Department of Physical Therapy Articles
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Item Using machine learning to detect sarcopenia from electronic health records(Sage, 2023-08-29) Luo, Xiao; Ding, Haoran; Broyles, Andrea; Warden, Stuart J.; Moorthi, Ranjani N.; Imel, Erik A.; Physical Therapy, School of Health and Human SciencesIntroduction: Sarcopenia (low muscle mass and strength) causes dysmobility and loss of independence. Sarcopenia is often not directly coded or described in electronic health records (EHR). The objective was to improve sarcopenia detection using structured data from EHR. Methods: Adults undergoing musculoskeletal testing (December 2017-March 2020) were classified as meeting sarcopenia thresholds for 0 (controls), ≥1 (Sarcopenia-1), or ≥2 (Sarcopenia-2) tests. Electronic health record diagnoses, medications, and laboratory testing were extracted from the Indiana Network for Patient Care. Five machine learning models were applied to EHR data for predicting sarcopenia. Results: Of 1304 participants, 1055 were controls, 249 met Sarcopenia-1 and 76 met Sarcopenia-2. Sarcopenic participants were older, with higher fat mass, Charlson Comorbidity Index, and more chronic diseases. All models performed better for Sarcopenia-2 than Sarcopenia-1. The top performing models for Sarcopenia-1 were Logistic Regression [area under the curve (AUC) 71.59 (95% confidence interval [CI], 71.51-71.66)] and Multi-Layer Perceptron [AUC 71.48 (95%CI, 71.00-71.97)]. The top performing models for Sarcopenia-2 were Logistic Regression [AUC 91.44 (95%CI, 91.28-91.60)] and Support Vector Machine [AUC 90.81 (95%CI, 88.41-93.20)]. For the best Logistic Regression Model, important sarcopenia predictors included diabetes mellitus, digestive system complaints, signs and symptoms involving the nervous, musculoskeletal and respiratory systems, metabolic disorders, and kidney or urinary tract disorders. Opioids, corticosteroids, and antihyperlipidemic drugs were also more common among sarcopenic participants. Conclusions: Applying machine learning models, sarcopenia can be predicted from structured data in EHR, which may be developed through future studies to facilitate large-scale early detection and intervention in clinical populations.Item Multidirectional basketball activities load different regions of the tibia: A subject-specific muscle-driven finite element study(Elsevier, 2022) Yan, Chenxi; Bice, Ryan J.; Frame, Jeff W.; Warden, Stuart J.; Kersh, Mariana E.; Physical Therapy, School of Health and Human SciencesThe tibia is a common site for bone stress injuries, which are believed to develop from microdamage accumulation to repetitive sub-yield strains. There is a need to understand how the tibia is loaded in vivo to understand how bone stress injuries develop and design exercises to build a more robust bone. Here, we use subject-specific, muscle-driven, finite element simulations of 11 basketball players to calculate strain and strain rate distributions at the midshaft and distal tibia during six activities: walking, sprinting, lateral cut, jumping after landing, changing direction from forward-to-backward sprinting, and changing direction while side shuffling. Maximum compressive strains were at least double maximum tensile strains during the stance phase of all activities. Sprinting and lateral cut had the highest compressive (-2,862 ± 662 με and -2,697 ± 495 με, respectively) and tensile (973 ± 208 με and 942 ± 223 με, respectively) strains. These activities also had the highest strains rates (peak compressive strain rate = 64,602 ± 19,068 με/s and 37,961 ± 14,210 με/s, respectively). Compressive strains principally occurred in the posterior tibia for all activities; however, tensile strain location varied. Activities involving a change in direction increased tensile loads in the anterior tibia. These observations may guide preventative and management strategies for tibial bone stress injuries. In terms of prevention, the strain distributions suggest individuals should perform activities involving changes in direction during growth to adapt different parts of the tibia and develop a more fatigue resistant bone. In terms of management, the greater strain and strain rates during sprinting than jumping suggests jumping activities may be commenced earlier than full pace running. The greater anterior tensile strains during changes in direction suggest introduction of these types of activities should be delayed during recovery from an anterior tibial bone stress injury, which have a high-risk of healing complications.Item A Handheld Quantifiable Soft Tissue Manipulation Device for Tracking Real-Time Dispersive Force-Motion Patterns to Characterize Manual Therapy Treatment(IEEE, 2023) Bhattacharjee, Abhinaba; Anwar, Sohel; Chien, Stanley; Loghmani, M. Terry; Physical Therapy, School of Health and Human SciencesObjective: Low back pain (LBP) is one of the leading neuromusculoskeletal (NMSK) problems around the globe. Soft Tissue Manipulation (STM) is a force-based, non-invasive intervention used to clinically address NMSK pain conditions. Current STM practice standards are mostly subjective, suggesting an urgent need for quantitative metrics. This research aims at developing a handheld, portable smart medical device for tracking real-time dispersive force-motions to characterize manual therapy treatments as Quantifiable Soft Tissue Manipulation (QSTM). Methods: The device includes two 3D load-cells to quantify compressive and planar-shear forces, coupled with a 6 degrees-of-freedom IMU sensor for acquiring volitionally adapted therapeutic motions while scanning and mobilizing myofascial restrictions over larger areas of the body. These force-motions characterize QSTM with treatment parameters (targeted force, application angle, rate, direction, motion pattern, time) as a part of post-processing on a PC software (Q-Ware©). A human case study was conducted to treat LBP as proof-of-concept for the device's clinical usability. Results: External validation of treatment parameters reported adequate device precision required for clinical use. The case study findings revealed identifiable therapeutic force-motion patterns within treatments indicating subject's elevated force-endurance with self-reported pain reduction. Conclusion: QSTM metrics may enable study of STM dosing for optimized pain reduction and functional outcomes using documentable manual therapy. Clinical trials will further determine its reliability and comparison to conventional STM. Significance: This medical device technology not only advances the state-of-the-art manual therapy with precision rehabilitation but also augments practice with reproducibility to examine neurobiological responses of individualized STM prescriptions for NMSK pathology.Item Effects of Gabapentin and Pregabalin on Calcium Homeostasis: Implications for Physical Rehabilitation of Musculoskeletal Tissues(Springer, 2022) Reyes Fernandez, Perla C.; Wright, Christian S.; Warden, Stuart J.; Hum, Julia; Farach-Carson, Mary C.; Thompson, William R.; Physical Therapy, School of Health and Human SciencesPurpose of review: In this review, we discuss the mechanism of action of gabapentinoids and the potential consequences of long-term treatment with these drugs on the musculoskeletal system. Recent findings: Gabapentinoids, such as gabapentin (GBP) and pregabalin (PGB) were designed as antiepileptic reagents and are now commonly used as first-line treatment for neuropathic pain and increasingly prescribed off-label for other pain disorders such as migraines and back pain. GBP and PGB exert their analgesic actions by selectively binding the α2δ1 auxiliary subunit of voltage-sensitive calcium channels, thereby inhibiting channel function. Numerous tissues express the α2δ1 subunit where GBP and PGB can alter calcium-mediated signaling events. In tissues such as bone, muscle, and cartilage, α2δ1 has important roles in skeletal formation, mechanosensation, and normal tissue function/repair that may be affected by chronic use of gabapentinoids. Long-term use of gabapentinoids is associated with detrimental musculoskeletal outcomes, including increased fracture risk. Therefore, understanding potential complications is essential for clinicians to guide appropriate treatments.Item Reference data and calculators for second-generation HR-pQCT measures of the radius and tibia at anatomically standardized regions in White adults(Springer, 2022) Warden, Stuart J.; Liu, Ziyue; Fuchs, Robyn K.; van Rietbergen, Bert; Moe, Sharon M.; Physical Therapy, School of Health and Human SciencesPurpose: To provide age- and sex-specific reference data for high-resolution peripheral quantitative computed tomography (HR-pQCT) measures of the distal and diaphyseal radius and tibia acquired using a second-generation scanner and percent-of-length offsets proximal from the end of the bone. Methods: Data were acquired in White adults (aged 18-80 years) living in the Midwest region of the USA. HR-pQCT scans were performed at the 4% distal radius, 30% diaphyseal radius, 7.3% distal tibia, and 30% diaphyseal tibia. Centile curves were fit to the data using the LMS approach. Results: Scans of 867 females and 317 males were included. The fitted centile curves reveal HR-pQCT differences between ages, sexes, and sites. They also indicate differences when compared to data obtained by others using fixed length offsets. Excel-based calculators based on the current data were developed and are provided to enable computation of subject-specific percentiles, z-scores, and t-scores and to plot an individual's outcomes on the fitted curves. In addition, regression equations are provided to convert estimated failure load acquired with the conventional criteria utilized with first-generation scanners and those specifically developed for second-generation scanners. Conclusion: The current study provides unique data and resources. The combination of the reference data and calculators provide clinicians and investigators an ability to assess HR-pQCT outcomes in an individual or population of interest, when using the described scanning and analysis procedure. Ultimately, the expectation is these data will be expanded over time so the wealth of information HR-pQCT provides becomes increasingly interpretable and utilized.Item Essential Components of Physical Therapist Management of Patients With Osteoporosis: A Delphi Study(Wolters Kluwer, 2022-04) Avin, Keith G.; Nithman, Robert W.; Osborne, Raine; Betz, Sherri R.; Lindsey, Carleen; Hartley, Gregory W.; Physical Therapy, School of Health and Human SciencesBackground and Purpose: Osteoporosis is a systemic, metabolic bone disease that affects bone quality, increases susceptibility to low-trauma bone fracture, and has downstream effects on falls and fragility fractures. Osteoporosis is a multifactorial disease process that requires management from multiple health care providers including physicians, nurses, and physical therapists. However, the paucity of information regarding comprehensive physical therapist management for patients with osteoporosis indicated the need for an evidence-based document. The purpose of this document was to provide the best available expert guidance for clinicians in the selection of screening tools, essential tests and measures, treatment goals, and interventions for patients with osteoporosis. Methods: A Delphi process was used. Thirty-one physical therapists with expertise in the care of patients with osteoporosis participated in a series of 3 sequential surveys designed to build and reach agreement on the management of patients with osteoporosis. The desired survey outcomes were to: (1) identify the range of examination and plan of care components considered important to physical therapists' care for patients with osteoporosis, (2) determine which components should be considered essential, and (3) achieve consensus on the final list of essential components and related operational definitions. Results: A clear consensus on the essential components of examination and interventions was achieved. In general, there were 4 to 6 items across each category of history, tests and measures, education/goals, and treatment. Conclusions: The prioritization of these management items will better support clinicians working with adults who have osteoporosis.Item Gabapentin Disrupts Binding of Perlecan to the α2δ1 Voltage Sensitive Calcium Channel Subunit and Impairs Skeletal Mechanosensation(MDPI, 2022-12-12) Reyes Fernandez, Perla C.; Wright, Christian S.; Masterson, Adrianna N.; Yi, Xin; Tellman, Tristen V.; Bonteanu, Andrei; Rust, Katie; Noonan, Megan L.; White, Kenneth E.; Lewis, Karl J.; Sankar, Uma; Hum, Julia M.; Bix, Gregory; Wu, Danielle; Robling, Alexander G.; Sardar, Rajesh; Farach-Carson, Mary C.; Thompson, William R.; Physical Therapy, School of Health and Human SciencesOur understanding of how osteocytes, the principal mechanosensors within bone, sense and perceive force remains unclear. Previous work identified "tethering elements" (TEs) spanning the pericellular space of osteocytes and transmitting mechanical information into biochemical signals. While we identified the heparan sulfate proteoglycan perlecan (PLN) as a component of these TEs, PLN must attach to the cell surface to induce biochemical responses. As voltage-sensitive calcium channels (VSCCs) are critical for bone mechanotransduction, we hypothesized that PLN binds the extracellular α2δ1 subunit of VSCCs to couple the bone matrix to the osteocyte membrane. Here, we showed co-localization of PLN and α2δ1 along osteocyte dendritic processes. Additionally, we quantified the molecular interactions between α2δ1 and PLN domains and demonstrated for the first time that α2δ1 strongly associates with PLN via its domain III. Furthermore, α2δ1 is the binding site for the commonly used pain drug, gabapentin (GBP), which is associated with adverse skeletal effects when used chronically. We found that GBP disrupts PLN::α2δ1 binding in vitro, and GBP treatment in vivo results in impaired bone mechanosensation. Our work identified a novel mechanosensory complex within osteocytes composed of PLN and α2δ1, necessary for bone force transmission and sensitive to the drug GBP.Item Physical activity induced adaptation can increase proximal femur strength under loading from a fall onto the greater trochanter(Elsevier, 2021) Fuchs, Robyn K.; Carballido-Gamio, Julio; Keyak, Joyce H.; Kersh, Mariana E.; Warden, Stuart J.; Physical Therapy, School of Health and Human SciencesPhysical activity enhances proximal femur bone mass, but it remains unclear whether the benefits translate into an enhanced ability to resist fracture related loading. We recently used baseball pitchers as a within-subject controlled model to demonstrate physical activity induced proximal femur adaptation in regions associated with weight bearing and increased strength under single-leg stance loading. However, there was no measurable benefit to resisting common injurious loading (e.g. a fall onto the greater trochanter). A lack of power and a small physical activity effect size may have contributed to the latter null finding. Softball pitchers represent an alternative within-subject controlled model to explore adaptation of the proximal femur to physical activity, exhibiting greater dominant-to-nondominant (D-to-ND) leg differences than baseball pitchers. The current study used quantitative computed tomography, statistical parametric mapping, and subject-specific finite element (FE) modeling to explore adaptation of the proximal femur to physical activity in female softball pitchers (n = 25). Female cross-country runners (n = 15) were included as symmetrically loaded controls, showing very limited D-to-ND leg differences. Softball pitchers had D-to-ND leg differences in proximal femur, femoral neck, and trochanteric volumetric bone mineral density and content, and femoral neck volume. Voxel-based morphometry analyses and cortical bone mapping showed D-to-ND leg differences within a large region connecting the superior femoral head, inferior femoral neck and medial intertrochanteric region, and within the greater trochanter. FE modeling revealed pitchers had 19.4% (95%CI, 15.0 to 23.9%) and 4.9% (95%CI, 1.7 to 8.2%) D-to-ND leg differences in predicted ultimate strength under single-leg stance loading and a fall onto the greater trochanter, respectively. These data affirm the spatial and strength adaptation of the proximal femur to weight bearing directed loading and demonstrate that the changes can also have benefits, albeit smaller, on resisting loads associated with a sideways fall onto the greater trochanter.Item Preventing Bone Stress Injuries in Runners with Optimal Workload(Springer, 2021) Warden, Stuart J.; Edwards, W. Brent; Willy, Richard W.; Physical Therapy, School of Health and Human SciencesBone stress injuries (BSIs) occur at inopportune times to invariably interrupt training. All BSIs in runners occur due to an "error" in workload wherein the interaction between the number and magnitude of bone tissue loading cycles exceeds the ability of the tissue to resist the repetitive loads. There is not a single optimal bone workload, rather a range which is influenced by the prevailing scenario. In prepubertal athletes, optimal bone workload consists of low-repetitions of fast, high-magnitude, multidirectional loads introduced a few times per day to induce bone adaptation. Premature sports specialization should be avoided so as to develop a robust skeleton that is structurally optimized to withstand multidirectional loading. In the mature skeleton, optimal workload enables gains in running performance but minimizes bone damage accumulation by sensibly progressing training, particularly training intensity. When indicated (e.g., following repeated BSIs), attempts to reduce bone loading magnitude should be considered, such as increasing running cadence. Determining the optimal bone workload for an individual athlete to prevent and manage BSIs requires consistent monitoring. In the future, it may be possible to clinically determine bone loads at the tissue level to facilitate workload progressions and prescriptions.Item Effects of Dietary Protein Source and Quantity on Bone Morphology and Body Composition Following a High-Protein Weight-Loss Diet in a Rat Model for Postmenopausal Obesity(MDPI, 2022-05-28) Wright, Christian S.; Hill, Erica R.; Reyes Fernandez, Perla C.; Thompson, William R.; Gallant, Maxime A.; Campbell, Wayne W.; Main, Russell P.; Physical Therapy, School of Health and Human SciencesHigher protein (>30% of total energy, HP)-energy restriction (HP-ER) diets are an effective means to improve body composition and metabolic health. However, weight loss (WL) is associated with bone loss, and the impact of HP-ER diets on bone is mixed and controversial. Recent evidence suggests conflicting outcomes may stem from differences in age, hormonal status, and the predominant source of dietary protein consumed. Therefore, this study investigated the effect of four 12-week energy restriction (ER) diets varying in predominate protein source (beef, milk, soy, casein) and protein quantity (normal protein, NP 15% vs. high, 35%) on bone and body composition outcomes in 32-week-old obese, ovariectomized female rats. Overall, ER decreased body weight, bone quantity (aBMD, aBMC), bone microarchitecture, and body composition parameters. WL was greater with the NP vs. HP-beef and HP-soy diets, and muscle area decreased only with the NP diet. The HP-beef diet exacerbated WL-induced bone loss (increased trabecular separation and endocortical bone formation rates, lower bone retention and trabecular BMC, and more rod-like trabeculae) compared to the HP-soy diet. The HP-milk diet did not augment WL-induced bone loss. Results suggest that specific protein source recommendations may be needed to attenuate the adverse alterations in bone quality following an HP-ER diet in a model of postmenopausal obesity.