9 minute read
Cory Christiansen, PhD, PT
by AOPA
Researcher applies movement science principles and addresses health behaviors to optimize outcomes
O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare professionals who have carried out studies and gathered quantitative and/ or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.
FOR PHYSICAL THERAPIST AND researcher Cory Christiansen, PhD, PT, working closely with colleagues early in his career led him down the path of O&P research. He recalls collaborating with local physical therapists and prosthetists in Colorado to identify why rates of community reintegration for older adults who had undergone lower-limb amputation were very low.
“As we studied this problem, we identified a link between the lack of community reintegration and very poor physical function outcomes following rehabilitation,” Christiansen says. His doctorial training in exercise science from the University of Northern Colorado guided him to initially examine biomechanical mechanisms. However, “it was becoming clear to me that many issues beyond movement mechanics explained, at least in part, the poor function and high levels of disability we saw in the rehabilitation clinic,” he says. He expanded his research to assess potential factors of disability, such as chronic poor health behaviors, the influence of multiple comorbid health conditions, and limited continuity of care related to lower-limb amputation rehabilitation.
Today, Christiansen focuses on optimizing exercise and physical activity outcomes for a variety of populations with movement dysfunction, including patients with lower-limb amputation, in his roles as a professor in the Department of Physical Medicine and Rehabilitation at the University of Colorado (CU) in Aurora, Colorado, and as co-director of the Interdisciplinary Movement Science Lab at CU’s School of Medicine, where he leads a clinical trial research team.
Christiansen also works with the Department of Veterans Affairs (VA). In his appointment as rehabilitation researcher at the VA Eastern Colorado Healthcare System, he directs the Movement Analysis Lab for the Rocky Mountain Geriatric Research Education and Clinical Center. “In this lab, we work with older veterans in rehabilitation clinical trials,” he explains. More specifically, he leads the research arm of the Regional Amputation Center—one of seven such VA centers nationwide—where his team studies both in-person and telehealth rehabilitation interventions.
Paul Kline, PhD, PT; Matthew Miller, PhD, PT; Emily Hager, MS; Cory Christiansen, PhD, PT; and Chelsey Anderson, CPO
Ongoing Investigations
Much of Christiansen’s current work centers on improving quality of life for people with major lower-limb amputations due to complications of severe diabetes mellitus and severe peripheral artery disease, or a combination of these two pathophysiologies. “When I first began research in lower-limb amputation rehab, much of the exercise evidence was based on studies of people with traumatic amputation. However, lower-limb amputations are mostly due to vascular, nontraumatic causes,” he explains. He sought to better serve people with nontraumatic amputation—an approach that fit well with his clinical research expertise in working with older adults with complex health conditions.
One recent line of research focuses on ways older adults can sustain walking exercise and physical activity after nontraumatic lower-limb amputation, Christiansen explains. “It has been demonstrated by our lab and others that conventional physical rehabilitation and prosthetic care for people with lower-limb amputation results in their improved functional capacity,” including improved walking speed and walking distance. “However, walking—both intentional exercise and habitual walking activity—is not sustained at a therapeutic level for many older adults after they complete their initial postamputation rehab.” Christiansen’s research team helped identify critically low levels of walking after lower-limb amputation, linked low walking levels to poor health self-management behaviors, and then developed and piloted a walking exercise self-management intervention.
Christiansen presented a poster session on “Exploring Patient Rehabilitation Experience After Lower-Limb Amputation.”
Specifically, his team has used both quantitative and qualitative research methods to determine how health self-efficacy—the ability of a person to cope with their health condition— affects physical function capacity and disability. “Prior work had identified self-efficacy as a predictor of health outcomes for people living with chronic disease,” Christiansen explains. His team identified relationships between self-efficacy and functional capacity, as well as self-efficacy and disability for people with lower-limb amputation. “We demonstrated that a person’s level of self-efficacy partially explains, or mediates, the relationship between functional capacity and disability,” he says. “These findings show a potential critical role of self-efficacy in managing personal health for older adults in the causal path to disability after lower-limb amputation.”
In addition, Christiansen’s team has developed and tested a walking exercise self-management intervention—a tool that aims to improve exercise behavior and includes outcomes of walking, exercise, and health selfmanagement, he says. The intervention was developed from evidence-based health behavior approaches used with other chronic disease populations. The project included only participants with unilateral transtibial amputation who had either diabetes mellitus or peripheral artery disease.
“We enrolled participants at the end of their conventional prosthetic training,” explains Christiansen. The intervention included 12 weekly telehealth sessions between participants and an interventionist; each session involved a discussion to promote participant motivation and exercise behavior change. The intervention sessions comprised six primary components: self-monitoring (with use of a step-count monitor), tailored feedback, barrier/facilitator identification for reaching exercise goals, problem-solving, action planning, and encouragement. The overall goal was to have the participant use this behavior change framework to direct the sessions by the final week, according to Christiansen.
In an early clinical trial of the intervention, participants demonstrated a high level of adherence, and the results showed improved daily walking activity. Average daily step count in the intervention group increased by approximately 1,100 steps per day from baseline to the three-month time point, according to Christiansen. “Based on established cut points, the improvement in steps was clinically meaningful and represented a nearly 90 percent increase in overall daily steps.”
One of the biggest lessons learned from the research is that improving health self-management behaviors after lower-limb amputation requires focus on promoting self-efficacy and motivation, according to Christiansen. “In addition, our research results indicate that telehealth walking exercise selfmanagement intervention may help people with lower-limb amputation and vascular comorbidities be more physically active, potentially decreasing disability.”
The findings of Christiansen’s clinical trials provide outcome data that will inform not only patients and clinicians, but payors as well. “As our lines of research move from early phases conducted in our local region, to national multisite trials, we will be able to provide rationale for or against implementing and funding the novel interventions we study,” he says. His team has worked with implementation scientists to ensure they design interventions that can be easily translated to clinical practice. “In doing so, we have designed outcomes that can directly support the necessity of the interventions for all rehabilitation stakeholders, including payors.”
Promoting Teamwork
Christiansen notes that the success of his investigations depends on collaboration with allied health professionals. “As the Interdisciplinary Movement Science Lab name suggests, we intentionally focus on interdisciplinary work to maximize the clinical relevance of our research trials,” he explains. His research team comprises multiple professionals, including prosthetists, physical therapists, occupational therapists, psychologists, physiatrists, surgeons, nurses, engineers, and even patient-stakeholders. “We work within a framework that values the need for considering all rehabilitation disciplines to best address the complex nature of rehabilitation after lower-limb amputation.”
Christiansen believes it’s necessary for prosthetists to understand the value of addressing health behaviors to optimize physical health and disability outcomes. “This is particularly important for people with multiple comorbidities,” he says. “Our research
demonstrates that we must, as rehabilitation clinicians, address health behaviors to optimize rehabilitation and reverse some of the historically poor functional outcomes for older adults with nontraumatic amputation.”
Looking to the future, Christiansen hopes to examine ways to promote shared decision making between prosthetists and patients. One of the prosthetists on his team, Chelsey Anderson, CPO, is leading a study to inform development of a shared decision-making tool that addresses prosthesis design decisions for first-time prosthesis users. “This is an exciting line of research, as it blends qualitative and quantitative research in a manner to develop a novel tool that could be directly translated into O&P practice,” he says. The goal is to address gaps in knowledge for how to best support prosthesis design decisions and better incorporate patient-specific values and preferences. “Chelsey is leading her current study as the first PhD student on our team who is also a CPO, and I hope to have other prosthetists join our team as PhD students in the future.”
Added Responsibilities
Christiansen wears many hats and appreciates the many opportunities Christiansen at Yellowstone National Park
he has been afforded. In addition to research duties, Christiansen teaches movement science and amputation rehabilitation in the CU Doctor of Physical Therapy program and professional topics and research methods in the CU Rehabilitation Sciences doctoral program. He also mentors PhD students.
Before settling into a clinical research career, Christiansen, who is married with three active children, worked a variety of jobs. “I grew up in a family of blue-collar workers and spent much of my time working in physical labor jobs growing up,” he explains. To help fund his education, he worked as a fast-food employee, homebuilder, grocery-store clerk, tutor, and several other jobs. “In doing so, I learned the value of hard work. There is clear purpose in my work,” he says.
“I honestly love my job and find an academic research career to be very rewarding,” Christiansen adds. “It is exciting to work with people who are focused on advancing knowledge with the common goal of helping to improve the lives of others.”
Notable Works
Cory Christiansen, PhD, PT, has been involved in dozens of important published studies, including the following: • Anderson, C.B., Wurdeman, S.R., Miller, M.J.,
Christiansen, C.L., Kittelson, A.J. “Development of a Physical Mobility Prediction Model To Guide
Prosthetic Pehabilitation.” Prosthet Orthot Int, 2021; 45(3): 268-275. PMID: 33840752. • Miller, M.J., Mealer, M.L., Cook, P.F., Kittelson, A.J.,
Christiansen, C.L. “Psychometric Assessment of the
Connor-Davidson Resilience Scale for People With
Lower-Limb Amputation.” Phys Ther, 2021; April 4; 101(4): pzab002. PMID: 33421074. PMCID: PMC8023555. • Miller, M.J., Blankenship, J.M., Kline, P.W.,
Melanson, E.L., Christiansen, C.L. “Patterns of
Sitting, Standing, and Stepping After Lower-Limb
Amputation.” Phys Ther, 2021; 101(2): pzaa212.
PMID: 33336706; PMCID: PMC7921296. • Miller, M.J., Cook, P.F., Magnusson, D.M., Morris, M.A., Schenkman, M.L., Christiansen, C.L. “SelfEfficacy and Social Support Are Associated With Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation.” PM & R, 2021; 13(7): 737-745. PMID: 32926546; PMCID: PMC7873129. • Christiansen, C.L., Miller, M.J., Murray, A.M., Stephenson, R.O., Stevens-Lapsley, J.E., Hiatt, W.R., Schenkman, M.L. “Behavior-Change Intervention Targeting Physical Function, Walking, and Disability After Dysvascular Amputation: A Randomized Controlled Pilot Trial.” Arch Phys Med Rehabil, 2018; 99(11): 2160-2167. PMID: 29746823; PMCID: PMC6215727.
