Physical Therapy EBP 2016

Gabrielle Abate, SPT

Background:
• Post Partum Depression (PPD) 10-16% with symptoms lasting up to 1 year.
• Often goes undiagnosed or untreated.
• Adverse effects of pharmacological therapy with breast feeding and the stigma associated with taking antidepressants.

Clinical Scenario:
• 30 year-old female with complaints of low back and hip pain since having her first baby 4 months ago.
• She is worried her pain affects her ability to take care her daughter “the way a mother should”.
• She is taking antidepressant medication, but would rather not because she heard it may be harmful while breastfeeding
• She cannot sleep even if her baby sleeps. She cries daily and worries constantly. She does not feel hungry and is not eating regularly. Making decisions is overwhelming. She says she is not herself.
• Experiences urinary incontinence.
• She has not exercised in years.

PICO Question:
In women diagnosed with post partum depression (PPD) is exercise (including yoga and/or Pilates) a more effective treatment than standard care or no intervention for decreasing depressive symptoms?

Search Strategy:
Search Terms: “Exercise” AND “Post partum depression“ AND “Standard care” or “Usual care”.
Inclusion criteria:
• English language
• Dates 2000-2016
• Women diagnosed with PPD
• Exercise (one article including yoga or Pilates intervention)
• Control group consisting of usual care or no treatment
• Outcome measures
• Edinburg Postnatal Depression Scale (EPDS) score of greater or equal to 10
• Hamilton Depression Scale (HAM-D) score of greater or equal to 10

Results:

Evidence Summary:
• Exercise interventions are statistically significant and clinically meaningful for mild to moderate PPD.
• The experimental group may decrease symptoms quicker than the control group.

Clinical Bottom Line:
• Exercise interventions are statistically significant and clinically meaningful for mild to moderate PPD versus trial medicine especially given the adverse events to the infant.
• CEBM Level 2 recommendation that women diagnosed with mild to moderate PPD could benefit from receiving an exercise program to decrease depressive symptoms compared to usual care or no intervention.
• At long term follow up both groups had similar decrease in depressive symptoms.

Limitations:
• Poor generalizability due to lack of diversity in participant demographics and small sample sizes.
• No blinding of participants.
• Participants in the intervention group were not excluded if taking pharmacological therapies

Application to Case:
Evaluate and treat low back and hip pain while providing education on the benefits of exercise in treating PPD. Additionally, patient is provided with a home exercise program to increase endurance, strength, and flexibility. The program should consist of a walking program and strengthening and stretching exercises which could include a yoga video. Patient will attend therapy twice per week for two weeks and once per week for the next two weeks. Patient is referred to a pelvic floor therapist to treat urinary incontinence.

The Future:
• Exercise is an emerging treatment to treat post partum depression.
• What is our role in treating post partum depression in physical therapy?
o Thorough history-taking
o Adequate time spent with patients throughout care
o Administering a depression scale when applicable 
o Tailor treatment plan to our patients’ needs

References:
1. Armstrong and Edwards. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. International journal of nursing practice. 2004. 10.4: 177-194.
2. Buttner. Brock. O’Hara, et al. Efficacy of yoga for depressed postpartum women: A randomized controlled trial. Complementary Therapies in Clinical Practice, 2015; 21, 94e100.
3. Da Costa, Lowensteyn, Abrahamowicz, et al. A Randomized clinical trial of exercise to alleviate postpartum depressed mood. Journal of Psychosomatic Obstetrics & Gynecology. 2009. 30(3): 191-200.
4. Daley, Blamey, Jolly, et al. A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM- PeRS trial. Psychological Medicine, 45(11), pp. 2413–2425. doi: 10.1017/S0033291715000409.
5. Shu-Shya Heh, RN, MPhil, Lian-Hua Huang, RN, PhD, Shiao-Ming Ho, EdD, et al. Effectiveness of an Exercise Support Programin Reducing the Severity of Postnatal Depression in Taiwanese Women. BIRTH 35:1 March 2008.

Background:

It is well documented that survivors of stroke are at an increased risk of falls relative to age-matched controls.^1,2 Ability to take a reactive step is paramount in recovery from an unexpected loss of balance.^3,4 Therefore impaired reactive stepping has been proposed as one important component of the multivariate nature of falls following a stroke. One value that has been the topic of discussion in reactive stepping literature is the TFO, or time to foot off. This measure represents the time between the release of external support of an individual leaning their center of mass (anteriorly) outside of their base of support, to the time in which their body weight is no longer supported by the limb in which they choose to step. Characteristics of impaired reactive stepping have been shown to correlate with falls in elderly populations.²

Search Strategy:

Pub Med:  Search Terms: (((stepping) OR reactive stepping) AND poststroke) OR reactive stepping[Title/Abstract]

CINAHL: Boolean/phrase: reactive stepping OR stepping AND poststroke

WOS: Search strategy : TITLE: (reactive stepping) AND TOPIC: (stroke)

Inclusion Criteria:

-Participants must be above the age of eighteen and had their neurologic incident at least two weeks prior to enlisting in the study in order to be considered ‘chronic.’

-The methodology of how the researchers obtained values related to perturbation or reactive response must be clearly explained within the article.

-At least one outcome related to falls in the stoke population must have been collected.

Exclusion Criteria

-Articles which only examined metrics on gait or focused on outcomes related to gait.

-Level V evidence

Rationale for data collection:

A lack of association between reactive stepping impairment and utilized clinical measures (BBS, gait velocity, STRATIFY falls risk tool) has been identified. This suggests a limitation may exist when drawing inferences with these measures to predict likelihood of falls. Therefore we may be missing a critical evaluative component in this patient population, which could also help us streamline our intervention. In addition, falls render increased healthcare utilization and diminished quality of life of affected individuals.

Methods:

-Setting and participants:

Leahy lab at the University of the Sciences in Philadelphia. Subjects (n=6) recruited as part of a larger study at the university lab investigating moderate intensity walking in people with stroke. Subjects recruited from local physical therapy clinics, stroke support groups, and individuals who have participated in research and classroom activities previously at the USciences Department of Physical Therapy. Healthy controls (n=5) are healthcare students recruited by convenience.

Inclusion:

-People over the age of 18 years with one or more strokes at least 3 months previously

-Ambulatory without physical assistance of other person (orthotic devices, canes or walkers will be allowed)

-Able to follow instructions and able to communicate with investigators as assessed by specific NIH Stroke Scale questions.

Exclusion:

-Bone or joint problems that limit the ability to walk

-Resting hear rate outside of the range of 40-100 beats per minute

-Resting blood pressure outside of the range of 90/60 to 170/90 mm Hg

-Chest pain or shortness of breath with exertion

-Score of >1 on question 1b and >0 on question 1c on the NIH Stroke Scale inability to communicate with investigators.

Demographics:

Control group:

Affected group:

Upon entering clinic individuals were oriented to the purposed of the study, screened to be deemed fit for inclusion, and consented for participation. Then the following outcomes were collected: TUG, TUG_manual, TUG_cognitive, 6MWT, 4 square step test (modified if unable), gait velocity-preferred, and gait velocity-fast.

They then underwent the reactive stepping assessment. They underwent five trials where they were able to step with whatever limb they desired. Following this five trials were done while blocking the preferred limb in an attempt to elicit a step with the non-preferred limb.

The method for each trial is as follows:

1. Participant is to stand statically in their preferred foot position inside of a body weight support system designed to catch them if an attempt to regain balance is failed.
2. Patient will be positioned on a GaitRite system. (Collecting data through ProtoKinetics Movement analysis software)
3. A gait belt is then locked into a closed loop around the patient by tester #1 and placed outside of the subject’s shoulders, utilizing the acromion bilaterally as the landmark of standardization.
4. A Lafayette Manual Muscle Testing myometer is then placed inside of the gait belt (with the screen visible to tester #1) so as to garner the force paced upon it when the gait belt pulls forward, as described in step #6.
5. Tester #1 checks to make sure both feet are in alignment before having subject lean.
6. As tester #1 holds the myometer statically in place, the individual is instructed to progressively lean forward into the gait belt until 8-10% of their precalculated bodyweight is displayed on the readout. The subject is then instructed to hold this position as best they can.
7. The subject is then released 2-10 seconds after they are instructed to hold their ‘forward leaning’ position with the desired % body weight. At this time the subject is release by tester #1, inducing a reactive stepping response. If at any point the subject falls outside of the 8-10% range of their bodyweight, the process will be started over again from step #4.

Data Extraction

Extracting the TFO value was done utilizing the PKMAS software system for the GaitRite mat. In the photo below the box labeled ‘temporal 4’ gives the indication of when the subject was released through the sharp increase in slope of the center of pressure (red) reading. This time is noted, and the time at which pressure is no longer picked up by the stepping limb is noted. The time between these two values is noted. The GaitRite mat has a sampling rate of 120 Hertz, therefore frames are captured every 8 milliseconds.

_{Statistical analysis:}

Nonparametric

Independent-samples Mann-Whitney U test

-To identify between-group differences in TFO and outcome measures

Spearman rank correlation coefficient (Spearman’s rho)

-To identify correlation between TFO and outcome measures

Wilcoxon signed-ranks test

-To identify between-limb differences in stroke and control group

Results:

**Red indicates statistical significance

Wilcoxon Signed ranks test

-No significant difference between TFOu and TFOr in either group.

M-WU:

Limitations:

-Inherent limitation in methodology (e.g. handheld myometer use). Non age-matched controls from sample of convenience. Small sample size limits generalizability and ability to establish validity.

Suggestions for future research:

Larger sample sizes. Research individuals who have experienced a stroke compared to age-matched cohort. Correlate TFO values with fall rates in the community. Explore utility of this measure as an outcome and how it responds to interventions. Cost-effective methods of collecting value in outpatient realm.

Citations

1.Maki B, Edmonstone M, Perry S, Heung E, Quant S, McIlroy W. Control of rapid limb movements for balance recovery: do age-related changes predict falls risk? Control of Posture and Gait. Maastricht, the Netherlands: International Society for Postural and Gait Research; 2001: 126-129.

2.Hilliard MJ, Martinez KM, Janssen I, et al. Lateral balance factors predict future falls in community-living older adults. Arch Phys Med Rehabil. 2008;89: 1708-1713

3.Maki BE, McIlroy WE. The role of limb movement in maintaining upright stance: the “change-in-support” strategy. Phys Ther. 1997;77: 488-507.

4.Maki BE, McIlroy WE. Control of rapid limb movements for balance recovery: age-related changes and implications for fall prevention. Age Ageing. 2006;35(suppl 2): ii12-ii18.

5 articles from search:

1. Mansfield A, Inness EL, Wong JS, Fraser JE, McIlroy WE. Is impaired control of reactive stepping related to falls during inpatient stroke rehabilitation? Neurorehabil Neural Repair. 2013;27:526-33.
2. Inness EL, Mansfield A, Lakhani B, Bayley M, McIlroy W. Impaired reactive stepping among patients ready for discharge from inpatient stroke rehabilitation. Phys Ther. 2014;94:1755-64.
3. Martinez KM, Mille M, Zhang Y, Rogers MW. Stepping in persons poststroke: comparison of voluntary and pertubation-induced responses.  Arch Phys Med Rehabil. 2013; 94:2425-32.
4. Inness EL, Mansfield A, Bayley M, McIlroy WE. Reactive stepping after stroke: determinants of time to foot off in the paretic and nonparetic limb. Journal of Neurologic Physical Therapy. 2016; 40:196-202.
5. Lakhani B, Mansfield A, Inness E, McIlroy WE. Compensatory stepping responses in individuals with stroke: a pilot study. Physiotherapy Theory and Practice. 2011; 27(4): 299-309.

Background:

• More than 795,000 people suffer from a cerebral vascular accident (CVA) each year
  • Ischemic strokes account for approximately 87% of all CVA’s
• Leading cause of disability in the United States
• CVA’s cost an estimated $34 billion each year
  • Includes medication costs, health care services, and missed work days
• Repetitive Transcranial Magnetic Stimulation (rTMS) is a device that uses an electromagnet to stimulate small areas of the brain
  • This is achieved by low or high frequency magnetic pulses that send an electric current across the brain tissue
• Low frequency stimulation has inhibitory effects
  • Transcallosal Disinhibition: By inhibiting the non-lesioned hemisphere the theory is that competition between hemispheres is decreased and it allows for more cortical excitability due to the non-lesioned hemisphere no longer inhibiting the affected hemisphere.
• High frequency stimulation has excitatory effects

Image source: www.practicalpainmanagement.com

Case Scenario:

• Hank is a 66 y.o. male diagnosed with a left middle cerebral artery thrombotic infarction 2 weeks ago.  He underwent surgery for recanalization of his left MCA and was placed on anticoagulants. Hank has a past medical history of hypertension, diabetes mellitus II, and peripheral vascular disease.

  Upon exam Hank was A&O x 3, able to follow commands, and provide social history. He is a retired school teacher who enjoys working on antique cars in his free time. Hank lives at home in a 1 story house with his wife and was previously independent with all ADLs and IADLs. He denies any pain but states, “I just can’t really feel my left hand very well.”  Hank is 6’1” and 182 lbs and right hand dominant.

   

  Hank is very hopeful that PT will “get his arm moving like it used to” so he has the upper extremity strength and hand dexterity to continue working on his cars.

Image Source: www.radiologyassistant.nl

Key Exam Findings:

• Right upper extremity demonstrates a flexion synergy pattern with AROM
• Manual muscle tests of the right upper extremity
  • Shoulder flexion 3/5
  • Elbow flexion 2/5
  • Elbow extension 2/5
  • Decreased grip strength
• Diminished sensation to light touch in right upper extremity throughout C6-T1 dermatomes

PICO Question:

Does repetitive transcranial magnetic stimulation before activity training enhance upper extremity motor recovery in adults s/p CVA?

Search Strategy:

The following limits were applied: Published within the past 10 years, human species, English language, Meta-analyses, Systematic Reviews, RCTs

Inclusion Criteria, article must include:

• Adults (>18 years old) who present with upper extremity paresis after stroke
• At least one intervention arm that consisted of repetitive transcranial magnetic stimulation to either the ipsilesional or contralesional hemisphere
• At least one intervention arm that consisted of motor/activity training after stimulation
• Assessment of at least one of the following outcome measures:
  • Fugl- Meyer Assessment
  • Wolf Motor Function Test
  • 9 Hole Peg Test
  • Grip strength
  • Upper limb force production

Exclusion Criteria, article cannot include:

• Stimulation to areas of the brain other than M1 or the premotor cortex
• Other non-invasive brain stimulation techniques

Evidence Summary Table:

Clinical Bottom Line:

There is moderate to high-quality evidence that suggests low frequency, inhibitory repetitive magnetic transcranial stimulation (rTMS) to the contralesional hemisphere may be an effective intervention in facilitating upper extremity motor recovery in those with chronic stroke. However, more research is needed to determine this treatments effectiveness in other stroke populations.

rTMS is an emerging intervention in stroke rehabilitation, and the current evidence varies greatly in terms of acuity of stroke, type of stimulation administered, hemisphere stimulated, and type of motor training performed after rTMS intervention. These variations across studies made it more difficult to draw a consistent conclusion from all articles reviewed.

Application to Case Scenario:

• The literature does not suggest that rTMS will have a significant effect on the patient in my case scenario based on the acuity of his stroke as he is 2 weeks s/p CVA.
  • POC for my patient:
    • Interventions will include:
      • Weight bearing exercises through the affected upper extremity
      • Reaching tasks
      • Active assisted range of motion exercises
      • Goal of progressing to strength training and fine motor skill training
  • Discharge plan for outpatient PT

Acknowledgements: Dr. Richard Lauer, PhD

References:

1.  Hao Z, Wang D, Zeng Y, Liu M. Repetitive transcranial magnetic stimulation for improving function after stroke. Cochrane Database Syst Rev. 2013;(5):CD008862.

2. Hsu WY, Cheng CH, Liao KK, Lee IH, Lin YY. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: a meta-analysis. Stroke. 2012;43(7):1849-57.

3. Etoh S, Noma T, Ikeda K, et al. Effects of repetitive trascranial magnetic stimulation on repetitive facilitation exercises of the hemiplegic hand in chronic stroke patients. J Rehabil Med. 2013;45(9):843-7.

4. Seniów J, Bilik M, Leśniak M, Waldowski K, Iwański S, Członkowska A. Transcranial magnetic stimulation combined with physiotherapy in rehabilitation of poststroke hemiparesis: a randomized, double-blind, placebo-controlled study. Neurorehabil Neural Repair. 2012;26(9):1072-9.

5. Wang CC, Wang CP, Tsai PY, Hsieh CY, Chan RC, Yeh SC. Inhibitory repetitive transcranial magnetic stimulation of the contralesional premotor and primary motor cortices facilitate poststroke motor recovery. Restor Neurol Neurosci. 2014;32(6):825-35.

For further questions please contact: brooke.walters@temple.edu

Background

Parkinson’s disease is a progressive neurological condition that often results in a high risk of falls due to disordered motor control and postural instability. Research involving this population has focused on challenging impaired systems, and has demonstrated that using motor learning principles individuals with Parkinson’s disease are capable of learning motor tasks. In unimpaired populations self-controlled practice has consistently been shown to have positive effects on learning motor skills. Using this type of practice method, learners are given control over a certain aspect of the practice condition. To determine learning effects, controls are “yoked,” or matched to, self-controlled practice conditions.

Clinical Scenario

Mr. Parker is a 65 year old retired entrepreneur who presents to outpatient physical therapy with a 9 year history of Parkinson’s disease classified as Stage III on the Hoehn and Yahr scale. His past medical history is unremarkable with the exception of reporting two falls in the past month while walking in his home. Current medication includes Levadopa.

On examination, key findings were consistent with a typical Parkinsonian presentation including rounded shoulders and a forward head posture. He had diminished sensation on the plantar surface of his feet and reduced ROM and strength bilaterally. Balance and proprioception were decreased. The patient required minimal assist with bed mobility and transfers and presented with hypokinetic movement patterns. Gait assessment with close supervision and assistive device use revealed reduced stride length and speed, festination and freezing, reduced head, trunk, and arm movement, decreased hip and knee flexion during swing, and decreased ankle dorsiflexion at heel strike.

Mr. Parker’s goals include decreasing caregiver burden and difficulty with ADLs, improving strength in his lower extremities, improving balance to reduce falls and promote adherence to his HEP, and accompanying his wife of 40 years on long walks around their retirement community.

PICO Question

In patients with Parkinson’s disease (Stages II-IV Hoehn and Yahr) are self-controlled practice conditions during functional activity training an effective motor learning technique for improving balance and reducing the risk of falls?

Search Strategy & Results

Limits: English language & Humans

PubMed

(self-controlled feedback) AND motor learning

Ovid

self-controlled AND balance

CINAHL

Self-controlled feedback AND balance

Evidence Appraisal & Study Participants

Interventions

In the first study by Hartman (2007) participants were required to balance on a stabilometer, attempting to maintain it in a horizontal position. After each practice phase, participants completed a questionnaire adapted from Chiviacowsky and Wulf (2002). The self-control group was asked when and why they did or did not request the balance pole. The yoked group was asked if they received the pole after the correct trials and if not when they would have preferred to have used the pole. The self-control group chose when and whether they used a balance pole during practice trials.

Acquisition Days 1 & 2: 10 – 30 sec trials; 15 sec rest periods

Retention Day 3: 10 – 30 sec trials; 15 sec rest periods

In the second study by Wulf and Adams (2014) participants were asked to perform 3 balance tasks: Toe Touch, Head Turn, and Ball Pass using their dominant leg first. The choice group was able to choose the order of the tasks.

Acquisition Day 1: 3 exercises 5x each (R & L leg)

Retention Day 2: 3 exercises 2x each (R & L leg)

In the third study by Lewthwaite, et al. (2015) participants were once again required to balance on a stabilometer, keeping the platform as close to horizontal as possible. They were given feedback about their time in balance after each practice trial. The choice group was presented with two choices unrelated to the primary motor task to determine if it would have an impact on task learning.

Acquisition Day 1: 10 – 30 sec trials; 90 sec rest periods

Retention Day 2: 5 – 30 sec trials; 90 sec rest periods

In the fourth study by Yoon, et al. (2013) subjects had to maintain an upright position for 10 seconds on a stabilometer. The choice group chose when they wanted visual feedback from the monitor, while a third group, the control group, received none.

Acquisition Day 1: 10 trials/block x 4 blocks

Retention Day 2: 10 trials/block x 2 blocks

In the fifth study by Chiviacowsky, et al. (2012) participants with Parkinson’s disease balanced on a stabilometer while wearing a safety harness to prevent falls. At the end of practice on day 1 and after the retention test on day 2 a customized questionnaire was completed. Participants in the self-control group could request the pole on any trial     during the practice session.

Acquisition Day 1: 10 – 30 sec trials; 90 sec rest periods

Retention Day 2: 5 – 30 sec trials; 90 sec rest periods

*Participants in the yoked groups for all five studies were matched to self-controlled conditions.

Results

Wulf & Adams (2014)

In comparison to the control group the choice group had fewer errors (indicating a greater time in balance) during both the practice and retention phases when given a choice as to the order of their tasks.

Lewthwaite, et al. (2015)                                   Chiviacowsky, et al. (2012)

The learning curves pictured above depict time in balance during practice and retention trials for unimpaired university students highlighted in green and individuals with Parkinson’s disease in yellow. In both studies the self-controlled group had longer times in balance compared to the yoked group. In individuals with Parkinson’s disease less time in balance is spent overall compared to healthier counterparts, as indicated by the time intervals on the y axis. However, as compared to those in the yoked group, in individuals with Parkinson’s disease time in balance immediately improved after the first trial. During the retention phase there was a small drop-off in learning during the first trial, but improvements in time in balance continued throughout the fourth trial. Although individuals with Parkinson’s disease tend to learn balance tasks more slowly, this study provides evidence that greater learning effects can occur when self-controlled practice conditions are utilized.

Hartman (2007)

The self-control group outperformed the yoked group (greater time in balance) on day 2 and during retention trials.

Yoon, et al (2013)

The self-controlled group had significantly smaller left/right and anterior/posterior body sway amplitudes.

Evidence Summary

More effective learning occurs when participants have the opportunity to control some aspect of the practice condition, including the use of an assistive device or when they receive feedback.

Clinical Bottom Line

There is limited, low quality evidence that suggests that self-controlled practice conditions during functional activity training are an effective motor learning technique for improving balance and reducing the risk of falls in patients with Parkinson’s disease. Additionally, there is ample, higher quality evidence demonstrating more effective learning under self-controlled practice conditions relative to yoked conditions in unimpaired individuals.

Application of the Evidence

Although the evidence is limited, self-controlled practice conditions improved time in balance in study participants with Parkinson’s disease and should be implemented in Mr. Parker’s plan of care. Using a walking program to help improve his balance, Mr. Parker can choose when he receives kinesthetic feedback. He will be informed that he may touch the wall in the clinic as needed or when he chooses while maneuvering around and over a variety of objects and surfaces. Our goal will be to get him to eventually walk around his retirement community at least 20 minutes a day safely with an assistive device. As we work up to this goal, other forms of feedback will be provided as needed in order to ensure Mr. Parker’s safety and promote appropriate decision making processes during home and community ambulation.

References

1. Hartman JM. Self-controlled use of a perceived physical assistance device during a balancing task. Percept Mot Skills. 2007;104:1005-1016. http://pms.sagepub.com/content/104/3/1005.full.pdf.
2. Wulf G, Adams N. Small choices can enhance balance learning. Hum Mov Sci. 2014;38:235-240.
3. Lewthwaite R, Chiviacowsky S, Drews R, Wulf G. Choose to move: the motivational impact of autonomy support on motor learning. Psychon Bull Rev. 2015;22(5):1383-1388. http://link.springer.com/article/10.3758%2Fs13423-015-0814-7.
4. Yoon J-G, Yook D-W, Suh S-H, Lee T-H, Lee W-H. Effects of self-controlled feedback on balance during blocked training for patients with cerebrovascular accident. J. Phys. Ther. Sci. 2013;25:27-31. https://www.jstage.jst.go.jp/article/jpts/25/1/25_JPTS-2012-251/_pdf.
5. Chiviacowsky S, Wulf G, Lewthwaite R, Campos T. Motor learning benefits of self-controlled practice in persons with Parkinson’s disease. Gait Posture. 2012;35(4):601-605.

Case Scenario: 

A 50 year old male presents to physical therapy with a chief complaint of numbness and tingling as well as decreased sensation in his distal lower extremities, which he states has gradually gotten worse over the past 3 months. The patient has a 10 year history of Type II Diabetes, which he admits he does not manage well. When asked, the patient was unsure of his HbA(1c) and reports not measuring his glucose levels regularly or observing his feet for integumentary changes. After seeing his primary care practitioner last month, he was referred to an endocrinologist. The endocrinologist has recently prescribed him Lyrica for the nerve pain. The patient reports that the prescription makes drowsy and dizzy, and that “he’d really rather not take it”. The patient denies any acute trauma or injury, night pain, or changes in bowel or bladder. He is a construction worker in the local union and is on his feet for most of the work day. He states that the decreased sensation as well as the numbness and tingling in his toes is impacting his ability to perform at work, particularly climbing ladders at construction sites. He also says that he used to golf every other Saturday, but has not been able to because of the symptoms he is experiencing in his feet. His goal for physical therapy are to find the cause of his pain, and to be able return to golfing 2x/month, as well as safely climbing the ladder at work. After educating the patient on the importance of managing glucose levels through adhering to medications and through exercise and a healthy diet, the patient also made it a goal to exercise more, monitoring glucose levels after every meal, improve his diet, and monitor skin changes.

Outcomes:

HbA(1c)- 6.8%

NPRS: Average 5/10

PSFS: Golf- 3, Stand for >1 hour

Activities-Specific Balance Confidence Scale: 70%

Presentation:

Sitting posture examination appears within normal limits. When transferring from sit to stand, patient takes increase time to stand and weight bear through both lower extremities. Patient appears unsteady while standing and weight is transferred over right lower extremity. Lumbar active range of motion: within functional limits for flexion, extension, and right and left lateral flexion. Although, during these screens, patient was unsteady and had to use a “step-recovery” strategy to regain mild loses of balance. Lower quarter neuro examination consisting of dermatomes, myotomes, and deep tendon reflexes revealed decreased sensation along L5 and S1 (bilaterally), decreased deep tendon reflex (1+) left S2, and grossly normal myotomes. Slump test elicited no neural signs. When testing sensation using the Semmes-Weinstein Monofilaments, patient did not sense the 4.31 monofilament on the plantar surface of both lower extremities, which correlates to decreased protective sensation and diminished light touch. Supine examination revealed overall gross tightness in bilateral hamstrings, iliopsoas, and ITB. Central PAs over lumbar spine reproduced no pain or neural signs. Upon observation of plantar surface of feet, stage I ulceration was visible on both the heel and great toe of the left lower extremity.

Search Strategy & Results

Inclusion Criteria, Article must include:

• Adults (>45 years old)
• Patients with Type II Diabetes
• Intervention includes interval training, OR aerobic AND resistance training, but not solely resistance training
• Utilizes HbA(1c) as a clinical marker/outcome measure

Exclusion Criteria, Article cannot include:

• Patients (<45 years old)
• Patients with Type I Diabetes
• Articles examining outcomes of resistance interval training
• Article did not use HbA(1c) as a clinical marker/outcome measure

Databases Searched:

• PubMed
  • Search terms: “high intensity interval training” OR “aerobic interval training” AND “hemoglobin)” AND “diabetes”
    • Madsen SM, Thorup AC, Overgaard K, Jeppesen PB. High intensity interval training improves glycaemic control and pancreatic beta cell function of type 2 diabetes patients. PLoS One. 2015;10(8):e0133286. doi: 10.1371/journal.pone.0133286 [doi]
    • Mitranun W, Deerochanawong C, Tanaka H, Suksom D. Continuous vs interval training on glycemic control and macro- and microvascular reactivity in type 2 diabetic patients. Scand J Med Sci Sports. 2014;24(2):e69-76. doi: 10.1111/sms.12112 [doi].

• CINAHL
  • Search terms: “high intensity interval training” OR “aerobic interval training” AND “HbA(1c)” AND “diabetes”
    • Terada T, Friesen A, Chahal BS, Bell GJ, McCargar LJ, Boule NG. Feasibility and preliminary efficacy of high intensity interval training in type 2 diabetes. Diabetes Res Clin Pract. 2013;99(2):120-129. doi: 10.1016/j.diabres.2012.10.019 [doi].

• Web of Science
  • Search terms: “type II diabetes” AND “aerobic interval training” OR “high intensity interval training” AND “HbA(1c)
    • Alvarez C, Ramirez-Campillo R, Martinez-Salazar C, et al. Low-volume high-intensity interval training as a therapy for type 2 diabetes. Int J Sports Med. 2016;37(9):723-729. doi: 10.1055/s-0042-104935 [doi].
    • Karstoft K, Winding K, Knudsen SH, et al. The effects of free-living interval-walking training on glycemic control, body composition, and physical fitness in type 2 diabetic patients: A randomized, controlled trial. Diabetes Care. 2013;36(2):228-236. doi: 10.2337/dc12-0658 [doi].
    • Balducci S, Zanuso S, Cardelli P, et al. Effect of high- versus low-intensity supervised aerobic and resistance training on modifiable cardiovascular risk factors in type 2 diabetes; the italian diabetes and exercise study (IDES). PLoS One. 2012;7(11):e49297. doi: 10.1371/journal.pone.0049297 [doi].

Evidence Summary and Appraisal

There is moderate-level evidence that suggests that high intensity interval training is an effective method for lowering the HbA₁C levels in adults with Type 2 Diabetes. As the overall benefits of high intensity interval training are becoming more evident, it was prudent to justify its presence in the management of Type 2 Diabetes. However, it is difficult to draw a cohesive conclusion, as the studies examined utilize a variety of training protocols. Additionally, 4/6 studies compared high intensity training to continuous or low intensity, whereas 1 study compared high intensity to a non-exercise control group, and a final study compared the Type 2 Diabetes group to a healthy control group. This makes it challenging to draw a consistent parallel between the current published literature and the stance practitioners should take when prescribing exercise for patients with Type 2 Diabetes. Although many of the studies presented statistically significant results in favor of high intensity interval training, only one study was able to produce clinically significant results when comparing high intensity interval training to continuous training. In patients with already well-managed Type 2 Diabetes, training at either high or low intensities did not seem to make an effect on HbA₁C values. The American College of Sports Medicine along with the American Diabetes Association recommend >150 minutes of low-moderate exercise per week for the management of Type 2 Diabetes. HIIT provides these patients the same benefits, but the training protocols require less time and allow for periodic rest breaks. Overall, it is conclusive that both high intensity interval training and low intensity interval training can be utilized in

the management of Type 2 Diabetes. But, what sets high intensity interval training apart from other intervention is that it is more efficient, cost effective, and less time consuming, making it more favorable and potentially leading to higher adherence rates. There a variety of different forms of HIIT, which makes it utility in practice extremely practical and can be utilized in all physical therapy settings, and when prescribed from a health care practitioner, specifically a physical therapist, it can be safely performed in the home as a part of a home exercise program.

Application of Evidence

Sample Protocol:

High intensity interval training can be easily implemented into practice across all physical therapy settings. There is a large number of forms of high intensity training that can be utilized in practice. Depending on the technology available, 70-90% VO2max, 70-90% max HR, or Borg Rate of Perceived Exertion Scale can be used to ensure the patient is exerting themselves at the appropriate intensity. One of the protocols used in the reported studies can be used or modified to best suit the patient.

Depending on their preferred method of exercise, interventions can be tailored to best suit the desires/preferences of the patient. As presented in the literature, training programs can implement any form of exercise, from walking, cycling, and jogging. Other forms could include circuit training, such as plyometrics, or skipping rope. The main goal of treatment although, is to reach a particular pre-determined intensity, whether determined through heart rate, VO2 max, or RPE.

Based on our patient’s presentation, he will benefit from comprehensive and progressive balance training. Exercises can be taught to the patient in the clinic, but then can be completed at home a part of a home exercise program. Due to the flexibility of the training programs and its feasibility to be completed outside of the clinic, the patient should only have to be seen at the time of training progressions, in the absence of adverse events.

References 

1. Alvarez C, Ramirez-Campillo R, Martinez-Salazar C, et al. Low-volume high-intensity interval training as a therapy for type 2 diabetes. Int J Sports Med. 2016;37(9):723-729. doi: 10.1055/s-0042-104935 [doi].

2. Karstoft K, Winding K, Knudsen SH, et al. The effects of free-living interval-walking training on glycemic control, body composition, and physical fitness in type 2 diabetic patients: A randomized, controlled trial. Diabetes Care. 2013;36(2):228-236. doi: 10.2337/dc12-0658 [doi].

3. Madsen SM, Thorup AC, Overgaard K, Jeppesen PB. High intensity interval training improves glycaemic control and pancreatic beta cell function of type 2 diabetes patients. PLoS One. 2015;10(8):e0133286. doi: 10.1371/journal.pone.0133286 [doi].

4. Mitranun W, Deerochanawong C, Tanaka H, Suksom D. Continuous vs interval training on glycemic control and macro- and microvascular reactivity in type 2 diabetic patients. Scand J Med Sci Sports. 2014;24(2):e69-76. doi: 10.1111/sms.12112 [doi].

5. Terada T, Friesen A, Chahal BS, Bell GJ, McCargar LJ, Boule NG. Feasibility and preliminary efficacy of high intensity interval training in type 2 diabetes. Diabetes Res Clin Pract. 2013;99(2):120-129. doi: 10.1016/j.diabres.2012.10.019 [doi].

6. Balducci S, Zanuso S, Cardelli P, et al. Effect of high- versus low-intensity supervised aerobic and resistance training on modifiable cardiovascular risk factors in type 2 diabetes; the italian diabetes and exercise study (IDES). PLoS One. 2012;7(11):e49297. doi: 10.1371/journal.pone.0049297 [doi].

Background

• Cerebral Palsy (CP) is the most common motor disability in children.¹
• 1986 Congress established the early intervention program for infants and toddlers with disabilities, as part of the Individuals with Disabilities Education Act (IDEA).²
• “IDEA Part C states that infants and toddlers with disabilities receive needed early intervention services in the natural environments to the maximum extent appropriate.”²
  • May be provided in other settings only when the services cannot be achieved satisfactorily in a natural environment.²
• “According to the Data Accountability Center, in 2011, a total of 336,895 eligible infants and toddlers birth through age 2 received early intervention services under Part C of IDEA.”²

Clinical Scenario

• 15 month old male with recent diagnosis of spastic diplegic Cerebral Palsy
• Born via C-Section at 32 weeks with initial Apgar score of 2
• 4^th degree intraventricular hemorrhage at 2 weeks
• Unable to sit up on his own
• Maintains ATNR & TLR Reflexes
• No righting responses
• Peabody Developmental Motor Scale: 45 (“very poor”)
• Goal: sit independently and introduce quadruped

PICO

• What are the effects of early intervention on motor function in children who have, or are at a high risk of developing cerebral palsy?

Search Strategy

Results

Hielkema et. Al, 2011³

• RCT, CEBM Level 2, PEDro 9/11; Netherlands
• Participants
  • 46 patients, corrected age 3 months with abnormal general movements at 10 weeks of age
• Intervention (3 month minimum; then varied)
  • COPCA (COPing and Caring for Infants with Special Needs)
  • TIP (Traditional Infant Physiotherapy)
• Outcome Measure
  • Infant Motor Profile (IMP)
• Results
  • No statistical difference between groups
  • Self-produced movement behavior with little variation has positive correlation

Morgan et. Al, 2015⁴

• Pilot RCT, CEBM Level 3, PEDro 9/11; Australia
• Population
  • 13 infants, corrected age 3-5 months with abnormal general movements between 11-18 weeks
• Intervention (3 months)
  • GAME (Goal- Activity- Motor Enrichment)
    • GAME Intervention- Focuses on goal oriented intensive motor training in which the infant can always actively complete part of the task.
    • Parent Education to identify when a child is voluntarily trying to move, how to stimulate progress and identify naturally occurring opportunities for learning.
    • Environment Enrichment- setting up an environment to stimulate movement and matching the toy selection to the desired task.
  • Standard Care (Movement patterns & parental advice on positioning & handling)
• Outcome Measure
  • PDMS-2 (Peabody Developmental Motor Scale 2)
• Results
  • Total Motor Quotient (TMQ) & the Total Motor Subscale of Peabody both statistically significant over the standard care group
    • GAME intervention had an 8.05 point improvement in TMQ and a 5.72 advantage improvement in total motor subscale over the standard care group.
  • Post hoc analysis- significant difference between groups in number of hours of therapy time and HEP time. GAME group received an average of 9.93 hours and the SC group received 3.49 (this could also account for the differences between groups outcome scores)

Morgan et. Al, 2016⁵

• RCT, CEBM Level 2, PEDro 7/11; Australia
• Population
  • 30 infants, corrected age 3-4 months with abnormal general movements or 5-6 months with CP diagnosis or abnormal neuroimaging resulting in CP diagnosis extremely likely
• Intervention (Until 1 y.o)
  • GAME (Goal-Activity- Motor Enrichment)
  • Standard Care (milestone attainment directed)
• Outcome Measure
  • PDMS-2 (Subscale- Total Motor Quotient)
  • GMFM (Gross Motor Function Measure)
• Results
  • All outcome measures were statistically significant in favor of the GAME intervention group

Zhang et. Al, 2015⁶

• Longitudinal Cohort, CEBM Level 3, Downs & Black 19/27; China
• Population
  • 48 infants (Under 2 years of age) with a confirmed diagnosis of CP
• Intervention (3 months)
  • Comprehensive Rehab
    • Comprehensive Rehab consisted of PT, OT, Speech, and multiple alternative medicine approaches
  • Outcome Measure
    • GMFM
    • FMFM (Fine Motor Function Measure)
  • Results
    • Greater improvements and more statistical significance seen when initiated before 12 months of age

Mahoney et. Al, 2001⁷

• Field Based Study, CEBM Level 3, Downs & Black 18/27; USA
• Population
  • 50 infants, average age of 14 months; 23 with CP & 27 with DS
• Intervention (1 Year, Apx. 40 sessions)
  • DevS (Developmental Skills)
    • 5 Developmental skills sites- comprehensive early intervention service programs with 45% having physical therapy training.
  • NDT (Neuro-Developmental Treatment)
    • 4 NDT Sites– 3 hospital based, 1 comprehensive center-based early intervention program- children with motor disabilities– 77% of PTs at NDT sites were NDT certified
  • Outcome Measure
    • PDMS-2
  • Results
    • No statistical significance in PDMS scores
      • Unable to determine if the improved scores are due to treatment or the natural growth and development over a 1 year period.

Heathcock et. Al, 2015⁸

• Case Series, CEBM Level 4, Downs & Black 14/27; USA
• Population
  • 2 infants with spastic quadriplegic CP, GMFCS Level 5
• Intervention (4 weeks)
  • 2 hours/day for 5days/week for 4 consecutive weeks- 40 hours total
  • Outpatient therapist-directed PT treatment
    • Developmental positioning and anti-gravity movement
  • Outcome Measure
    • GMFM- 66
    • GMFM-88
  • Results
    • Clinically meaningful change for both children in both outcome measures
      • Clinically Meaningful Change: GMFM- 66- 1.58 points; GMFM-88- 1.29 points
      • Child A- GMFM- 66 score improved by 6.06 and GMFM-88 improved by 12 points
      • Child B- GMFM-66 scores improved by 9.3 and GMFM-88 improved by 16 points
    • Family & Therapist goals were met

Limitations

• Only 2 studies with similar interventions
• Experimental interventions were not standardized or explained in detail
• Lack of description of the standard care groups (control group)
• Small samples sizes
• Minimal to no description of intervention dosage
• Relatively short time frames for the length of the studies
• Lack of studies which are CEBM levels 1 & 2

Clinical Bottom Line

• The evidence shows that beginning early intervention PT before 1 year old has increased improvements for motor performance in children with, or are at a high risk of developing CP.
• There is insufficient evidence as to what form of physical therapy intervention is superior and what the correct dosage should be.
  • However, the lower quality studies included suggest high intensity is correlated with increased improvements.

Application to Case

• Multifactorial
  • Use aspects of GAME intervention with basic motor control and motor development patterns
• Goal oriented
  • Sitting with support à sitting independently
  • Rolling with time spent on his belly
  • Initiating quadruped
• Parent education and involvement
• High intensity recommended with PT 4x/week
• Extensive HEP

Acknowledgements

• Thank you Dr. Richard Lauer and Class of 2017!

References

• 1. Data & Statistics for Cerebral Palsy. Centers for Disease Control and Prevention. http://www.cdc.gov/ncbddd/cp/data.html. Published February 2016. Accessed October 2, 2016.
• 2. Center for Parent Information and Resources. Center for Parent Information and Resources. http://www.parentcenterhub.org/repository/ei-history/. Accessed October 2, 2016.
• 3. Hielkema T, Blauw-Hospers CH, Dirks T, Drijver-Messelink M, Bos AF, Hadders-Algra M. Does physiotherapeutic intervention affect motor outcome in high-risk infants? An approach combining a randomized controlled trial and process evaluation. Dev Med Child Neurol. 2011 Mar;53(3):e8-15. doi: 10.1111/j.1469-8749.2010.03876.x. PubMed PMID: 21291457.
• 4. Morgan C, Novak I, Dale RC, Badawi N. Optimising motor learning in infants at high risk of cerebral palsy: a pilot study. BMC Pediatr. 2015 Apr 1;15:30. doi: 10.1186/s12887-015-0347-2. PubMed PMID: 25880227; PubMed Central PMCID: PMC4389951.
• 5. Morgan C, Novak I, Dale RC, Guzzetta A, Badawi N. Single blind randomised controlled trial of GAME (Goals—Activity—Motor enrichment) in infants at high risk of cerebral palsy. Res Dev Disabil. 2016;55:256-267. http://libproxy.temple.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2016-37412-024&site=ehost-live&scope=site. doi: 10.1016/j.ridd.2016.04.005.
• 6. Zhang H, Zhang B, Jia F, et al. The effects of motor and intellectual functions on the effectiveness of comprehensive rehabilitation in young children with cerebral palsy. J Int Med Res. 2015;43(1):125-138.

Background

Knee OA is a common diagnosis causing chronic pain, decreased physical function, and diminished quality of life.  Research has demonstrated that physical therapy is effective at improving pain and function in adults with knee OA, but long term follow ups have demonstrated that these improvements are not being maintained.  As our population ages and rates of obesity rise we expect to continue to see an increase in knee OA, and add to this that up to 42% of Americans with health insurance were considered underinsured in 2014.  Booster sessions are aimed at improving patients long term benefits from PT by allowing the therapist to monitor patients over a longer period of time and encourage more compliance with home exercises.  For the purposes of this research booster sessions are considered any physical therapy that is delivered after the initial course of consecutive treatments.

Case Scenario

The patient is a 63 year old female with bilateral knee OA, BMI = 44.4, with a chief complaint of worsening knee pain that began insidiously 15 years ago. Her outcome measures were as follows; LEFI = 33/80, 30 second sit to stand test = 3.  When observing her gait she ambulates with a single point cane, decreased step length, decreased cadence, decreased hip flexion during swing, maintains knee flexion throughout patter.  The patients goals include walking four blocks to go shopping and playing with her grandchildren without pain.

Search Strategy

The inclusion criteria for my literature search were as follows; all articles must (1) include adult patients with knee OA, (2) include one group that receives exercise therapy in consecutive sessions followed by a home exercise program, (3) include one group that receives exercise therapy with “booster sessions” of supervised therapy provided at time intervals separated from the consecutive sessions of the initial episode of care, and (4) provide outcomes including pain and/or Western Ontario McMaster Universities Osteoarthritis Index.

Results: Pain

Results: Function

Weaknesses/Limitations

The two most recent randomized control trials that had identical study design found that a combination of manual therapy and Booster sessions had a negative impact outcomes, that the interactions between these two factors is not well understood.  The initial period of care was not standardized across studies.  A number of the studies were underpowered to test group interactions.  The number of booster sessions was not standardized between groups/studies.  None of the research provided data on a long term follow up after the conclusion of booster sessions.

Clinical Bottom Line

Two of the five articles demonstrated a significant difference between groups on outcomes for pain.  One of the four articles demonstrated a significant difference between groups on the WOMAC.  I recommend that future research  explore the possible negative interaction between manual therapy and booster sessions, the most effective dosage of booster sessions, and include a long term follow up after cessation of PT.

Clinical Application

The patients plan of care will be as follows: 8 sessions in the first 9 weeks, 2 sessions at 5 months, 1 session at 8 months, and 1 session at 11 months.  Treatment focus in the first 8 weeks will focus on decreasing the patient’s pain and increasing her weight bearing tolerance.  The patient will also perform aerobic exercise consisting of cycling and treadmill walking.  As her pain decreases and her weight bearing tolerance increases I will begin to progress her aerobic exercise and add weight bearing resistive training.  The patients home exercise program will be performed 3-4 times per week, and consist of 3 exercises to be performed in the home.  The patient will also be advised to begin a home walking program in which the patient will be asked to walk outside for 20 minutes 4 times per week.

References

1. Abbott JH, Chapple CM, Fitzgerald GK, et al. The incremental effects of manual therapy or booster sessions in addition to exercise therapy for knee osteoarthritis: A randomized clinical trial. J Orthop Sports Phys Ther. 2015;45(12):975-983. doi: 10.2519/jospt.2015.6015 [doi].

2. Bennell KL, Kyriakides M, Hodges PW, Hinman RS. Effects of two physiotherapy booster sessions on outcomes with home exercise in people with knee osteoarthritis: A randomized controlled trial. Arthritis Care Res (Hoboken). 2014;66(11):1680-1687. doi: 10.1002/acr.22350 [doi].

3. Fitzgerald GK, Fritz JM, Childs JD, et al. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: A multi-center, factorial randomized clinical trial. Osteoarthritis Cartilage. 2016;24(8):1340-1349. doi: 10.1016/j.joca.2016.03.001 [doi].

4. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376. doi: 10.1002/14651858.CD004376.pub3 [doi].

5. Mahon M. 31 million people were underinsured in 2014; many skipped needed health care and depleted savings to pay medical bills. www.commonwealthfund.org. Updated 2015. Accessed September 28th, 2016.

6. Pisters MF, Veenhof C, van Meeteren NL, et al. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review. Arthritis Rheum. 2007;57(7):1245-1253. doi: 10.1002/art.23009 [doi].

7. Veenhof C, Koke AJ, Dekker J, et al. Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: A randomized clinical trial. Arthritis Rheum. 2006;55(6):925-934.