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. Author manuscript; available in PMC: 2022 Aug 1.
Published in final edited form as: Clin Biomech (Bristol). 2021 Jul 21;88:105436. doi: 10.1016/j.clinbiomech.2021.105436

Trunk movement compensation identified by inertial measurement units is associated with deficits with physical performance, muscle strength and functional capacity in people with hip osteoarthritis

Jesse C Christensen 1, David L Quammen 2, Justin H Rigby 3, Cory L Christiansen 4, Jennifer E Stevens-Lapsley 5
PMCID: PMC8691225  NIHMSID: NIHMS1761345  PMID: 34364100

Abstract

Background:

Trunk movement compensation characterized as ipsilateral trunk lean and posterior rotation with respect to pelvis during stance phase of walking is common in people with hip osteoarthritis and a biomarker of deficits in physical function in older adults. However, the relationship between trunk movement compensation on deficits on physical performance, muscle strength and functional capacity is unknown.

Methods:

A cross-sectional study design was used. Two inertial measurement units were used to assess trunk movement compensation during the six-minute-walk-test. Knee extension, knee flexion and hip abduction strength were measured using hand-held dynamometer. Multivariate regression models were used to regress trunk movement compensation onto six-minute-walk-test and muscle strength measures. Pairwise t-tests were used to evaluate the difference trunk movement compensation has on functional capacity by comparing the first and last minute of the six-minute-walk-test.

Findings:

Thirty-five participants (63.3 ° 7.4 years, 57% male, 28.6 ° 4.5 kg/m2) were enrolled. Greater trunk movement compensation was related to poorer six-minute-walk-test (p=0.03; r=−0.46). Greater hip abduction weakness was related to increased trunk movement compensation in both the sagittal (p=0.05; r=−0.44) and frontal (p=0.04; r=−0.38) planes. Participants demonstrated greater frontal plane trunk movement compensation during the last minute compared to the first minute of the six-minute-walk-test (p<0.01).

Interpretation:

Trunk movement compensation, identified by inertial measure units, is a clinically relevant measure and has a moderate-to-strong relationship on deficits in physical performance, muscle strength and functional capacity. Inertial measurement units can be used as a practical means of measuring movement quality in the clinical setting.

Keywords: hip osteoarthritis, trunk movement compensation, inertial measurement units, six-minute walk test, muscle strength

1. Introduction

Hip osteoarthritis (HOA) is among the most prevalent and disabling disease affecting older adults (Murphy NJ, 2016). An estimated 25% of people in the United States are at risk for developing symptomatic HOA in their lifetime (Murphy LB, 2010). Trunk movement compensation characterized with an ipsilateral lateral trunk lean and posterior rotation of the trunk with respect to pelvis during the stance phase of the affected limb in walking (Hoppenfeld, 1976; Magee, 1992; McGee, 2012), is common and adopted to reduce pain and joint stress in people with unilateral HOA (Watelain E, 2001).

Identifying trunk movement compensation has traditionally been quantified in laboratories that require expensive motion analysis equipment and do not represent people’ own natural environment. Instead, the detection of trunk movement compensation with novel inertial measurement units (IMUs) may allow for evaluation of movement quality outside a motion capture laboratory. In short, IMUs can provide real-time information to clinicians on trunk movement compensation during functional activities such as a prolonged walking, providing a more practical means of improving care for people with HOA.

Poor physical function is a hallmark sign of HOA and measured by physical performance, muscle strength and functional capacity testing. Reduced physical performance, measured by gait speed, balance and chair standing ability, are associated with disability, short-term mortality and poorer quality of life in older adults (Freire AN, 2012; Fusco O, 2012; Guralnik JM, 1994). Muscle weakness, particularly in the hip abductors, knee extensors and knee flexors, is also common in people with HOA (Loureiro A, 2013), induced by pain-mediated disuse, diminished physical activity and older age (Hurley, 1999). Reduced functional capacity, due to hip pain, has further shown to be predictive of decrease physical function (Foucher KC, 2020) and activity (Murphy SL, 2013) in people with HOA.

There is no cure for HOA (Vignon E, 2006), therefore, it is important to identify methods that serve as sensitive biomarkers of decline in physical function. It is unknown if trunk movement compensation is predictive of physical function in people with HOA. However, insight into the relationship trunk movement compensation has on decline in physical function would provide clinicians 1) a more cost-effective and practical method of evaluating movement quality relative to the traditional laboratory setting, 2) important information in managing functional status over time and 3) provide new insight on developing targeted interventions to optimize outcomes in this vulnerable patient population.

Therefore, the purpose of this study was to compare the relationship between trunk movement compensation of the frontal (primary) and sagittal (secondary) planes, using IMU technology, onto physical function, using validated physical performance, muscle strength and functional capacity metrics. We hypothesized that greater trunk movement compensation would be associated with poorer six-minute walk test (6MWT) performance. We also hypothesized that greater trunk movement compensation would be associated with greater knee extension, knee flexion and hip abduction weakness. Finally, we hypothesized that greater trunk movement compensation would be observed during the last minute compared to the first minute of the 6MWT.

2. Methods

2.1. Participants

This was a cross-sectional analysis (level of evidence, 3) of a cohort study of people with end-stage unilateral HOA who were scheduled to undergo a total hip arthroplasty. All participants were Veterans or spouses of Veterans affiliated with the Denver Veterans Affairs Medical Center. Persons who were interested in participating and met the eligibility criteria were scheduled for physical function testing. Inclusion criteria were 1) Veteran status or spouse of Veteran, 2) between 50-85 years old, 3) anticipated total hip arthroplasty to treat HOA, 4) English speaking and 5) body mass index ≤ 40 kg/m2. Exclusion criteria were 1) severe contralateral leg osteoarthritis (> 5/10 pain with stair climbing) or other unstable orthopedic conditions that limit function, 2) neurological or pulmonary problems that severely limit function, 3) uncontrolled hypertension or diabetes and 4) use of illegal substances. All procedures were approved by the University of Colorado Institutional Review Board and Veterans Affairs Eastern Colorado Health Care System Rehabilitation Research and Development committee. All participants provided written, informed consent prior to participating in the study. A sample size calculation was conducted with an expected large effect size (Cohen’s f2 = 0.35) (Cohen, 1988) and a two-sided alpha level of p ≤ 0.05; approximately n =25 participants, were needed to achieve 80% statistical power (G*Power) (Faul F, 2007). The obtained sample size (N=35) was therefore acceptable for the analyses.

2.2. Procedures

All participants completed a battery of physical function testing during a single session. The 6MWT was conducted as a sub-maximal measure to evaluate physical performance and functional capacity (Pichurko, 2012). The distance covered over a time of six minutes was used for analysis. Participants were instructed to walk as far as possible over the six minutes within in a 100 ft (30.5 m) straight walkway. Once the participants reached the end of the walkway, they were instructed to pivot briskly and continue back the other way without hesitation. Participants were permitted to slow down, to stop and to rest, as necessary. The 6MWT has shown excellent reliability (ICC = 0.94) (Kennedy et al., 2005) in people with osteoarthritis and adequate construct validation with the Short Form-36 physical function subscale (r = 0.55) (Harada ND, 1999) and general health perceptions subscale (r = 0.39) (Harada ND, 1999) in older adults.

Participants donned compressive tops and bottoms prior to conducting the 6MWT. One IMU (Wearnotch, Notch Interfaces, Inc., NY, USA) was affixed to the right anterior superior iliac spine of the pelvis and another IMU was affixed to the sternum (Figure 1). A stationary calibration trial, performed by standard manufacturing procedures, was performed with each participant in a neutral standing position to align the global coordinate system. Each participants’ local coordinates were aligned to their standing position to control for inter-subject variation in anatomical alignment during the static calibration. The IMU data were wirelessly collected on a local iOS device through the manufacture’s software during the 6MWT. Isometric knee extension, knee flexion and hip abduction, strength were also assessed using a handheld dynamometer (Layfayette Corp., Lafayette, IN, USA). Participants completed strength testing first on the non-involved limb followed by the involved limb. Maximum isometric knee extension was performed with the participant seated with the knee secured at 60° of knee flexion and the hips flexed to approximately 90° with the transducer attached anteriorly approximately one inch superior between the malleoli. Maximum isometric knee flexion was performed with the participant in prone with the knee secured at 60° of knee flexion and the hips in appropriately 0° with the transducer attached posteriorly approximately one inch superior between the malleoli. Maximum isometric hip abduction was performed with the participant in side-lying with tested limb secured in a neutral position with the transducer attached laterally approximately one inch superior to the lateral malleolus. A strap was used to stabilize the dynamometer and eliminate the influence of tester strength on this measurement. For all testing, two submaximal (50% and 75%) contractions and one maximal (100%) contraction was performed, prior to collecting three maximal isometric contractions for analysis. The submaximal contracts were based on qualitative estimate of maximal effort by the participant to familiarize them with the task prior to formal data collection. The three maximal trials were averaged and computed as maximal force output (lbs.) for each limb. Maximum isometric strength testing has shown good to excellent reliability for knee extension (ICC=0.88-0.93) (Martins J, 2017);(Ford-Smith CD, 2001), knee flexion (ICC=.62-.83) (Ford-Smith CD, 2001; Martins J, 2017) and hip abduction (ICC=0.81-0.98) (Alnahdi AH, 2014; Martins J, 2017).

Figure 1.

Figure 1.

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Inertial measure unit placement used to measure trunk movement compensation.

2.3. Data Processing and Analysis

The IMU sensors contained an accelerometer, gyroscope and magnetometer mounted in a triaxial arrangement on a small circuit board unit (dimensions: 35.9 H x 31.2 W x 8.8 D mm; weight=8.9 g). The sensors logged acceleration and angular velocities and segment angular data in the three orthogonal planes at 100 Hz. The range of the sensors was as follows: accelerometer ±32 g, gyroscope ±4000 dps and magnetometer ±16 gauss. Initial calibration of the IMUs was conducted, per product recommendations, to orient the coordinate system (Y-X-Z) prior to each data collection. This was followed by a steady position collection to orient the IMU position relative position of the trunk and pelvic units’ local coordinate system. The Notch system then performed a sensor-to-segment calibration procedure that relates the two sensor orientations to derive the kinematics of two body segments. The participant was then instructed to begin the 6MWT. The IMU sensors wirelessly logged the positional data to a local iOS device. Raw data from the IMU were imported into the manufacture’s data server for frontal and sagittal plane trunk excursion. The trunk movement compensation was defined in two ways: 1) frontal plane trunk excursion was the difference between peak trunk angular displacement (degrees) on the involved and uninvolved limbs and 2) sagittal plane trunk excursion was the difference between peak anterior to posterior trunk angular displacement (degrees) during each gait cycle.

2.4. Validation of IMU Trunk Movement Compensation

Validation of the IMU system was conducted prior to participant data collection using comparison to a 3D motion capture system (Vicon, CO, USA), the gold standard for motion analysis, in a subset of people undergoing total hip arthroplasty. Ten people [mean, 64.6 (SD, 4.8) years, 90% male, BMI: mean, 28.6 (SD, 3.2) kg/m2] were analyzed for validation purposes. The people performed a single walking trial at a self-selected speed on an instrumented treadmill. The placement of the IMUs was the same as described above. Frontal plane trunk angle relative to the pelvis was recorded. For the 3D motion analysis system, trunk and pelvis segment position were tracked using reflective markers and sampled at 100 Hz. Frontal plane trunk angle relative to the pelvis was computed using Visual3D (C-Motion, MD, USA). A two-way mixed, intraclass correlation coefficient (ICC) was calculated between the two systems for the first 10 successful steps during the walking session. The mean frontal plane trunk excursion for the IMU system was mean, 7.6 (SD, 3.8) degrees compared to mean, 6.9 (SD, 2.9) degrees for the motion analysis system [mean difference, 0.7 (SD, 0.9) degrees]. The ICC between the IMU and motion analysis system was 0.82 (95% CI 0.73-0.88, p<0.001). Conclusion was the two-sensor IMU system showed good agreement compared to the gold standard 3D motion analysis system for assessing frontal plane trunk movement during walking in people undergoing total hip arthroplasty.

2.5. Statistical Analysis

Descriptive statistics were used to provide demographic characteristics of the participants in this study. Trunk movement compensation data was screened for normality and univariate outliers using scatterplots, k-density plots, boxplots and z-scores (using a ± 2.5 z-score cut-point). Sensitivity analyses were employed omitting potential outliers (> 2.5 z-scores) and results were compared to the original data. If the parameter estimates did not significantly change between the two statistical models, the values were kept in the subsequent analysis. Multivariate regression models were used, controlling for self-reported hip pain, to regress 1) frontal and sagittal plane trunk movement compensation onto the total distance covered during the 6MWT (Hypothesis1) and 2) muscle strength of the involved limb onto frontal and sagittal plane trunk movement compensation during the 6MWT (Hypothesis 2). Paired t-test were used to compare frontal and sagittal plane trunk movement compensation from the first minute to the last minute of the 6MWT (Hypothesis 3). We did not examine normality or homogeneity of variance as linear regression and t-tests are known to be robust to those assumptions, even with sample sizes as small as four (Lumley et al., 2002). Alpha level to test for statistical significance was set at p ≤ 0.05 and post-hoc correction was conducted using the Tukey-Ciminera-Heyse procedure to minimize risk of multiplicity (Wright, 1992). Effect sizes (ES) were calculated based on partial correlations (Cohen’s f2). Cohen’s f2 equal to or greater than 0.02 present a small effect, equal to or greater than 0.15 present a medium effect, and equal to or greater than 0.35 present a large effect (Cohen, 1988). Analyses were performed using STATA v14.0 statistical software package (College Station, TX, USA).

3. Results

Thirty-five participants with end-stage unilateral HOA were included in this observational study (Table 1). For hypothesis one, participants with greater frontal plane trunk movement compensation demonstrated poorer performance on the 6MWT after adjusting for self-report hip pain (beta=−0.41; 95% CI= −39.84, −3.75; ES=0.19; p= 0.03; Figure 2). No significant association were observed with sagittal plane trunk movement compensation on 6MWT (p>0.05). For hypothesis two, participants with greater hip abduction weakness demonstrated greater frontal plane trunk movement compensation during the 6MWT (beta=−0.41; 95% CI=−0.38, −0.02; ES=0.18; p=0.04; Figure 3). No significant association were observed with knee extensor or flexor muscle weakness on frontal plane trunk movement compensation during the 6MWT. Participants with greater hip abduction weakness demonstrated greater sagittal plane trunk movement compensation during the 6MWT (beta=−0.36; 95% CI=−0.42, −0.02; ES=0.16; p=0.05; Figure 3). No significant association were observed with knee extensor or flexor muscle weakness on sagittal plane trunk movement compensation during the 6MWT (p>0.05). For hypothesis three, participants demonstrated greater frontal plane trunk movement compensation during the last minute compared to the first minute of the 6MWT (mean difference= 2.06; 95% CI=0 .72, 3.40; p<0.01; Table 2]. No significant differences were observed during sagittal plane trunk movement compensation during the last minute compared to the first minute of the 6MWT (p>0.05).

Table 1.

Baseline Characteristics of Study Participants

Characteristics Total Participants (n=35)
Age, yrs. 63.3 (7.4)
Sex, no. male (%) 20 (57)
Mass, kg 84.5 (15.4)
Height, m 1.7 (0.1)
BMI (kg/m2) 28.6 (4.5)
Kellgren–Lawrence grade 3.5 (0.5)
WOMAC 48.5 (17.5)
VR-12 Physical 35.6 (9.6)
VR-12 Mental 45.5 (5.2)
CCI 0.3 (1.1)
NPRS 4.0 (2.0)
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Note: Values represented as mean (standard deviation) unless otherwise stated. BMI, body mass index; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; CCI, Charlson Comorbidity Index; VR-12, Veterans Rand 12-item; NPRS, involved hip numeric pain rating scale.

Figure 2.

Figure 2.

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Unadjusted association between trunk movement compensation on six-minute walk test performance.

P-values adjusted based upon Tukey-Ciminera-Heyse multiple comparison procedure

Effect size categories (0.02 small, 0.15 medium, 0.35 large)

Figure 3.

Figure 3.

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Unadjusted association between muscle weakness on trunk angular displacement during six-minute walk test.

P-values adjusted based upon Tukey-Ciminera-Heyse multiple comparison procedure

Effect size categories (0.02 small, 0.15 medium, 0.35 large)

Table 2.

Peak trunk movement compensation during six-minute walk test

Variable 6MWT First Minute 6MWT Last Minute
Max Min Sum^ Max Min Sum^ Mean Diff† SE p-valueƚ
Frontal Plane a 12.24 (9.30) 0.36 (8.75) 12.61 (3.70) 13.95 (12.03) 0.72 (10.8) 14.68 (5.32) 2.06 0.66 0.005*
Sagittal Plane b 11.70 (6.07) 1.19 (6.41) 13.21 (4.48) 13.80 (6.72) 0.08 (7.15) 13.88 (5.86) 0.67 0.55 0.312
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Note: Angular displacement of the trunk (degrees) during sagittal and frontal plane movement during six-minute walk test. 6MWT, six-minute walk test; Max, maximum; Min, minimum; Diff, difference score between the maximum and minimum peak mean values.

a

Values are peak means (standard deviations) from raw data (degrees), positive values indicate angular displacement over the involved limb. Negative values indicate angular displacement over non-involved limb.

b

Values are peak means (standard deviations) from raw data (degrees), positive values indicate angular displacement anteriorly. Negative values indicate angular displacement posteriorly.

^

Values are the summation of the magnitude of the maximum and minimum angular displacement.

†

Values are peak mean differences (standard error) from paired t-tests.

ƚ

p-values adjusted based upon Tukey-Ciminera-Heyse multiple comparison procedure.

*

significant at p<0.05.

4. Discussion

The purpose of this study was to compare the relationship between trunk movement compensation of the frontal (primary) and sagittal (secondary) planes, using IMU technology, onto physical function, using validated physical performance, muscle strength and functional capacity metrics. Our primary findings of this study were people with HOA 1) with greater frontal plane trunk movement compensation demonstrated poorer performance on the 6MWT, 2) with greater hip abduction weakness demonstrated greater frontal and sagittal plane trunk movement compensation during the 6MWT and 3) demonstrated greater frontal plane trunk movement compensation during the last minute compared to the first minute of the 6MWT.

These findings provide new insight on how cost-effective and unobstructive IMU technology can identify trunk movement compensation in a non-laboratory setting and provide clinically relevant relationships to key outcome measures in people with HOA. To our knowledge, this is the first study to associate common trunk movement compensations observed in people with HOA to physical performance, muscle strength and functional capacity outcomes.

Quantifying kinematic gait mechanics is typically assessed using sophisticated camera systems, while most patients and providers do not have access to these resources. Thus, direct translation to clinical practice is limited. Limited research has also been conducted on how trunk movement compensation relates to physical function in people with HOA, despite current findings showing movement compensation being so prevalent. Our data showed trunk movement compensation to be moderately to strongly related to 6MWT (r=−0.46). Meaningful levels of movement compensation, particularly trunk excursion, are present in people with HOA (Zeni JJ, 2015). However, it is unclear how these movement compensations relate to physical function. Other studies have shown people with early states of HOA have altered pelvis kinematics (Watelain E, 2001), joint power generation or absorption (Watelain E, 2001), gait speed (Rutherford D, 2015; Watelain E, 2001; Zugner R, 2018), stride length (Martinez-Ramirez A, 2013; Rutherford D, 2015; Watelain E, 2001), and knee flexion (Ornetti P, 2010) of the involved limb compared to healthy peers. Additionally, people with severe HOA demonstrate greater knee flexion at initial contact and longer stance phase on the non-involved limb and reduced sagittal plane knee motion on the involved limb compared to those with less severe HOA (Rutherford D, 2018). It is clear that people with HOA demonstrate movement quality that is atypical and these movement compensations worsen as the severity of the disease progresses (Schmidt A, 2017; Watelain E, 2001). Although these findings are important, they provide no clinically relevant findings on how movement compensation associate with physical function. Our findings relate trunk movement compensation to the 6MWT, one of the core-set of recommended physical performance measures by the Osteoarthritis Research Society International (Dobson F, 2013), a standard measure for monitoring decline in physical function.

Our data also showed hip abduction strength was moderately to strongly related to sagittal (r=−0.44) and frontal (r=−0.38) plane trunk movement compensation in people with HOA. Targeted hip abduction strengthening is recommended in people pre- and post-total hip arthroplasty (Loureiro A, 2013). Despite these recommendations, people with HOA can demonstrate a 39% reduction in hip abduction strength between involved and uninvolved limbs (Rossi MD, 2006), and 37% decreased in involved hip abduction strength compared to healthy peers (Klausmeier V, 2010). Strength deficits as high as 25% in the hip abductor and knee extensor muscles have been observed 6 months after total hip arthroplasty when compared to healthy peers (Fukumoto Y, 2013). The relationship between strength deficits and trunk movement compensation is understudied. However, prior work has shown people post-total hip arthroplasty demonstrate spatiotemporal and kinematic gait compensations even 12 months following surgery when compared to healthy peers (Bahl JS, 2018), despite improvements in hip pain. People continue to demonstrate significant residual deficits, despite efforts to improve muscle strength pre- and post-total hip arthroplasty (Loureiro A, 2013). Clinicians should consider adopting innovative strategies such as movement retraining or high-intensity strength training strategies to increase dose and volume response to hip abductor muscles.

Finally, our findings showed people with HOA demonstrated greater frontal plane trunk movement compensation during the last minute compared to the first minute of the 6MWT. This data provides important information on how reduced functional capacity contributes to greater trunk movement compensation over time with continuous walking. Although statistically significant, these findings should be interpreted with caution as the overall change from the first to last minute were only a few degrees. However, our findings showing greater trunk movement compensation is clinically relevant as increased physical activity is commonly recommended and shown to be effective at improving hip pain and sedentary health consequences in people with HOA (Wellsandt E, 2018). The benefits of appropriate increase in physical activity are important in conservative management of HOA and may even have a protective roll in reducing the likelihood of a total hip replacement (Agberg E, 2012). However, the movement compensation during daily physical activity might have negative consequences on secondary joints over time as greater compensation occurs. Trunk movement compensations adopted by people with HOA has shown to increase mechanical stress, particularly on the non-involved hip (Schmidt A, 2017) and involved knee and ankle joints (Watelain E, 2001). This overloading of secondary joints may lead to increased joint pain and risk of osteoarthritis in other joints (Schmidt A, 2017). Therefore, evaluating the quality of movement may be as important as the amount of physical activity performed daily. Promotion of physical activity with use of innovative technologies to correct movement compensation should be a focused area of future research to improve long-term health outcomes.

This study should be interpreted considering several limitations. Our study used a cross-sectional design, which limited our ability to differentiate cause and effect. Therefore, further prospective cohort studies are needed. Our sample size was based on detecting large effects, so a more robust sample size is warranted to identify smaller effects, if they exist, and determine if current results can be replicated. Selection bias could have influenced our results, as most of the research participants were generally healthy, having been screened for comorbidities. Validation of the IMUs with the motion analysis system was conducted only in the frontal plane, which could lead to unvalidated findings with the sagittal plane data collected.

5. Conclusion

Trunk movement compensation has a negative association on physical function in people with HOA. Greater trunk movement compensation relates to poorer performance on the six-minute walk test and greater hip abduction weakness. Prolonged walking leads to greater increase in trunk movement compensation, which could have future ramifications of increased pain and accelerated osteoarthritic changes in secondary joints. These findings show the importance of identifying and correcting trunk movement compensation in people with unilateral hip osteoarthritis. Inertial measurement units were effective at identifying trunk movement compensation and serves as a promising method for future interventions to identify and intervene on compensatory strategies in people with hip osteoarthritis in the home, outpatient or hospital setting.

Acknowledgement:

This work was supported by VA Merit Award # RR&D I01 RX002251 from the United States (U.S.) Department of Veterans Affairs (Rehabilitation Research and Development). This project was funding in part by the Rheumatological Research Foundation and Advanced Geriatrics Fellowship from the Eastern Colorado Veterans Affairs Geriatrics Research, Education, and Clinical Center. The authors thank Karl Wojnar, SPT, Amy Peters, MS and Jill Rogers, SPT for their effort in data processing, management and providing invaluable input.

Footnotes

Conflict of Interest Statement:

The authors report no financial conflicts of interest related to this work.

Ethical Review Committee Statement:

The University of Colorado Institutional Review Board (Aurora, CO, USA) approved this study.

Contributor Information

Jesse C. Christensen, Veterans Affairs Salt Lake City Health Care System, United States of America, University of Utah, Department of Physical Therapy and Athletic Training.

David L. Quammen, University of Utah, Department of Physical Therapy and Athletic Training, United States of America.

Justin H. Rigby, University of Utah, Department of Physical Therapy and Athletic Training, United States of America.

Cory L. Christiansen, University of Colorado School of Medicine, Department of Physical Medicine and Rehabilitation and VA Eastern Colorado Geriatric Research Education and Clinical Center, United States of America.

Jennifer E. Stevens-Lapsley, University of Colorado School of Medicine, Department of Physical Medicine and Rehabilitation and VA Eastern Colorado Geriatric Research Education and Clinical Center, United States of America.

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