The Oxford Knee Score (OKS) is a popular single summary questionnaire developed to measure the effect of knee replacement surgery from the patients' perspective. There has been a recent interest in the use of the OKS in populations of patients and in roles it has not been originally developed for. To date, no evidence has been provided about the measurement properties of the OKS when it is used outside the context or purpose for which it was originally designed. The general aim of this thesis is to investigate the measurement properties of the OKS when used in extended roles: a) within the population for which the OKS was originally intended and developed for (knee replacement) and, b) when applied on a different population, viz. patients undergoing non-operative treatment for knee osteoarthritis (OA). Four existing large-scale databases of patients undergoing knee replacement surgery and a database obtained from a prospective study on patients undergoing non-surgical management for knee OA were analyzed. The results demonstrate that: 1) it is possible to extract separate information on pain and functional disability from the OKS in a meaningful way (in the form of subscales). 2) For the first time, anchor-based Minimal Important Change (MIC) of 9 points and Minimal Important Difference (MID) of 5 points were established for joint replacement surgery. 3) The OKS demonstrated satisfactory evidence reliability, validity, responsiveness, and interpretability, when used in patients who are undergoing non-operative management for their knee OA. 4) Further evidence of validity was demonstrated by fitting the OKS to the Rasch model. 5) Lastly, it was demonstrated that thresholds can be applied on the OKS to distinguish between patients who consider their knee problem to be severe enough to warrant joint replacement surgery versus patients who do not. This supports the potential use of the OKS in decision making aids for secondary care referral. Overall the thesis provides critical evidence, not previously existing, to support the continued use, and extended use, of the OKS in orthopaedic medicine.

Thesis Title: Enhancing rehabilitation following anterior cruciate ligament reconstruction. Context: Physical training with a neuromuscular focus has been shown to reduce anterior cruciate ligament (ACL) injury. However, ACL injury remains prevalent and often leads to joint instability, which requires surgical reconstruction. Following reconstructive surgery, a minimum of 6 months supervised rehabilitation is recommended with associated with financial cost implications to the National Health Service (NHS), the patient and society. Traditionally rehabilitation is offered in a concurrent format, whereby strength and cardio-vascular endurance exercises are performed in the same session. However, accumulating evidence from healthy populations, suggests that the development of strength might be attenuated by cardio-vascular endurance conditioning performed in close temporal proximity. This thesis comprises an entirely novel investigation of potential attenuation of strength gains in rehabilitating clinical populations that is associated with temporal incompatibility of physiological conditioning stimuli. No study has previously investigated this phenomenon, whether it might compromise the efficacy of treatment or recovery, or its potential influence on objectively-measured and patients’ perception of functional, musculoskeletal and neuromuscular performance capabilities. Objectives: The purpose of this thesis was to assess the effects of reconstruction surgery and 24 weeks of non-concurrent strength and endurance rehabilitation (with 48 week post-operative follow-up) on (a) subjective (IKDC; KOOS; PP [Chapter 4]) and objective measures of function (HOP [Chapter 5]) (primary outcome measures for this thesis), and (b) objective measures of musculoskeletal (ATFD) and neuromuscular performance (PF, EMD, RFD, SMP [Chapter 5]) (secondary outcome measures), in patients with anterior cruciate ligament deficiency. The secondary aim was to evaluate the relationships amongst a subjective outcome of function (IKDC), an objective outcome of function (HOP), and the secondary objective outcomes of musculoskeletal (ATFD) and neuromuscular (PF, RFD, EMD, SMP) performance at pre-surgery and at 24 weeks post-surgery (Chapter 6). Setting: Orthopaedic Hospital NHS Foundation Trust. Design: Prospective random-allocation to group trial involving iso-volume rehabilitative intervention versus contemporary practice, using contralateral limb assessment and clinico-social approbation controls. The design compared the effects of experimental post-surgical rehabilitation comprising non-concurrent strength and endurance conditioning with two conditions of control reflecting contemporary clinical practice (matched versus minimal assessment interaction). Participants: Eighty two patients (69♂, 13♀, age: 35.4 ± 8.6 yr; time from injury to surgery 9.4 ± 6.9 months [mean ± SD]) electing to undergo unilateral ACL reconstructive surgery (semitendinosus and gracilis graft [n = 57]; central third, bone-patella tendon-bone graft [n = 25]); were allocated to groups (2:2:1 purposive sampling ratio, respectively). Nineteen patients were lost to follow-up. Intervention: A standardised traditional concurrent (CON) ACL rehabilitation programme acted as the control versus an experimental non-concurrent (NCON) ACL rehabilitation programme that involved separation of strength and cardio-vascular endurance conditioning. An additional control group (Limited testing CON) matched the CON group rehabilitation applied within contemporary clinical practice. Outcome Measures: Chapter 4: The self-perceived primary outcome measures of function IKDC, KOOS and PP were assessed on five separate occasions (pre-surgery, and at 6, 12, 24 and 48 weeks post-surgery). However, assessment occasions were purposefully reduced to pre-operative and 48 weeks post-operative for the Limited testing CON group. Chapter 5: The primary objective outcome of function was HOP; the secondary outcomes were ATFD, PF, RFD, EMD and SMP associated with the knee extensors and flexors of the injured and non-injured legs. These objective outcomes were assessed on five separate occasions (pre-surgery, and at 6, 12, 24 and 48 weeks post-surgery). However, assessment occasions were purposefully reduced to pre-operative and at 48 weeks post-operative only for the Limited testing CON group. Chapter 6 Self-perceived (IKDC) subjective knee evaluation and the objective outcome of function (HOP), and selected objective outcomes of musculoskeletal and neuromuscular performance including ATFD, PF, RFD, EMD and SMP of the knee extensors and flexors of the injured and non-injured legs where applicable; measured at pre-surgery and at 24 weeks post-surgery were analysed for association, using Pearson product-moment correlation coefficients. A priori alpha levels were set at p<0.05. Results: Chapter 4: Factorial analyses of variance (ANOVAs) with repeated-measures investigating the primary aim showed significant group (NCON; CON) by test occasion (pre-surgery, 6, 12. 24 and 48 weeks post-surgery) interactions for self-perceived outcomes of function IKDC, KOOS and PP confirmed increased clinical effectiveness of NCON conditioning (F(2.0, 82.9)GG = 4.0 p<0.05, F(2.2, 134.7)GG = 5.5 p<0.001, F(1.9, 121.4)GG = 14.6 p<0.001, respectively) and the group mean peak relative difference in improvement for NCON was ~5.9% - 12.7% superior to CON. The greatest interaction effect was found to occur between pre-surgery and the 12 weeks post-operative test occasion for IKDC and KOOS, and between pre-surgery and the 24 week test occasion for PP. Patterns of improvements in self-perceived fitness over time were represented by a relative effect size range of 0.71 to 1.92. Improvement patterns were not significantly different between control groups offering matched or minimised assessor-patient interaction (CON vs. Limited testing CON; pre-surgery vs. 48 weeks post-surgery) indicating that clinical approbation by patients had not contributed to the outcome. Chapter 5: Factorial analyses of variance (ANOVAs) with repeated-measures showed significant group (NCON; CON) by leg (injured/non-injured) by test occasion (pre-surgery, 6, 12, 24 and 48 weeks post-surgery) interactions of the objective measure of function (HOP) together with the secondary outcomes of ATFD, PF, RFD, EMD and SMP. Similar responses were noted for the knee extensors and flexors of the injured and non-injured legs (F(2.1, 248) GG = 4.5 to 6.6; p<0.01) and confirmed increased clinical effectiveness of NCON conditioning (range ~4.7% - 15.3% [10.8%]) better than CON between 12 and 48 weeks. Patterns of improvements in physical fitness capabilities over time were represented by a relative effect size range of 1.92 to 2.89. Improvement patterns were not significantly different between control groups offering matched or minimised assessor-patient interaction (CON vs. Limited testing CON; pre-surgery versus 48 weeks post-surgery) indicating that clinical approbation by patients had not contributed to the outcome. Chapter 6: Two-tailed probabilities were used due to the exploratory nature of this study. A limited number of weak to moderate statistically significant correlations were confirmed (ranging from r = 0.262 – 0.404; p<0.05; n=48 [amalgamated NCON and CON groups] ) between IKDC and most notably, the neuromuscular performance outcome of EMD. Conclusion: Overall, the patterning and extent of changes amongst self-perceived, functional, musculoskeletal and neuromuscular performance scores offer support for the efficacy of using non-concurrent strength and endurance conditioning to enhance post-surgery rehabilitation. The limited robustness of relationships amongst the validated and frequently-used self-perceived outcome of function [IKDC], and objectively-measured outcomes of function and musculoskeletal and neuromuscular performance suggested that each might properly reflect an important but separate aspect of clinical response and should be deployed to detect change.

Patient adherence to in-clinic rehabilitation is between 30-70% and even lower for home exercise programs (HEPs). Barriers to patient adherence have been identified and include but are not limited to anxiety, depression, lack of positive feedback, lack of social support, lack of time, low levels of physical activity at baseline, pain during exercise, and low self-efficacy. As clinicians prescribing rehabilitation may not be able to influence all of the identified barriers, they may positively influence others. Self-efficacy, or an individual’s belief in his/her ability to successfully complete a task, is a patient barrier that may be addressed by a clinician when aware of low self-efficacy and have tools to improve this barrier. Interventions to overcome this specific barrier have demonstrated an increase in not only self-efficacy but patient adherence as well. Although interventions have proven to be successful, patient adherence has yet to increase according to the literature. At this time, there is no evidence to suggest that clinicians are assessing an individual’s level of self-efficacy prior to prescribing HEPs. In addition, there is no known metric to measure self-efficacy for HEPs in patients rehabilitating musculoskeletal conditions. Assessment of patient barriers, specifically self-efficacy, needs to be a standard of care in order to increase adherence, in turn, improve patient outcomes and to reduce the cost to our healthcare system. The first purpose of this dissertation was to determine in patients with musculoskeletal conditions what scales have been developed and evaluated for assessing self-efficacy in conjunction with adherence. In addition, to determine if a tool exists specifically to assess self-efficacy for HEPs. Due to the task and situation-specific nature of self-efficacy, it is important that this construct is reflected in the assessments utilized by clinicians. The second purpose was to determine the importance and utilization of patients’ self-efficacy to physical therapists when addressing patient barriers. This included determining how physical therapists assess patient self-efficacy and barriers to assessment. The third purpose was to develop the Self-Efficacy for Home Exercise Programs Scale and determine the psychometric properties of the instrument. This also allowed for the examination of how self-efficacy relates to patient adherence in a musculoskeletal patient population. The results of the first study suggest that within the musculoskeletal literature, a number of scales are being used to assess patient self-efficacy. These scales are either task, situation, or condition specific. No scale was found to assess self-efficacy for HEPs. This finding indicates the need to develop a scale to assess self-efficacy for HEPs. In the second study, 71% (n = 329/464) of physical therapists, disclosed assessing self-efficacy prior to prescribing HEPs and rated self-efficacy as very to extremely important when it comes to their patients’ adherence. Verbal discussion is the most common method of self-efficacy assessment (50%), followed by observation of the patient (38%), then patient self-report questionnaires (10%). Commonly, physical therapists report using verbal discussion and observation in combination. Of the 29% of the physical therapists that do not assess self-efficacy, 40% report not knowing how to assess self-efficacy, 19% are not sure what to do with the information once self-efficacy is assessed, 16% claim there are other barriers to assessment, 15% claim that assessing self-efficacy will not change their practice, another 9% claim assessing self-efficacy takes too much time, and the last 1% do not know what self-efficacy is. These results further suggest the need for a scale to assess self-efficacy for HEPs. The purpose of the final study was to developed a Self-Efficacy for Home Exercise Programs Scale. The scale was found to have high internal consistency (α = 0.96), acceptable test-retest reliability (ICC = 0.8, SEM = 5, MDC = 7), and strong convergent validity with the Self-Efficacy for Exercise scale (rho(ρ) = 0.83, p < 0.01). Unique to this scale, a cutoff score was determined to be 59 points with a positive likelihood ratio of 2.0 (95% CI 1.1 – 2.5) indicating those who score below 59 points on the SEHEPS would be 2 times more likely to be non-adherent than adherent to their HEP. A weak to moderate, positive relationship was detected between the patients’ initial level of self-efficacy for their HEP and adherence (rho(ρ) = 0.38, p = 0.03). These results suggest that the Self-Efficacy for Home Exercise Programs Scale may be utilized by rehabilitation clinicians to assess self-efficacy for HEPs. Clinically, this scale may provide clinicians the ability to decipher patients who are not likely to adhere to their prescribed HEP, allowing clinicians to intervene immediately. Early intervention to improve self-efficacy may increase adherence to HEPs and eventually patient outcomes.

Femoral acetabular impingement (FAI) is a bony hip condition that often results in tears to the acetabular labrum. Patients with FAI experience pain, decreased function, and quality of life. FAI and its’ sequela are treated definitively with hip arthroscopy. Hip arthroscopy is being performed with increasing frequency, and while most patients respond favorably, a subset of 10-20% of patients have suboptimal outcomes. Previous research suggests that mental status may be a primary driver in the way patients with FAI respond to and feel pain. Measures of mental status include the presence of mood disorders and psychosocial patient reported outcomes (PROs). Psychosocial constructs that have yet to be examined in patients with FAI include self-efficacy, kinesophobia, and pain catastrophizing. The Pain Self-Efficacy Questionnaire (PSEQ) gauges an individual’s confidence, or self-efficacy, in their ability to complete tasks despite their current pain. Previous research has established that a patient’s self-efficacy is an important determinant of long-term success following orthopedic surgery. Kinesophobia, measured via the Tampa Scale for Kinesiophobia (TSK), is a measure of movement-related fear. In contrast to self-efficacy, fear of movement has been identified as a predictor of early success following orthopedic surgery. Lastly, pain catastrophizing is a set of maladaptive behaviors including ruminating on pain, feeling helpless to overcome painful situations, and magnifying the circumstances surrounding the painful experience. Catastrophizing behaviors, measured via the Pain Catastrophizing Scale (PCS), have been repeatedly linked to increased pain and decreased functionality in a variety of orthopedic populations. To date, the relationship between these psychosocial variables and pain has not been examined in patients with FAI. The primary aim of this dissertation was to evaluate the role of psychosocial factors on pre and postoperative pain in patients with FAI undergoing hip arthroscopy. To accomplish this aim we performed a series of three studies. The first study was a retrospective chart review to determine the prevalence of mental health disorders and compare preoperative clinical presentation between patients with and without mental health disorders. The second was a cross-sectional study designed to determine if any psychosocial variables could predict preoperative hip pain. The final study utilized a longitudinal, cohort design. Patients were tested preoperatively and at 12-weeks postoperative. The primary outcomes measured were self-efficacy, kinesiophobia, pain catastrophizing, and hip pain at rest and during activity measured via a visual analog scale (VAS). The purpose of this study was to determine the effect of preoperative psychosocial variables on postoperative pain, and to determine if these variables were predictive of persistent postoperative pain three months following hip arthroscopy. Based on the results from these studies we can conclude the following: 1) Mental health disorders are more common in patients with FAI than other orthopedic populations, and self-reported pain and function are worse in this subset of patients, but neither symptom chronicity nor the severity of joint deformity differs; 2) Low self-efficacy is predictive of worse preoperative pain in patients with FAI; and 3) Patients with high preoperative pain catastrophizing or low self-efficacy are more likely to have increased postoperative pain. Low preoperative self-efficacy is predictive of persistent hip pain during activity three months following hip arthroscopy, while low self-efficacy and mental health disorders are predictive of persistent hip pain at rest. Future studies are necessary to develop and implement interventions targeting low self-efficacy and elevated catastrophizing in patients undergoing hip arthroscopy to improve patient outcomes for this high-risk group.

Hundreds of state regulations were passed during the “managed care backlash” of the late 1990s and early 2000s. Many of these anti-managed care regulations eased or eliminated constraints on patient utilization of health care services imposed by managed care organizations. Other regulations gave managed care providers more flexibility in the way they practiced care or helped patients appeal denials of claims. Despite the effort undertaken to pass these regulations, limited research exists on whether the regulations achieved their goal. To fill this gap, this study takes advantage of the variety of regulations enacted during the managed care backlash of the late 1990s and early 2000s to investigate their impact on patient-reported quality of care and mortality for managed care enrollees. The results indicate the regulations did improve patient-reported outcomes, but to varying degrees and only in the latter period of the backlash. Specifically, managed care enrollees who lived in states that adopted moderate-intensity regulations between 2000 and 2004 reported relatively better improvements in access to care and confidence in their provider than did managed care enrollees in states with low-intensity backlash regulations. The positive effect on access to care was similar in states that adopted high-intensity regulations. However, no positive effect was found for any outcome in the first period (1996-2000). These results show that states with the most intense regulatory backlash did not realize better patient-reported outcomes. Instead, states that pursued moderate-intensity backlash regulations experienced relatively better outcomes for their managed care enrollees.

Background: Health-Related Quality of Life (HRQOL) can be negatively affected in patients living with arrhythmias and many patients experience a pronounced symptom burden. The arrhythmia can cause both uncertainty and limitations, including interference with work, reluctance to perform and plan for leisure activities and leading to self-imposed restrictions in daily life situations. There are patients striving to find strategies to manage the arrhythmia and for some this can become the focus in their lives. Treatment options are often a choice between pharmaceuticals and radiofrequency ablation (RFA) where RFA is an option for many arrhythmia-patients to be cured. In the care of arrhythmia-patients it is of great importance to combine objective examinations with patient-reported outcomes (PROs) to achieve patient’s own experiences of treatment efficacy and arrhythmias interference in daily life situations. Aims: The overall aims of this thesis were to assess symptom burden and HRQOL in patients with arrhythmias and to develop and validate an arrhythmia-specific questionnaire, suitable for most arrhythmia-patients. Design and Methods: Studies I and II were single-centre studies including patients referred for RFA, with two different arrhythmia diagnoses. Assessments of patient-reported outcomes (PROs) concerning HRQOL were performed using two questionnaires, SF-36 and EQ-5D (I-II). Further, patients were asked some disease-specific questions (I). Study I describes assessments before the RFA treatment and Study II the follow-up assessments at three and twelve months after RFA. Patients’ scoring of HRQOL was compared to age and gender matched reference groups before and after RFA (I-II). Studies III and IV describe the development and validation of a disease-specific questionnaire ASTA (Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia) assessing symptom burden and HRQOL. Studies III and IV were multicentre studies. Patients planned for DC-conversion, AF patients seeking emergency care and those with different forms of arrhythmias referred for RFA were included. Results: Patients scored significantly lower HRQOL in seven of SF-36’s eight scales compared to the age and gender matched reference groups before RFA treatment. Frequent arrhythmia attacks had a great negative impact on HRQOL, and female gender and older age were factors contributing to worse HRQOL (I). Treatment with RFA restored the patients’ HRQOL. Most positive effects were seen at three months follow-up. One year after treatment patients and the matched reference group scored their HRQOL to a similar level, assessed with SF-36 and EQ-5D index (II). The validated ASTA questionnaire was found to have good psychometric properties. Construct validity was confirmed with sufficient levels of item-total correlations in the ASTA symptom burden scale and HRQOL scales. The dimensionality of the ASTA HRQOL scale was established with confirmatory factor analysis, supporting a physical and a mental subscale. The internal consistency, demonstrated with Cronbach’s alpha (α), was satisfactory for the ASTA symptom burden scale and the ASTA HRQOL scales, varying from α 0.79 to α 0.91 (III-IV). Conclusions and clinical implications: The studies in this thesis confirmed how negatively affected the arrhythmia-patients can be with a pronounced symptom burden and impaired HRQOL. Treatment with RFA was demonstrated to restore the patients HRQOL to an equal level of that of the matched reference group. PROs are important to take into consideration in the care of arrhythmia-patients, to achieve the patients’ subjective experiences of their daily life situation. To the best of our knowledge ASTA is the first arrhythmia-specific questionnaire assessing symptom burden and HRQOL, suitable for most arrhythmia forms. The newly validated ASTA questionnaire can be an important contribution to assessment of PROs in arrhythmia-patients.

Background: Exemestane is a drug of great interest for breast cancer prevention, because it inhibits estrogen production. Estrogen may operate by increasing breast density, a well-established biomarker for increased breast cancer risk. The NCIC CTG MAP.2 trial examined the efficacy of exemestane in decreasing breast density. Menopausal health-related quality of life (HRQL) and adverse events were also carefully monitored during the study. Purpose: To elucidate the impact of exemestane on menopausal HRQL and to examine the relationship between clinician and participant methods of reporting side effects. Methods: 98 postmenopausal women with increased breast density were randomized to exemestane or placebo daily for one year. HRQL was measured with the MENQOL questionnaire, which has four domains. Mean changes in MENQOL domain scores from baseline were compared between treatment groups using the Wilcoxon rank-sum test. The difference between groups in the proportion of women with a clinically meaningful decline was compared by domain with the Chi-square test; change scores were considered worsened if increased by ≥ 0.5 points. The association between time-to-decline in menopausal HRQL and treatment was evaluated using Cox PH regression. The kappa statistic quantified the level of agreement between participant-reported and clinician-reported symptoms. Kaplan-Meier estimates of time-to-decline as communicated by clinicians and participants were compared, using three thresholds to define meaningful change. Results: No significant differences in mean change scores were detected, however, a significantly greater proportion of women on exemestane experienced a clinically meaningful decline in physical menopausal HRQL at three months (absolute difference=19%, p= 0.03), while the absolute difference approached significance for vasomotor menopausal HRQL at six months (21%, p= 0.05), and at nine months (21%, p=0.06). The rate of decline in physical menopausal HRQL was 2.08 times greater (95% CI 1.10-3.94) in the exemestane group compared to the placebo group. Agreement between raters was low for all symptoms except hot flashes; in general participants detected symptoms more rapidly than clinicians, regardless of the defined cut-off for meaningful change on the MENQOL. Conclusions: A subset of women on exemestane experienced significant declines in physical and vasomotor symptoms. Generally, participants reported symptoms more frequently and faster than clinicians. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-06-06 23:55:24.011

Objective: To explore the measurement of subsyndromal mood symptoms in relation to studies of maintenance therapy for bipolar disorder. Methods: Literature review of the Medline database using the following selection criteria: (1) ‘bipolar disorder’ plus ‘inter-episode or interepisode or subsyndromal or subclinical or residual or subthreshold’ and (2) ‘bipolar disorder’ plus ‘maintenance or prophylaxis or longitudinal’. Studies of children or adolescents and non-English-language reports were excluded. Results: Of the studies published between 1987 and October 2007, 77 articles about subsyndromal mood symptoms and 257 studies of maintenance therapy agents were found. Only 11 of the 257 studies of maintenance therapy agents discussed subsyndromal mood symptoms. Of the 77 articles, two thirds were published after 2000. Inconsistent definitions of subsyndromal mood symptoms and different evaluation tools and methodologies were used in the studies. Conclusions: There is a need to standardize definitions and validate measuring approaches for subsyndromal mood symptoms. However, when measured in both naturalistic studies and clinical trials, subsyndromal mood symptoms were frequently reported by patients receiving maintenance therapy and were associated with poor functioning. As with other chronic illnesses, knowledge of the patient’s perspective of daily morbidity is important for improving the clinical outcome. Studies of maintenance therapy for bipolar disorder, regardless of the approach, should measure subsyndromal mood symptoms as an additional outcome. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Little is known regarding the health-related quality of life among myocardial infarction (MI) survivors in the United States. The purpose of this population-based study was to identify differences in health-related quality of life domains between MI survivors and propensity score matched controls. Methods: This retrospective, cross-sectional matched case-control study examined differences in health-related quality of life (HRQoL) among MI survivors of myocardial infarction compared to propensity score matched controls using data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) survey. Propensity scores were generated via logistic regression for MI survivors and controls based on gender, race/ethnicity, age, body mass index (BMI), smoking status, and comorbidities. Chi-square tests were used to compare differences between MI survivors to controls for demographic variables. A multivariate analysis of HRQoL domains estimated odds ratios. Life satisfaction, sleep quality, and activity limitations were estimated using binary logistic regression. Social support, perceived general health, perceived physical health, and perceived mental health were estimated using multinomial logistic regression. Significance was set at p < 0.05. Results: The final sample consisted of 16,729 MI survivors matched to 50,187 controls (n = 66,916). Survivors were approximately 2.7 times more likely to report fair/poor general health compared to control (AOR = 2.72, 95% CI: 2. 43-3.05) and 1.5 times more likely to report limitations to daily activities (AOR = 1.46, 95% CI: 1.34-1.59). Survivors were more likely to report poor physical health > 15 days in the month (AOR = 1.63, 95% CI: 1.46-1.83) and poor mental health > 15 days in the month (AOR = 1.25, 95% CI: 1.07-1.46) compared to matched controls. There was no difference in survivors compared to controls in level of emotional support (rarely/never: AOR = 0.75, 95% CI: 0.48-1. 18; sometimes: AOR = 0.73, 95% CI: 0.41-1.28), hours of recommended sleep (AOR = 1.14, 95% CI: 0.94-1.38), or life satisfaction (AOR = 1.62, 95% CI: 0.99-2.63). Conclusion: MI survivors experienced lower HRQoL on domains of general health, physical health, daily activity, and mental health compared to the general population.

Articular cartilage defects in the knee are common, and can result in pain, decreased function and decreased quality of life. Untreated defects are considered to be a risk factor for developing osteoarthritis, a progressive degenerative joint disease with minimal treatment options. To address these issues, various surgical procedures are available to treat articular cartilage defects in the knee. While these procedures overall have positive results, after surgery patients experience large and persistent deficits in quadriceps strength. A contributing factor to this post-surgical weakness is believed to be the extended post-operative non-weight bearing period, with full weight bearing not initiated until approximately 4 – 6 weeks after surgery. During this non-weight bearing period a minimal amount of demand is placed upon the muscle. Subsequently, the quadriceps muscle undergoes a large degree of atrophy with a significant decrease in muscle strength. Muscular strength deficits reduce the knee joint stability, also increasing the risk of osteoarthritis development. Interventions that can be used to facilitate quadriceps strength while protecting the articular cartilage repair are needed. Neuromuscular electrical stimulation (NMES) is an effective post-knee surgery rehabilitation technique to regain quadriceps musculature. In recent years manufactures have been developing knee sleeve garments integrated with NMES allowing for portability of the NMES treatment. The primary aim of this study was to evaluate the effectiveness of a 12-week home-based neuromuscular electrical stimulation treatment on post-surgical clinical outcomes (quadriceps strength, lower extremity function, and patient reported outcomes) after articular cartilage knee surgery. Patients were randomized between a standard of care home-treatment group and a NMES home-treatment group. Patients completed isometric quadriceps strength testing, the Y-balance test, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) before surgery and at 3-months after surgery. The secondary aims of this study were to determine the most effective NMES parameters for post-surgical quadriceps strength; and to develop a framework to identify factors that may influence a patient’s adherence to a prescribed therapy program. From our results we can make several conclusions. First, we found only a small number of studies utilize similar parameters for post-surgical quadriceps strength treatments. The majority of the parameters reported in the literature were highly variable between studies. Second, clinicians can utilize the expanded Health Belief Model to identify situational and personal factors unique to a patient that may impact adherence to a prescribed treatment. Clinicians can then implement the proposed interventional strategies to address the identified situational and personal factors. Finally, there was no difference in quadriceps strength, lower extremity function, or self-reported scores at 3-month between a home-based NMES treatment and a standard of care home-based treatment. Patients’ adherence to the treatment protocols may have been a major factor contributing to these results. Utilizing a model, such as the proposed expanded Health Belief Model, may assist clinicians in improving a patients’ adherence to future prescribed home-treatment programs.