findings from the retirement community back pain study

OBJECTIVE Low back pain (LBP) is the most frequently reported musculoskeletal problem in older adults, but its impact on health status is not well understood. Our objective was to determine whether LBP and concurrent leg pain are associated with health-related quality of life (HRQOL) and function in a cohort of older adults, and to examine care-seeking behaviors related to LBP. METHODS This was a population-based, cross-sectional survey study of 522 community-dwelling men and women (67.4%) ages >or=62 living in 4 retirement communities in Maryland and northern Virginia. LBP status in the past year was categorized as no pain in the low back or leg, LBP only, and LBP with leg pain. HRQOL and function were measured with the Medical Outcomes Study Short Form 36 (SF-36). RESULTS A total of 26.8% of the sample reported LBP only and 21.3% reported LBP plus leg pain. Participants with LBP and LBP plus leg pain had lower scores in all SF-36 domains, reflecting worse HRQOL (P < 0.0001). LBP and LBP plus leg pain were associated with 2-fold greater odds of falling and increased difficulty lifting grocery bags, walking several blocks, and bathing. LBP plus leg pain was associated with difficulty in social interactions (odds ratio 10.63, 95% confidence interval 3.57-31.60). Less than half sought care for LBP and those who did had poorer health status and greater pain burden. CONCLUSION LBP is common among older adults and strongly associated with reduced HRQOL and function. These findings argue strongly for both identifying cases of LBP by health care practitioners and pursuing effective treatments for LBP given the potential consequences.

Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation

Background No gold standard exists for identifying successful outcomes 1 and 2 years after operative and non-operative management of anterior cruciate ligament (ACL) injury. This limits the ability of a researcher and clinicians to compare and contrast the results of interventions. Purpose To establish a consensus based on expert consensus of measures that define successful outcomes 1 and 2 years after ACL injury or reconstruction. Methods Members of international sports medicine associations, including the American Orthopaedic Society for Sports Medicine, the European Society for Sports Traumatology, Surgery, and Knee Arthroscopy and the American Physical Therapy Association, were sent a survey via email. Blinded responses were analysed for trends with frequency counts. A summed importance percentage (SIP) was calculated and 80% SIP operationally indicated consensus. Results 1779 responses were obtained. Consensus was achieved for six measures in operative and non-operative management: the absence of giving way, patient return to sports, quadriceps and hamstrings’ strength greater than 90% of the uninvolved limb, the patient having not more than a mild knee joint effusion and using patient-reported outcomes (PRO). No single PRO achieved consensus, but threshold scores between 85 and 90 were established for PROs concerning patient performance. Conclusions The consensus identified six measures important for successful outcome after ACL injury or reconstruction. These represent all levels of the International Classification of Functioning: effusion, giving way, muscle strength (body structure and function), PRO (activity and participation) and return to sport (participation), and should be included to allow for comparison between interventions.

Low-serum carotenoid concentrations and carotenoid interactions predict mortality in US adults: the Third National Health and Nutrition Examination Survey

Evidence regarding the health benefits of carotenoids is controversial. Effects of serum carotenoids and their interactions on mortality have not been examined in a representative sample of US adults. The objective was to examine whether serum carotenoid concentrations predict mortality among US adults. The study consisted of adults aged ≥20 years enrolled in the Third National Health and Nutrition Examination Survey, 1988 to 1994, with measured serum carotenoids and mortality follow-up through 2006 (N = 13,293). Outcomes were all-cause, cardiovascular disease, and cancer mortality. In adjusted Cox proportional hazards models, participants in the lowest total carotenoid quartile (<1.01 μmol/L) had significantly higher all-cause mortality (mortality rate ratio, 1.38; 95% confidence interval, 1.15-1.65; P = .005) than those in the highest total carotenoid quartile (>1.75 μmol/L). For α-carotene, the highest quartile (>0.11 μmol/L) had the lowest all-cause mortality rates (P < .001). For lycopene, the middle 2 quartiles (0.29-0.58 μmol/L) had the lowest all-cause mortality rates (P = .047). Analyses with continuous carotenoids confirmed associations of serum total carotenoids, α-carotene, and lycopene with all-cause mortality (P < .001). In a random survival forest analysis, very low lycopene was the carotenoid most strongly predictive of all-cause mortality, followed by very low total carotenoids. α-Carotene/β-cryptoxanthin, α-carotene/lutein+zeaxanthin and lycopene/lutein+zeaxanthin interactions were significantly related to all-cause mortality (P < .05). Low α-carotene was the only carotenoid associated with cardiovascular disease mortality (P = .002). No carotenoids were significantly associated with cancer mortality. Very low serum total carotenoid, α-carotene, and lycopene concentrations may be risk factors for mortality, but carotenoids show interaction effects on mortality. Interventions of balanced carotenoid combinations are needed for confirmation.

Associations Between Vitamin D Status and Pain in Older Adults: The Invecchiare in Chianti Study

OBJECTIVES: To examine cross‐sectional associations between vitamin D status and musculoskeletal pain and whether they differ by sex.

Minimal detectable change for gait variables collected during treadmill walking in individuals post-stroke

Post-stroke gait impairments are common and result in slowed walking speeds and decreased community participation post-stroke. Treadmill training has recently emerged as an effective gait rehabilitation intervention. Furthermore, kinematic and kinetic data collected during treadmill walking are commonly used for assessing gait performance. The minimal detectable change (MDC) for gait variables provides a useful index to determine whether the magnitude of change in gait produced after an intervention is greater than the amount of change attributable to day-to-day variability in gait or test-retest measurement errors. The MDC values for kinematic, ground reaction force (GRF), spatial, and temporal variables collected during treadmill walking post-stroke have not been previously reported. The objective of this study was, therefore, to compute MDCs for post-stroke gait kinematics, GRF indices, temporal, and spatial measures during treadmill walking. Nineteen individuals with chronic post-stroke hemiparesis (12 males; age=47-75 years; 72.6±63.4 months since stroke) participated in 2 testing sessions separated by 20.7±26.8 days. Our results showed that test-retest reliability was excellent for all gait variables tested (intraclass correlation coefficients=0.799-0.986). MDCs were reported for hip, knee, and ankle joint angles (range 3.8° for trailing limb angles to 11.5° for hip extension), peak anterior GRF (2.85% body weight), mean vertical GRF (4.65% body weight), all temporal variables (range 3.2-4.2% gait cycle), and paretic step length (6.7 cm). These MDCs provide a useful reference to help interpret the magnitudes of changes in post-stroke gait variables.