All posts for the month October, 2016


Patient Profile:

  • 35 year old male
  • Presented to outpatient physical therapy 4 weeks ago with golf related LBP
  • Re-evaluation: 0/10 pain at rest, 2/10 pain with golf related activities, ODI: 12%
  • Completed goal of playing 18 holes of golf with a pain level no greater than 3/10

Patient Goals:

  • Improve golf performance (driving distance, iron distance, etc.)


Is exercise effective in improving golf performance and sport specific strength in adult male golfing athletes?

  • search terms “Golf Performance” and “exercise” used in PubMed, Cinahl, and PEDro
  • 97 articles found
  • 3 duplicates removed
  • 94 abstracts screened
  • 80 irrelevant
  • 13 articles retrieved in full
  • 8 excluded after application of inclusion/exclusion criteria
  • 5 articles included

Inclusion Criteria:

  • male golfing athletes
  • adult population
  • preference given to RCT’s


  • Case studies
  • Female
  • Pediatrics
  • Musculoskeletal injuries within last 6 months


Author Date and Country Patient Group Study Type and Level of Evidence Outcomes Key Results Study Weaknesses
Fletcher, 2004 United Kingdom 11 male golfers handicap 5.5 SD 3.7 (classified as very good) Randomized Control Trial

Level 2

PEDro: 6/10

Club head Speed (km/h)

Driving Distance (m)

Golfers showed a significant improvement in both club head speed and average drive distance following the completion of an 8 week sport specific training program when comparing pre and post treatment test outcome measures (1.5% and 4.3% increase respectively).


Golfers showed significant improvement in club head speed and driving distance following an 8 week training program when compared to the control, but club head speed improvements may not be considered clinically significant.




Extremely small sample size

No blinding of subjects or researchers

No long term follow up

Alvarez, 2012


10 right handed male golfers, age 24 SD 6.7 years, handicap below 5 Randomized Control Trial

Level 2

PEDro: 5/10

Ball Speed (km/h)


Club mean acceleration (m/s2)

Golfers who completed a supervised 18-week strength training program showed a statistically and clinically significant improvement in both ball speed and club mean acceleration upon program completion compared to pre-intervention test and compared to control group.


Golfers who completed 18-week strength training program showed significant decreases in improvements made to ball speed and club mean acceleration at 5-week post training follow up.


Ball speed improvements were still significant at 5 week follow up compared to pre-intervention, but club mean acceleration improvements were not significant at 5 week follow up when compared to pre-intervention outcome measures.






Very small sample size

Validity and reliability of outcome measures not reported

Many outcome measures considered for this experiment are not relevant to improved golf performance

Patient population extremely specific –male, right handed, elite level golfers, age = early-mid 20’s so results cannot be generalized to all golfing athletes

Weston, 2013

United Kingdom

36 male golfers Randomized Control Trial

Level 2

PEDro 6/10

Club-head speed (mph) Golfers who completed the 8 week isolated core training program showed a 3.6% mean increase in club head speed.


exercise program focused primarily on core isometric exercises with spine in neutral alignment.  This study produced results similar to those focusing on swing specific exercises and thus suggests these benefits can be achieved at a reduced cost to the spine.

Small sample size

Other outcomes considered not well correlated with improved performance

No long term follow up

Compliance of exercise program in experimental group not accounted for



Fradkin, 2004


20 male golfers of various age and ability levels (handicaps) Randomized Control Trial

Level 2


Club-head speed (m/s) Mean club head speed in exercise group improved by 12.8% between weeks 1&2 and by 24% between weeks 1 and 7.


Mean club head speed improved in the exercise group both within each exercise session and between each exercise session in a linear fashion.  Suggests that a warm up routine may have immediate impact on club head speed and if continued may continue to improve club head speed over time.

Small sample size

Lack of long term follow up

Validity and reliability of outcome measures not reported

Only one outcome measure reported




18 male, right handed golfers, handicap 6 or less, age 23 SD 3.2 Clinical Trial

Level 3

Pedro: 4/10

Club-head speed (m/s)


Ball speed (m/s)

Dynamic stretching offered the greatest improvements in club head speed and ball speed when compared to static stretching and no stretching at all.

Club head speed was approximately 5% faster following dynamic stretching compared to static and no stretching.  Ball speed was approximately 6% faster.

No control group for comparison

Small sample size

Validity and reliability of outcome measures not reported

No long term follow up

Results cannot be generalized to entire golfing population

Clinical Bottom Line:

  • Current literature suggests that there is limited, low quality evidence proposing that exercise is effective in improving golf performance in male golfers
  • All studies mentioned feature very small sample size, most lack long term follow up, and most are not generalizable to all male golfers
  • Outcome measures are only correlated with increased golf performance.
  • No literature on what constitutes clinically significant change in outcome measures.

Application of Evidence:

  • Two pronged approach-implement a warm up conditioning routine focusing on dynamic stretching to increase ROM along with sport specific strength training program with use of medicine ball plyometric
  • Conversation with client about available evidence – what increases do they consider significant to them


1.Fletcher I, Hartwell M. EFFECT OF AN 8-WEEK COMBINED WEIGHTS AND PLYOMETRICS TRAINING PROGRAM ON GOLF DRIVE PERFORMANCE. Journal Of Strength & Conditioning Research (Allen Press Publishing Services Inc.) [serial online]. February 2004;18(1):59-62. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed September 16, 2016.

2.ÁLvarez M, Sedano S, Cuadrado G, Redondo J. EFFECTS OF AN 18-WEEK STRENGTH TRAINING PROGRAM ON LOW-HANDICAP GOLFERS’ PERFORMANCE. Journal Of Strength & Conditioning Research (Lippincott Williams & Wilkins) [serial online]. April 2012;26(4):1110-1121. Available from: CINAHL, Ipswich, MA. Accessed October 21, 2016.

3.Weston M, Coleman N, Spears I. The Effect of Isolated Core Training on Selected Measures of Golf Swing Performance. Medicine & Science In Sports & Exercise [serial online]. December 2013;45(12):2292-2297. Available from: CINAHL, Ipswich, MA. Accessed September 19, 2016.

4.Fradkin A, Sherman C, Finch C. Improving golf performance with a warm up conditioning programme. British Journal Of Sports Medicine [serial online]. December 2004;38(6):762-765. Available from: CINAHL, Ipswich, MA. Accessed September 19, 2016.

5.Moran K, McGrath T, Marshall B, Wallace E. Dynamic Stretching and Golf Swing Performance. International Journal of Sports Medicine [serial online]. February 2009;30(2):113-118. Available from: Academic Search Complete, Ipswich, MA. Accessed September 19, 2016.


Patient profile

  • 14 year old male
  • Spastic diplegic Cerebral Palsy
  • GMFCS Level II
  • History of tendon lengthening
  • Forearm crutches for community distances
  • Has not been attending PT regularly
  • Cognitively intact and motivated

Patient goals

  • Participate in physical education class
  • Play basketball without requiring rest breaks

Example of GMFCS Levels:


What are the effects of functional strength training versus typical physical therapy on walking ability in a pediatric population (<22 years of age) with spastic cerebral palsy?

Search Strategy 

100 articles identified

in: PubMed, CINAHL, OVID- Medline

16 duplicates removed

84 records screened

74 not relevant

10 full text screened

4 full text excluded

6 included

Inclusion Criteria

  • Pediatric Population (<22 years old) with a diagnosis of spastic cerebral palsy who are also ambulatory
  • Interventions that include strength or resistance training of lower extremities
  • Assessment of at least one of the following: 6 minute walk test, TUG, 20 meter walk test, GMFM D/E

Exclusion Criteria

  • Patient’s who had undergone botox injections within the past 3 months
  • Surgery in the past 6 months
  • Non-ambulatory patients
  • Adult population
  • Upper extremity training
  • Inability to follow direction or cognitive/behavioral diagnosis





  • Small sample sizes, underpowered
  • Cross-contamination of intervention
  • Undefined control interventions; “typical PT”
  • Lack of randomized controlled trials
  • Lack of blinding
  • Recruitment of convenience

Clinical Bottom Line

There is conflicting and limited, low quality, evidence that suggests that strength training does not improve walking ability in pediatric populations with spastic cerebral palsy with diagnoses that fall into GMFCS Levels I, II, & III.

  • 2 studies were randomized controlled trials, both looking specifically at strength training, and lacking defined controls. Neither of these studies found significant improvement in any measures of walking ability, such as the TUG or GMFM D/E.
  • 3 studies, all lower level evidence; case studies or quasi-experimental studies, found evidence that strength training improved measures of walking ability, but did not have control groups and included other intervention strategies within their therapeutic sessions, such as dynamic balance or gait training.
  • The final study found that strength training and treadmill training both led to clinically detectable improved walking ability.

Application to Case

Strength training should be included in a standard physical therapy plan of care if it aligns with patient-specific goals or to specifically increase strength. Interventions that focus on gait training and walking endurance may be more beneficialwhen implemented as primary interventions to improve walking ability

Strength training does not appear to cause any negative effects to patients with spastic CP, although range of motion and spasticity should be monitored if strength training regimens are implemented.


Auld ML, Johnston LM. “Strong and steady”: a community-based strength and balance exercise group for children with cerebral palsy. Disabil Rehabil. 2014;36(24):2065-71.

Aviram R, Harries N, Namourah I, Amro A, Bar-haim S. Effects of a group circuit progressive resistance training program compared with a treadmill training program for adolescents with cerebral palsy. Dev Neurorehabil. 2016:1-8.

Aye T, Thein S, Hlaing T. Effects of strength training program on hip extensors and knee extensors strength of lower limb in children with spastic diplegic cerebral palsy. J Phys Ther Sci. 2016;28(2):671-6.

Dos Santos AN, da Costa CS, Golineleo MT, Rocha NA. Functional strength training in child with cerebral palsy GMFCS IV: case report. Dev Neurorehabil. 2013 Oct;16(5):308-14. doi: 10.3109/17518423.2012.731085. Epub 2013 Apr 25. PubMed PMID: 23617884.

Scholtes VA, Becher JG, Janssen-Potten YJ, Dekkers H, Smallenbroek L, Dallmeijer AJ. Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: a randomized controlled trial. Res Dev Disabil. 2012 Jan-Feb;33(1):181-8. doi: 10.1016/j.ridd.2011.08.026. Epub 2011 Oct 11. PubMed PMID: 22093663.

Taylor NF, Dodd KJ, Baker RJ, Willoughby K, Thomason P, Graham HK. Progressive resistance training and mobility-related function in young people with cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2013 Sep;55(9):806-12. doi: 10.1111/dmcn.12190. Epub 2013 Jun 22



Background Information:


  • 4% of spinal cord injuries (SCI) lead to chronic mechanical ventilation
  • Mechanical ventilation, currently the gold standard for respiratory dependent patients, has many potential complications
  • Serious complications include:
    • Pneumonia, the leading cause of decreased life expectancy amongst this population
    • Respiratory Infection
  • Via transcutaneous electrical stimulation, the patency of the phrenic nerve can be determined preoperatively
  • If intact, these patients may be candidates for phrenic nerve pacing
  • Phrenic nerve pacers can be laparoscopically placed, including internal electrodes and an external transmitter

Clinical Scenario:

A 36 year old male sustained a C3 ASIA B SCI 1 week ago He is currently in the ICU being mechanically ventilated with no significant improvement. Prior to his injury, he was living at home with his wife and two young children and working as an investment banker. Physical examination findings include diminished sensation throughout thoracic region and no motor function below level of injury. Patient goals are to return to home and work independently with focus on resuming his role as a father.

PICO Question:

Does diaphragmatic pacing improve respiratory independence and QOL in individuals with spinal cord injury as compared to mechanical ventilation.

Search Strategy:

21 articles identified using PubMed, CINAHL and Cochrane.

Variations of Terms Used: “spinal cord injury”, “diaphragm pacing”, “respiratory”, “phrenic nerve”

Inclusion Criteria: Diagnosis of cervical spinal cord injury, ventilator dependence, English studies, published 2005-present

Exclusion Criteria: Diagnosis of  Amyotrophic Lateral Sclerosis, phrenic nerve lesions





Patient Population Study Type and Level Of Evidence Outcomes Key Results
Tedde ML, et. al. (2012)


Ventilator dependent quadriplegics post cervical trauma Clinical Trial

Level 3 Evidence

D&B: 12/27

Independence from MV3 •N=5

•At 6 month f/u:

•3 patients continuous DPS4

•1 patients 6 hours/day

•1 patient unable to sustain

Romero FJ, et. al. (2012)


Ventilator Dependent High-Cervical SCI patients Retrospective Review

Level 3 Evidence

D&B: 17/27

SF-36 •Social Functioning:

•PNP: 7.67 ± 1.80

•MV Group: 5.67 ± 1.17

•P value <.001

•No significant change in physical functioning, general health, role limitations, physical pain, vitality

Poluszny JA, et. al. (2013)

United States

Ventilator dependent SCI patients with intact phrenic nerves Retrospective Cohort Study

Level 3 Evidence

D&B: 16/27

Independence from MV3 •N=22

•18 participants continuous DPS4

•2 participants: 4 and 12 hours/day

•1 patient unable to sustain

•1 patient with prolonging life measures withdrawn

Hirschfeld S, et. al. (2008)


SCI patients with induced respiratory device dependency Prospective Cohort Study

Level 3 Evidence

D&B: 20/27

Patient and Physician reported QOL •Unanimous patient reported improved self confidence with PNP over MV
Onders RP, et. al. (2007)

United States

Ventilator dependent tetraplegics with a C2 injury occurring in childhood Prospective Cohort Review

Level 3 Evidence

D&B: 9/27

Independence from MV3, Patient reported QOL •N=10

•4 patients continuous DPS4

•4 patients day time only

•2 unable to sustain

•Unanimous patient reported preferences for DPS4, improvements in mobility and ease of integration into society


  • Lacking validated outcome measures
  • Small Sample Sizes
  • Procedures for implantation and weaning were variable
  • Lacking long term follow up
  • No control groups
  • Lack of homogeneity amongst groups
    • Age
    • Time on MV
    • Level of injury
    • Severity of Injury

Clinical Bottom Line:

There is low-level evidence that suggests phrenic nerve pacing is a safe and effective alternative treatment for ventilator dependent, high-level, cervical spinal cord injury patients. Additionally, this evidence supports decreased complications common with mechanical ventilation and improved resocialization, mobility, independence, and overall quality of life.


Phrenic nerve pacing has been shown to improve independence and quality of life. Due to my patient’s goals of returning to his work and family responsibilities, and the lack of any serious adverse events reported with this treatment, phrenic nerve pacing may be an appropriate alternative. After transcutaneous nerve testing determines the patency of his phrenic nerve, offering this as a potential alternative treatment to chronic mechanical ventilation allows my patient to be an active participant in his plan of care.


Thank you to Dr. Richard Lauer for your assistance along the way.


  1. Posluszny JA, Onders R, Kewin AJ, Weinstein MS, Stein DM, Knight J, et al. Multicenter review of diaphragm pacing in spinal cord injury: Successful not only in weaning from ventilators but also in bridging to independent respiration. J Trauma Acute Care Surg. 2014;76(2):303-9. Doi:10.1097/TA.0000000000000112
  2. Romero FJ, Gabarrutta C, Garcia-Forcada A, et al. Long-term evaluation of phrenic nerve pacing for respiratory failure due to high cervical spinal cord injury. Spinal Cord. 2012; 50(12): 895-8. Doi: 10.1038/sc.2012.74
  3. Tedde ML, Filho PV, Hajjar LA, Almeida JP, Flora GF, et. al. Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management. Clinics. 2012. 67(11). Doi: 10.6061
  4. Hirschfeld S, Exner G, Luukaala T, Baer GA. Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency. Spinal Cord. 2008; 46(11): 738-42. Doi: 10.1038/sc.2008.43
  5. Onder RP, Elmo MJ, Ignagni AR. Diaphragm Pacing Stimulation System for Tetraplegia in Individuals Injured During Childhood or Adolescence. J Spinal Cord Med. 2007; 30(1):25-29.

With further questions please contact Rebecca Maidansky at


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.


-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.


-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.


-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.


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, TUGmanual, TUGcognitive, 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:


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





**Red indicates statistical significance

Wilcoxon Signed ranks test

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





-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.


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 Information:

  • An estimated 3.8 million people sustain a concussion every year1,4
  • 10% – 33% of individuals with mild traumatic brain injury experience symptoms months to years later1
  • Post-concussion syndrome (PCS) is defined as persistence of > 3 symptoms 7-10 days after injury5: Headache, Dizziness, Fatigue, Irritability, Insomnia, Concentration Difficulty, Memory Difficulty, Stress or emotion intolerance
  • One cause of PCS may be altered autonomic function and impaired autoregulation and distribution of cerebral blood flow

Clinical Case:

  • 15 y.o. female student s/p MVA 1 month ago hitting head on dash board
  • ER visit diagnosed mTBI –> prescribed “rest”
  • S/s:  headaches, fatigue, worsens with reading, noisy family, screen time
  • Goals: asymptomatic school day, return to tennis, recreational running
  • PT: Vestibular, postural, and cervicogenic exercises initiated

PICO: Is aerobic exercise beneficial in individuals with prolonged symptoms after mTBI?

Search Strategy: 1,247 articles identified in PubMed, CINAHL, Academic Search Complete

  • Terms: (concussion OR post-concussion syndrome OR mild traumatic brain injury) AND (exercise OR rehabilitation OR treatment). English language, peer reviewed, humans, 10 years.
  • Inclusion: subjects sustained mild TBI/concussion by means of sport, MVA, or other,  experiencing post-concussive symptoms > 2 weeks, exercise intervention defined, post-concussive related outcome measures (symptoms, fatigue, QOL, function)
  • Exclusion: acute phase mTBIs, moderate to severe TBI’s, non interventional studies



aPost-concussive symptoms > 4 weeks aa > 6 weeks, bBalke Treadmill test, BDI: Beck Depression Inventory, PCSI: Post Concussion Symptom Inventory, PCS: Post Concussion Scale, SE: statistically significant effects listed (p <0.05)

Limitations and suggestions:

  • “Active” control groups1,3, Lack of control group2,3,5
  • Small sample size1-5
  • Multiple treatment interference2
  • Inadequate follow up1-3,5
  • Lacking consensus on intensity and duration
  • Optimal timing of intervention unclear
  • Higher quality research suggested to directly compare aerobic exercise with other interventions such as dual tasking, cervicogenic, vestibular exercises, and non participants.

Clinical Bottom Line:

There is moderate to low level evidence to support the use of aerobic exercise in patients with prolonged symptoms after sustaining a mild traumatic brain injury.  This particular literature review offers recent interventional case studies and a randomized clinical trial in which aerobic exercise is the primary intervention and assessment tool used to prescribe a customized, progressive, aerobic rehabilitation program whether on a treadmill or stationary bike. Each study reported a statistically significant change in some aspects of post-concussive symptoms such as return to full daily functioning, ability to exercise maximally without symptom exacerbation, and decrease in post-concussion symptom specific scales. No adverse events or negative impacts were reported in the studies from engaging sub-symptom exacerbation aerobic exercise in patients still experiencing prolonged symptoms after mTBI, which had previously been thought to be deleterious until research as such as been published in the recent decades.

It is proposed that exercise assessment and aerobic exercise training may reduce concussion-related physiological dysfunction by restoring autonomic balance and by improving autoregulation of cerebral blood flow. Controlled progressive aerobic exercise treatment may help to restore normal CBF regulation by conditioning the brain to gradually adapt to repetitive mild elevations of systolic blood pressure.3-5


  • Obtain baseline (use of BALKE, BUFFALO CONCUSSION TREADMILL TEST, or Bike Test described in Kurowski 2016)
    • Treadmill or bike
      • Stationary bike program indicated if excess head movements are provoking on treadmill
    • Monitor vitals
      • HR, BP, RPE, & symptoms
    • Progress intensity until exacerbation
  • Prescribe aerobic exercise program
    • Intensity: 80% of symptomatic duration OR symptomatic heart rate/RPE if patient able to self monitor
    • Frequency: 5 days a week, 4 to 6 weeks
    • Monitor symptom trends and modify program accordingly weekly
      • progress it!
  • Consider multi-modal treatment
    • Though aerobic exercise seems beneficial in ameliorating prolonged symptoms, consider challenging your patient in other modes such as dual tasking, vestibular, balance, and sport specific exercises alongside your aerobic exercise treatment (see Gagnon 2016) for they may be symptomatic in some realms but not others.


Anne Galgon, PT, PhD, NCS

Contact: Jackie Pedersen, Temple Class of 2017.


1. Kurowski BG, Hugentobler J, Quatman-Yates C, Taylor J, Gubanich PJ, Altaye M, Wade SL. Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial.  J Head Trauma Rehabil. 2016 Apr 26. [Epub ahead of print] PubMed PMID: 27120294.

2.Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scand J Med Sci Sports. 2016;26(3):299-306

3.Leddy JJ, Cox JL, Baker JG, Wack DS, Pendergast DR, Zivadinov R, Willer B. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil. 2013 Jul-Aug;28(4):241-9

4. Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabilitation Research & Practice. 2012:1-7

5.Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clinical Journal of Sport Medicine. 2010;20(1):21-2




Prior to the 1990’s, physicians and their immediate family members could legally own ancillary healthcare services, as well as physical therapy clinics. A common method of abuse was physician self-referral of patients to their own facilities for testing, imaging, and rehab, and often times these services were not indicated.  In order to control excess spending, Congress looked to prohibit this type of conflict of interest between physicians and health services they refer to. Legislation was drafted in order to prohibit this type of practice in what came to be known as the Stark Law. However, several exceptions were put in place for “in-house” services. Among these included X-ray imaging and physical therapy services.


PICO Question:  In patients being referred to outpatient physical therapy treatment, are services utilized at a higher rate if the referring physician has a financial interest in the facility compared to a physician referring to an independently owned facility?


Search Strategy: Pubmed, CINAHL, and Web of Science were searched with terms “Physical therapy” AND “Physician owned practice” OR “POPs.” Abstracts were screened for inclusion and exclusion criteria.

Inclusion Criteria:

-Patients referred by a physician  to outpatient physical therapy

-Patients receiving care in the United States

-Comparison of physician owned facilities to independently owned facilities used some metric of utilization of care including total cost, frequency of referral, total number of visits per patient,  or relative value units.

Exclusion Criteria:

-Articles published prior to 1990





Clinical Bottom Line:

-Consistent level 3 evidence that physician ownership of physical therapy clinics results in a higher percent of patients under that physician’s care being referred for PT.

-Consistent level 3 evidence that PT clinics with physician ownership result in increased visits per patient.

-Fairly consistent level 3 evidence that physician ownership of PT clinics results in increased cost to the healthcare system, but may bill less services per patient episode.

-Some level 3 evidence that services billed by physician owned clinics may consist of less one-on-one care with licensed physical therapists as measured in RVUs.



The articles published within this CAT have several large limitations which reduces the ability to generalize the data to the entire healthcare system.

  1.  4 out of 5 studies published by the same author
  2. Each study only looked at claims from one state
  3. Data from only 3 states were included among the 5 articles
  4. Only one insurance provider was looked at per article
  5.  3 of the 5 studies contained data that is not current
  6. Outcome measures were not tracked in any of the articles
  7. Statistical analysis was not performed.

Application and Significance of Research:

The articles revealed more total expenditures and higher cost to the healthcare system for rehabilitation services when a referring physician had a financial interest in a physical therapy clinic. As a profession, we can use this data to push for legislation that prohibits or limits physician self referrals, which would both control healthcare spending and give physical therapists more autonomy within our profession.


Heidi Ojha, PT, DPT, OCS, FAAOMPT; DPT Class of 2017.



Mitchell, J. M. (1992). Physician Ownership of Physical Therapy Services. Jama, 268(15), 2055. doi:10.1001/jama.1992.03490150107033
Mitchell, J. M., & Sass, T. R. (1995). Physician ownership of ancillary services: Indirect demand inducement or quality assurance? Journal of Health Economics,14(3), 263-289. doi:10.1016/0167-6296(95)00003-z
Mitchell, J. M., Reschovsky, J. D., Franzini, L., & Reicherter, E. A. (2015). Physician Self-Referral of Physical Therapy Services for Patients with Low Back Pain: Implications for Use, Types of Treatments Received and Expenditures. Forum for Health Economics and Policy,0(0). doi:10.1515/fhep-2015-0026
Mitchell, J. M., Reschovsky, J. D., & Reicherter, E. A. (2016). Use of Physical Therapy Following Total Knee Replacement Surgery: Implications of Orthopedic Surgeons’ Ownership of Physical Therapy Services. Health Services Research,51(5), 1838-1857. doi:10.1111/1475-6773.12465
Swedlow, A., Johnson, G., Smithline, N., & Milstein, A. (1992). Increased Costs and Rates of Use in the California Workers’ Compensation System as a Result of Self-Referral by Physicians. New England Journal of Medicine, 327(21), 1502-1506. doi:10.1056/nejm199211193272107




  • Neck pain is the third most commonly reported type of pain
  • There is a higher prevalence in women than men
  • Chronic neck pain often leads to impaired movement coordination, endurance, and strength


Clinical Case and PICO:

  • 59 y.o. retired female seamstress with insidious onset of neck pain that has lasted over 5 yrs.
  • Current pain level of 4/10 and 8/10 at worst on NPRS| NDI: 30%
  • Denies any numbness, tingling, and headaches
  • Relief with lying down and NSAIDs
  • Family physician advised that general exercise would ↓ pain
  • Primary Impairments: ↓neck ROM (flexion, b/l rotation), ↓ endurance (per CCFT)
  • Functional Limitations: reading, crossing the street, care-taking grandson

PICO: For individuals with chronic neck pain, is general exercise as effective for reducing pain and improving function as specific exercise targeting deep neck flexors?



Figure 1: Deep Cervical Flexors – Longus Capitis and Longus Colli


Search Strategy:

  • 59 articles identified
  • via PubMed, CINAHL, and PEDro
  • 9 duplicates removed
  • 50 articles screened
  • 42 articles not relevant
  • 8 full-text articles screened
  • 3 articles excluded
  • 5 articles included


Key Results:

Author, Date, Country Patient Population Study Type, Evidence Outcomes Key Results
O’Leary, 2011, Australia N = 60

Pain > 6 mos., score btw. 10/50 – 15/50 on NDI


Level II

Pain (VAS)

Disability (NDI)

Specific exercises targeting endurance, strength, coordination, and ROM improved these respective motor performances with minor carry-over in performance in other motor domains.

Pain: Meaningful from baseline to 10 wks. for coordination group (↓19.2 mm)

Disability: All groups had similar reductions in disability

Ludvigsson, 2015, Sweden N = 216

Pain > 6 mos., > 10/50 on NDI,  > 20/100mm on VAS, post-WAD.


Level II

Pain (VAS)

Disability (NDI)

Neck-specific group resulted in better outcomes in pain and disability than general exercise group.

Pain: Significant ↓ over time in all three groups

Disability: Significant ↓ from baseline to 6 mos. for neck-specific group.

No improvement for general exercise.

Izquierdo, 2015, Spain N = 28

Pain > 3 mos., < 15/50 on NDI


Level II

Pain (VAS)

Disability (NDI)

Both CCF and proprioceptive groups  improved in pain and disability as well as positive outcomes for deep neck flexor neuromuscular control.

Pain: Meaningful for current pain from baseline to post 2 mos. (↓3.45mm in CCF and ↓4.00mm in proprioception). Resulted in no current pain.

Disability: Significant from baseline to post 2 mos. (↓3.25pts. for CCF and ↓3.28pts. for proprioception)

Borisut 2013, Thailand N = 100

Pain > 6 mos., > 30/100 mm on VAS

Clinical Trial

Level III

Pain (VAS)

Disability (NDI)

Pain and disability improved for strength-endurance, CCF, and combined group.

Pain: Meaningful from baseline to 12 wks. in combined group (↓44.6mm)

Disability: Meaningful from baseline to 12 wks. in strength-endurance (↓13.51pts.), CCF (↓15.55pts.), combo (↓13.52pts.)


Kim, 2016, South Korea N = 28

Pain > 3 mos., NDI < 15 pts.

Clinical Trial

Level III

Pain (NPRS)

Disability (NDI)

DCF group had better outcomes in pain and disability than general exercise group.

Pain: Meaningful at 8 wks. for DCF (↓3.5pts.)

Disability: Significant at 8 wks. for DCF (↓3.8 pts.)

Legend: CCF = craniocervical flexion  | VAS = Visual Analog Scale | CCFT = craniocervical flexion test

DCF = deep cervical flexor  | NDI = Neck Disability Index | NPRS = Numeric Pain Rating Scale


Clinical Bottom Line:

Upon review of moderate level evidence comparing general exercise to deep neck flexor exercise in treating chronic neck pain, general exercise is not as effective as deep neck flexor exercise but more specifically, the evidence suggests that any neck-specific exercise can improve pain and disability.



  • No long-term follow-up past 6 months
  • Only studied patients with mild neck pain and disability
  • Subjects and therapists were not blinded
  • Impairments were not targeted for patient interventions



As with most conditions, it is imperative to identify the key impairments related to the individual and to prescribe exercises that target that impairment.  The specific neck exercise that targets the impairment will address the impairment and also improve pain and disability.

Plan of Care –

Patient Education:

– Ergonomic modifications

– Discuss chronic pain

– Reassurance

Manual Therapy:

– Cervical Traction

– Atlantoaxial Joint Mobilization

Therapeutic Exercise:

– Endurance – CCF

– Mobility – cervical rotation and flexion


Figure 2: Craniocervical Flexion Exercise using objective measurement



Bill Egan, PT, DPT, OCS, FAAOMPT & Temple DPT Class of 2017



1. O’Leary S, Jull G, Kim M, Uthaikhup S, Vicenzino B. Training mode-dependent changes in motor performance in neck pain. Arch Phys Med Rehabil. 2012;93(7):1225-1233. doi: 10.1016/j.apmr.2012.02.018 [doi].

2. Ludvigsson ML, Peterson G, O’Leary S, Dedering A, Peolsson A. The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: A randomized clinical trial. Clin J Pain. 2015;31(4):294-303. doi: 10.1097/AJP.0000000000000123 [doi].

3. Gallego Izquierdo T, Pecos-Martin D, Lluch Girbés E, et al. Comparison of cranio-cervical flexion training versus cervical proprioception training in patients with chronic neck pain: A randomized controlled clinical trial. J REHABIL MED (16501977). 2016;48(1):48-55. doi: 10.2340/16501977-2034.

4. Borisut S, Vongsirinavarat M, Vachalathiti R, Sakulsriprasert P. Effects of strength and endurance training of superficial and deep neck muscles on muscle activities and pain levels of females with chronic neck pain. J PHYS THER SCI. 2013;25(9):1157-1162. doi: 10.1589/jpts.25.1157.

5. Kim JY, Kwag KI. Clinical effects of deep cervical flexor muscle activation in patients with chronic neck pain. J Phys Ther Sci. 2016;28(1):269-273. doi: 10.1589/jpts.28.269 [doi].


Contact Information:


  • Femoroacetabular impingement (FAI) is a bony abnormality of the acetabulum (pincer impingement) or the femoral head/neck junction (cam impingement)
  • This condition is common in young adults and can be congenital, or caused by repetitive motions
  • FAI is becoming recognized as a leading cause of hip pain, and surgical techniques for this condition have increased dramatically over the past decade
  • People in the field believe FAI may be over-diagnosed



The chart below represents a consensus for the diagnosis and treatment of individuals with symptomatic FAI


Clinical case scenario:

  • 30 year old active female with right anterolateral hip and groin pain. Imaging reveals a pincer type impingement with a partial superior anterior labral tear
  • The patient reports pain with ascending stairs and crossing legs (right over left). Increased hip adduction is demonstrated during functional activities, and she has a positive impingement and FABER test
  • This patients goals include return to running, however, she is reluctant to try physical therapy because she was told by her physician that she will most likely need surgery

PICO Question:

  • In adults (<18 years) with FAI and labral pathology, what is the effect of conservative management on decreasing pain and increasing functional ability?

Search strategy:

  • Databases searched: PubMed, CINAHL, Medline (via EBSCOhost)
  • Inclusion criteria: Adults: age >18 years, A diagnosis of femoroacetabular impingement and/or labral tear, patients are symptomatic, conservative treatment was received, outcome measures were used to assess pain/function
  • Exclusion criteria: Age < 18 years, patients are asymptomatic, hip surgery was received
  • 5 articles were included in my CAT. There is limited research on the conservative management of FAI/labral pathology (most research has focused on surgery as this has been seen to be the gold standard)

search-strategy ss-results






Clinical bottom line:

Multiple low level studies have shown that conservative treatment can play an important role in decreasing pain and increasing function in those presenting with symptomatic FAI


  • Limited research on FAI/labral treatments with low quality evidence overall
  • Small sample sizes and lack of long-term follow-up
  • Lack of control groups for majority of studies
  • Physician influence on the participants expectations of physical therapy and decision to choose surgery (based on whether or not they were examined by an orthopedic surgeon, or if they had already been pre-listed to receive surgery)

Application to case:

  • My patient is a candidate for physical therapy. I will see her 2-3x/week and then progress to more of an independent program
  • It is important to keep in touch with her other health care providers so everybody is on the same page during the treatment
  • Education is key: I will educate my patient on her condition, the treatment plan/prognosis, and the current research
  • The chart below is based off current research and what’s considered “the most effective treatments” for this condition


Suggestions for future research:

  • Longer term follow-up studies to document lasting effects of conservative treatment and surgery
  • Investigate patient responses in order to determine who would be successful with conservative care versus surgery
  • Studies that directly compare physical therapy outcomes to surgical outcomes (there are currently RCT’s in the making that are directly comparing surgery to conservative management, therefore, it is very important to stay up to date with the literature)

* People in the field have noted that this diagnosis of FAI may be following similar trends to other conditions such as shoulder impingement. In the past the diagnosis and surgical treatment for shoulder impingement greatly increased, but then after years of research they found these individuals do great with an active treatment program and physical therapy (a lot of us have seen/successfully treated patients with shoulder impingement!). My point being, stay up to date with the research, FAI is currently a hot topic that is gaining considerable attention in the literature and medical community. When a patient presents to us in the clinic with this “diagnosis” we want to be able to educate and provide them with evidence based care.



TU DPT Class Of 2017


1. Emara K, Samir W, Motasem el H, Ghafar K.A. Conservative treatment for mild femoroacetabular impingement. Journal of Orthopaedic Surgery (Hong Kong), 19 (1) (2011).

2. Hunt D, Prather H, Harris Hayes M, Clohisy JC. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R. 2012 Jul;4(7):479-87. doi: 10.1016/j.pmrj.2012.03.012.

3. Smeatham A, Powell R, Moore S, Chauhan R, Wilson M. Does treatment by a specialist physiotherapist change pain and function in young adults with symptoms from femoroacetabular impingement? A pilot project for a randomised controlled trial. Physiotherapy. 2016 Feb 27.

4. Wright AA, Hegedus EJ, Taylor JB, Dischiavi SL, Stubbs AJ. Non-operative management of femoroacetabular impingement: A prospective, randomized controlled clinical trial pilot study. J Sci Med Sport. 2016 Sep;19(9):716-21. doi: 10.1016/j.jsams.2015.11.008. Epub 2016 Jan 6.

5. Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum tears: A case series. J Orthop Sport Phys Ther. 2011 ;41:346-53.


  • 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:

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:

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:

Author, Date, and Country Patient Population Study Type and Level of Evidence Outcomes Conclusion Study Weaknesses
Hao, 2013


Patients of any age or sex after stroke, regardless of the duration of illness or severity of the initial impairment Systematic Review

Level I

PRISMA: 23/27

Motor Outcomes: Jebsen-Taylor Hand Function Test, Pegboard Task, Wolf Motor Function Test, Action Research Arm Test –Use of rTMS for patients with stroke is not recommended until its efficacy is verified in high-quality, large scale RCT’s

Subgroup analysis: Contralesional rTMS displayed a moderate effect size on motor outcomes

Small number of subjects across all articles reviewed with sample sizes ranging from 10 to 123.

Stimulation parameters varied across studies.

No studies included with long term follow-up.

Inclusion criteria for participants was not very strict, for example a study with pediatric patients was included.

Meta-Analysis for motor function was only performed on 4 of 19 studies.


Hsu, 2012


Adults diagnosed with stroke Systematic Review

Level I

PRISMA: 20/27

Wolf Motor Function Test, Nine-Hole Peg Test, Grip Strength  

–rTMS suggests a clinically positive effect on motor recovery in the affected upper limb of patients with stroke

Low frequency rTMS over the contralesional hemisphere being more effective in enhancing upper limb motor recovery based on subgroup analysis

Small number of subjects across all articles reviewed

Many articles reviewed report a wide variety of long term outcomes, if any (from 2 weeks to 1 year),

Outcome measures, experimental designs, inclusion criteria, and rTMS protocols varied between articles.


Etoh, 2013


Adults with chronic stroke; either first or second unilateral stroke Randomized Double-Blind Crossover Study

Level II

PEDro: 6/10

Fugl-Meyer Assessment, Action Research Arm Test, Simple Test for Evaluating Hand Function Low frequency inhibitory rTMS to the contralesional hemisphere facilitated the effects of repetitive facilitation exercises (100 reps of 5 to 8 exercises) in improving the motor function of the affected upper limb in patients with chronic stroke Very small sample size.

“Sham” stimulation still involved actual use of the rTMS coil and it is possible that there was some stimulation to the motor cortex or the sensory cortex that may have confounded the results.

No long term follow-up.

Generalizability limited to those with unilateral chronic stroke


Seniow, 2012


Adults diagnosed with stroke with onset of symptoms <3months Randomized Control Trial
Level II

PEDro: 9/10

Fugl-Meyer Assessment, Wolf Motor Function Test  

Contralesional inhibitory stimulation to the primary motor cortex by low frequency rTMS is not yet an evidence-based method during early rehab for patients with stroke

There were statistically significant differences in both groups from pre test to post test scores, however there were no significant between group differences




Small sample size, The article stated that those in the experimental group received more PT posttreatment, There was loss to follow-up in both groups potentially skewing the data, though an intention to treat analysis was performed.

Generalizability limited to those in early rehabilitation post stroke

Wang, 2014


Adults with chronic stroke Randomized Control Trial

Level II

PEDro: 9/10

Fugl-Meyer Assessment, Wolf Motor Function Test, Medical Research Council Scale (grip strength and shoulder flexion) Inhibitory rTMS to the contralesional premotor cortex or primary motor cortex facilitated restoration of motor function in patients with chronic stroke

The patients assigned to the contralesional M1 and contralesional  dorsal premotor cortex groups showed significant improvements in MRC, FMA, and WMFT scores post-rTMS compared with those of the sham groupwith stimulation to M1 demonstrating larger effect sizes than stimulation to the dorsal premotor cortex.




Small sample size with a very homogeneous sample of only right handed patients and those with an MCA infarct – not very generalizable. There was no control group for the premotor cortex stimulation. Stimulation to the dorsal premotor cortex was only 3 cm away from the M1 stimulation area, while simultaneously stimulating M1 was attempted to be controlled there may have been some overlap.

Generalizability limited to those with chronic stroke.


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


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:


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 & Humanssearch-strategy


(self-controlled feedback) AND motor learning


self-controlled AND balance


Self-controlled feedback AND balance

Evidence Appraisal & Study Participants



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

study-2a   study-2b   study-2c

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.



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.

For the questionnaire results, after the practice phase on day 1 self-control participants rated their motivation significantly higher than yoked participants. There were no significant group differences in questionnaire responses on day 2 when the balance pole was removed. Both groups enjoyed practicing the task, but self-control participants were significantly less nervous before beginning the trials on day 1 compared to yoked participants. Although there were no group differences in body-position related concerns on day 1, the self-control group indicated less concern on day 2.

Hartman (2007)

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

Following day 1, the self-control group reported on the questionnaire that they asked for the pole mostly because they wanted to try a new strategy on the next trial (44%) or for “other” reasons (44%). Other reasons ranged from “did not want assistance” to “used the pole at the beginning to try and get a feel for the stabilometer.” Although results were more varied on day 2, the main responses were once again new strategy (22%) or “other” (44%). Overall, 88% of participants on day 1 and 67% on day 2 reported that they did not ask for the pole mainly for strategic purposes. With regard to the yoked group, the majority of participants reported that they had not received the pole after the correct trials. Following day 1, 55% reported that they would have preferred to have received the pole when attempting a new strategy, 33% after bad trials, and 1 reported wanting it after alternating trials. On day 2, 77% indicated that they did not receive the pole after the correct trial, 33% would have preferred the pole after bad trials, 16% when wanting to try a new strategy, and 50% for other reasons. Other reasons included “do as well with or without the pole the more I do it” or “did not like the pole.”

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.


  1. Hartman JM. Self-controlled use of a perceived physical assistance device during a balancing task. Percept Mot Skills. 2007;104:1005-1016.
  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.
  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.
  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.