Background: A physically inactive lifestyle is associated with an increased risk for a variety of chronic diseases and health conditions. One population at greatest risk of physical inactivity is older adults. Studies: The specific aims for my dissertation research focused on further development of the Actigraph accelerometer to measure physical activity in community dwelling older adults. I proposed to first further define what an activity count from the Actigraph accelerometer represents. By comparing Actigraph counts to raw accelerometry, oxygen consumption and pedometer step count data at usual and slow walking speeds we found that counts per second were correlated with raw accelerometry and energy cost. Actigraph counts, raw acceleration, pedometer step counts and oxygen consumption were higher for usual versus slow walking conditions as expected. We were able to formulate a regression equation to estimate energy cost from Actigraph counts in community dwelling older adults. For the next project, I investigated the reliability and validity of the various ways to present data from the Actigraph accelerometer. All Actigraph measurement units of interest were highly correlated with each other as well as with performance based measures of mobility, function, age and self reported physical activity. Actigraph counts per minute and standard deviations of counts were able to distinguish between low and high mobility and functioning groups. Using ROC curves, we established a cut off value of 150 counts per minute to detect mobility and function problems. Finally, I determined meaningful change values of physical activity measured by the Actigraph over a 12 week exercise intervention in community dwelling older adults with walking difficulty. We found a value of 30 counts per minute to indicate substantial change beyond spurious error. Actigraph counts per minute did not change over the course of exercise intervention. However, people who were more active at baseline exhibited improvements in mobility and functional measures compared to those who were less active at baseline. Conclusion: From the projects described above, Actigraph counts have been validated in older adults against raw accelerometry, oxygen consumption, mobility, function, and self-reported physical activity measures. Inter-rater reliability was excellent for the multiple outputs of the Actigraph accelerometer. Actigraph counts per minute data output is our recommendation since it is the default output, has the least amount of processing, produces high inter-rater reliability and validity against mobility and function.

This research develops and implements a practical model of real-time redesign and problem solving for front line healthcare professionals using systems thinking methodologies. Healthcare quality, safety and service issues have been well-documented and lamented, calling into question the current approaches for addressing these issues. The work environment for healthcare professionals has become overburdened with time pressure, workarounds, waste, and failure to learn from the small events which occur on a frequent basis at the front-line. Desensitization may occur until sentinel events stimulate an organizational reaction. Other industries have developed system engineering methodologies, including the Toyota production system, theory of constraints, six sigma and others, to address manufacturing quality, service and safety issues. Many of these concepts were developed within the context of a linear manufacturing environment, with solutions often derived off-line by external experts. Healthcare reality is considered more complex and requires adaptive approaches, suggesting that modifications based on complex adaptive systems theory may be necessary. The development of the model evolved based on key systems thinking principles adapted to meet the needs of the healthcare experience and introduced to front-line healthcare workers using on-line problem solving. This research includes real-time understanding of what is working or not working in the current condition as it occurs, the ideas of the staff to improve the patient experience, including asset-based problem-solving and introduction of system thinking and design principles using ideas from various systems engineering methodologies in a healthcare worker friendly way. The research focuses on the deep systems of the organization (or clinical microsystem) and ability of front line teams to redesign processes in real-time using rapid cycle mini-experiments and the results of the redesign. Using case study and action research design, the research analyzes the experiences of an intact work group of a clinical microsystem to test the implementation of a model, labeled an Excellence Makeover. The researcher acts as a participant-observer of the emergent experience and solutions from the staff. The model will then be analyzed and additional refinements will be suggested for additional research.

ABSTRACT: Purpose and Study Design: Prospective cohort study to explore the clinical treatment effect of mechanical vs. manual manipulation for acute low back pain. Methods: 92 patients with a history of acute low back pain were recruited from three private chiropractic offices. Two of these offices utilized manual lumbar manipulation and one used mechanical instrument manipulation (Activator) as their primary modes of treatment. The chiropractors used a treatment as usual protocol with the participants for a maximum of eight visits or four weeks, which ever occurred first. Primary and secondary outcome measures were the differences in pain and Oswestry scores from baseline to four weeks, respectively. Results: Socio-demographic characteristics of the two cohorts at baseline were not found to show any significant differences between the groups except for age. The Activator cohort had a significantly higher utilization of adjunctive modalities and x-rays, with a mean number of office visits about twice that of the manual manipulation cohort at four weeks. The pain scores decreased in both groups with the manual manipulation group showing a slightly greater amount of pain reduction at four weeks, but this difference did not reach statistical significance after controlling for baseline pain. The manual manipulation group also showed a slightly greater reduction in Oswestry scores from baseline to four-weeks, but this difference was not statistically significant after adjusting for baseline Oswestry score. Conclusions: In this observational study of treatment-as-usual there was no significantly greater reduction in pain scores or Oswestry scores between the manipulation and Activator groups at four weeks. There were many differences between the Activator and manual manipulation groups with respect to treatment beliefs and expectations, modality usage, and frequency/duration of care, which are potential sources of confounding in the interpretation of these results. This study provides important pilot data and research issues for the design of a future randomized clinical trial that can control for these issues of confounding variables.

The role that wheelchairs and wheelchair mounted headrests play in rear impact occupant protection for children who remain seated in wheelchairs while traveling in motor vehicles was investigated using sled testing and computer simulation. Study goals were to establish pediatric wheelchair and headrest design guidelines and to determine the effect of headrests on relative injury risk outcome measures under rear impact conditions. Two series of sled tests (16 mph, 11g) were conducted using a Hybrid III 6-year old anthropomorphic test device (ATD) seated in identically configured manual pediatric wheelchairs, with and without headrests. Wheelchairs remained intact and the ATD remained upright. Rear impact front wheelchair securement points were subjected to loads similar to previously described (Ha, DongRan, 2004) rear securement points in frontal impact, although Ha used the more severe 30mph, 20g frontal impact WC19 Wheelchairs Used as Seats in Motor Vehicles (ANSI/RESNA, 2000) crash pulse. Sled test ATD data analysis indicated that wheelchair headrest use had a potentially protective effect based on pediatric head and neck injury risk outcomes. Sled test data established response corridors for MADYMO computer simulation model development, and defined statistical test target thresholds for model validation. Two simulation models were developed, with and without a headrest. The models validated well for tiedown loads, wheelchair acceleration, lap belt loads and chest acceleration. Outcomes related to head and neck response were not as strongly validated. Model ATD neck response characterization methods were developed. Finally, parametric sensitivity analyses were used to develop wheelchair and headrest design guidelines for pediatric manual wheelchairs in rear impact for front securement point loads, rear wheel loads and seatback loads. Pediatric injury outcome measure sensitivity to wheelchair, headrest and crash pulse parameters was evaluated. Neck injury criteria (Nij) was sensitive to headrest placement; resulting recommendations specify placing the headrest as close as possible to the back of the head, and top of the headrest pad should be at least 5 cm above the head center of gravity. Effects of stiffer 6-year old ATD neck response on injury risk outcome measures were evaluated and found to reduce likelihood of severe neck injury.

Myocardial infarction (MI) is a widespread occurrence, with approximately 610,000 new and 325,000 recurrent MIs experienced every year in the United States. While 84% of these victims will survive the attack, many will suffer poor outcomes as a result. These outcomes include increased risk for another MI, sudden death, heart failure, and stroke; chest pain; depression; and poor quality of life. The American Heart Association recommends that all MI patients participate in a cardiac rehabilitation program (CRP) to help reduce mortality and morbidity, control risk factors, and improve quality of life. CRPs are interventions that start soon after an MI and consist of a variety of components, including exercise programs, education, counseling, and stress management. Health-related quality of life (HRQoL) is a measure of how persons believe their general health status and any illnesses affect their physical, social, and mental functioning. HRQoL is an important patient outcome and should be considered when evaluating the effectiveness of any rehabilitation intervention. MI survivors have been shown to have a decreased HRQoL immediately after the MI and for up to 4 years thereafter. It is clear that any CRP should be designed to help return patients HRQoL to its pre-MI level. While many studies have looked at how CRPs influence HRQoL after an MI, a systematic review has not been found that specifically considers this outcome. The purpose of this study was to conduct a comprehensive review of how CRPs affect HRQoL following an MI, and which CRP designs are effective at improving HRQoL. A comprehensive literature search yielded 13 articles that studied HRQoL differences before and after a CRP following an MI. These studies were analyzed by CRP length; time between MI and CRP start; CRP components, type, and intensity; and effect on HRQoL. Findings indicated that CRPs do seem to positively influence HRQoL following an MI, regardless of design and components, possibly excluding inpatient CRPs and those that use only a few counseling sessions. Limitations included many non-controlled studies, heterogeneity of designs, and a bias towards younger, male participants.

The purpose of this project was to determine the effectiveness of a telerehabilitation (TR) consultation model to prescribe and procure an appropriate wheeled mobility and seating (WMS) device at a remotely located site. The availability of practitioners with specific expertise in this area was limited particularly in Westerns Pennsylvania. A telerehabilitation service delivery model was developed for a series of studies based on a current model implemented at the Center for Assistive Technology at the University of Pittsburgh Medical Center (CAT-UPMC). In a multi-center non-randomized clinical trial, 96 participants were evaluated: 50 In-Person (IP) at the CAT-UPMC and 46 TR participants at remote sites. The performance-based Functioning Everyday with a Wheelchair-Capacity (FEW-C) tool demonstrated excellent inter-rater reliability coefficients (ICC 2,k = 0.91) and good internal consistency measured by Cronbachs alphas with correlations ranging between 0.82 to 0.91 among the 46 TR participants. Results indicated that using a TR consultation model, a significant improvement in mean differences was observed for the each of the self-report Functioning Everyday with a Wheelchair (FEW) items and for the average FEW scores at the remotely sites. Effect size calculations indicated that nine of the ten items on the FEW as well as the total FEW had very large effect sizes using Cohens d, indicating the effectiveness of not only the new WMS device but the TR assessment as well. A significant relationship was found between the self-report FEW and performance-based FEW-C tools at baseline measured by Spearman rhos correlations. A significant difference was found for participants previous WMS device evaluation and prescription process compared to their current TR WMS device evaluation and prescription scores as well as patient satisfaction regarding the impact of the technology. The findings based on confidence intervals of post FEW scores indicated that TR was non-inferior to the standard IP care at CAT-UPMC. Telerehabilitation services resulted in decreased travel for participants, improved access to specialized services, education benefits for generalist practitioners, and service stabilization at the remote sites. A TR consultation model offers new alternative and effective opportunities to provide rehabilitation services in clinical settings, especially in rural or underserved locations.

Purpose: Low back pain (LBP) is a common condition in adolescents, and a specific pathoanatomical origin for the symptoms cannot always be determined. The purpose of this work was to examine the clinical presentation and outcomes of rehabilitation for adolescents with LBP. Methods: This study was completed in three phases. Phase 1 was a retrospective review of 25 patients under the age of 18 who were seen for treatment of LBP. Information regarding the patients diagnoses, history, examination, and outcome were collected from chart review. Phase 2 was a review of 99 patients under the age of 18 with LBP. Numerical Pain Rating Scale (NPRS) and the Modified Oswestry Questionnaire (OSW) were recorded. Phase 3 consisted of a prospective study of treatment-based classification (TBC) of 34 adolescent patients seen in physical therapy for LBP. Treatment duration and content were at the clinicians discretion. Patients completed an OSW and NPRS before and after physical therapy. Patients were classified using a TBC algorithm, and effectiveness of classification on outcome was examined. Results: In study 1, initial pain scores were lower if a specific pathology was present (P=.001). Initial pain and OSW scores were poorly correlated (r= 0.16). 44% (n=11) of patients scored under the floor value of 12% on OSW. A second examination of the OSW in study 2 concluded that OSW was moderately correlated with NPRS (0.59). Chronbachs alpha was 0.86. All 10 items in OSW appeared to load onto two latent factors. In study 3, a classification decision was able to be made with a moderate degree of reliability (0.53 (0.28, 0.79) ≤ κ ≤ 0.89 (.74, 1.0)) in all of the 34 patients. Stabilization was the most commonly prescribed treatment by clinicians. Those who were matched to their TBC classification experienced fewer numbers of visits than those who were not. Conclusions: It appears the OSW is a valid and reliable tool for assessing clinical outcome of physical therapy intervention for adolescents with LBP. These results also suggest that a TBC approach to treatment of LBP in this population may be effective for improvements in clinical outcome.

Older adults are the largest and fastest growing users of wheeled mobility devices (wheelchairs). Research in the areas of: utilization; and outcomes is very limited. Lack of evidence based research often results in the provision of lower quality of wheelchairs to aging adults. This problem is more predominant for those living in Nursing Homes (NH) or other institutional settings. The goal of this dissertation work was to present a continuum of research studies, conducted with older adults that emphasized on: the development of a methodology (utilization review); measurement of outcomes; and identification of problems associated with use of wheelchairs that may pose a threat to the health, and safety of older adults. We anticipate that the overall outcomes of this work will help rehabilitation professionals to move towards performing utilization reviews through appropriate use of clinical environment. Such research will help in both the development of standard of care guidelines, and proving effectiveness and efficiency of service provision. We also expect to see this work influencing the outcomes research for older adults using wheelchairs. This will help in needs assessment of potential users (of wheelchairs) and will also help to evaluate: quality of services (devices) provided, and impact of types of wheelchairs on mobility and safety of users. Finally, we anticipate to see application use of the Wheelchair Assessment Checklist (WAC) by clinicians in detection of problems associated with wheelchairs and prevention of component failures, which in turn, will control (to some extent) the occurrence of unintentional (acute and chronic) injuries.

Purpose and Study Design: Retrospective cohort cost-minimization analysis (payer perspective) with decision analysis model to access cost-effectiveness of a treatment-based algorithm (TBC) for low back pain (LBP) compared to a usual care strategy in the outpatient setting. Methods: charge data was examined on 750 subjects with LBP from 42 regional clinics over 1 year period. Subjects were determined to be on or off protocol for the classification algorithms based on provider responses to minimum required initial exam and history intake data and subsequent interventions provided. Primary outcome measures were total net direct health care and physical therapy costs, along with total member and physical therapy member burden costs. In addition, protocol status was examined as a predictor variable for the following: top quartile of total direct health care and physical therapy expenditures, as well as total direct health care and physical therapy member burden. A 4% / yearly discounting rate was applied. Results: Baseline characteristics of the combined sample demonstrated a significant proportion of Medical Assistance patients were given non-adherent care. In addition, a significant but not clinical difference was found in fear-avoidance behavioral questionnaire physical activity (FABQ_PA) scores. Incremental cost-savings were demonstrated in all primary outcome measures for the combined sample. The specific exercise and flexion off-protocol subgroups demonstrated member burden savings but this was explained exclusively after adjustment by having Medical Assistance as an insurance type. Off-protocol status accounted for significant variation in explaining differences in the statistically different outcomes, as well as demonstrating predictive ability for attaining the top quartile of total direct health care expenditures. The decision analysis model demonstrated the dominance of classification approach to usual care across a variety of associated variable ranges and distributions. Conclusions: This evidence supports the TBC as a cost-effective alternative for LBP treatment compared to usual physical therapy care. It appears beneficial for a payer to adopt strategies to improve compliance with the TBC. Further recommendations are suggested to either validate or cross-validate these findings and to improve outcomes reporting. The TBC should also be compared as a cost-effective alternative to treating LBP against primary-care (non-rehabilitative) and chiropractic.

Army soldiers engage in various types of vigorous physical fitness training daily and unintentional musculoskeletal injuries are quite common. Based on previous research, training principles, and theories, a training program was developed to target components of physical fitness and improve neuromuscular and biomechanical factors that are important to knee joint stability. The purpose of this study was to evaluate the effects of an 8-week nonlinear periodized training program on physical fitness and contributors of functional knee joint stability in 101st Division Army soldiers. Due to the timing of the study, the duration of this training overlapped with the soldiers deployment preparation schedule. As a result, of 52 soldiers who were initially enrolled (28 in the experimental group and 24 in the control group), only 26 soldiers completed the study (23 in the experimental group and 13 in the control group). Knee and hip strength, knee joint rate of force development, knee proprioception, and knee and hip neuromuscular and biomechanical characteristics during a stop-jump and a drop-jump task were measured before and after the intervention. There were no statistically significant findings for any dependent variables. High attrition rate and the lack of training exposure were the confounding factors for this study. Future studies must consider soldiers training/deployment schedules to avoid those confounding factors and should monitor the daily training exposure and types of training for the control group.