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

Results:

Limitations:

• 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.

Acknowledgements:

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

References:

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 rmaidansky@temple.edu

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 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

Results:

^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

Application:

• 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.

Acknowledgements:

Anne Galgon, PT, PhD, NCS

Contact: Jackie Pedersen, Temple Class of 2017. jacqueline.pedersen@temple.edu

References:

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

Background:

• 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:

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.

Limitations:

• 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

Application:

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

Acknowledgements:

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

References:

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. http://libproxy.temple.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=112739640&site=ehost-live&scope=site. 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. http://libproxy.temple.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=104154602&site=ehost-live&scope=site. 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:

georgechau@gmail.com

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.

Introduction:

Carpal Tunnel Syndrome (CTS) is caused by compression of the median nerve within the carpal tunnel of the hand and wrist. Compression can be caused by overuse of the wrist and digital flexors. This sort of overuse can occur in people with occupations requiring mechanical wrist motions i.e. construction, typing, texting, etc. CTS can also occur with weight gain, water retention, and pregnancy which is why this diagnosis is more common in women than men. It can be diagnosed clinically with a number of special tests, but the gold standard for diagnosis is electromyography (EMG) testing. The diagnosis is then typically categorized into mild, moderate, or severe.

Clinical Scenario:

The patient is a 55 year old female registered nurse with 1 year history of mild right wrist pain and numbness in her first 3 digits. She has been self-managing with a wrist brace she bought at a local pharmacy, which has helped decrease her pain. In the last 6 weeks, however, her pain has gotten worse after she spent all day cooking a large meal for her family. The brace no longer eases the pain, which is now at a 7/10 with activity. She hasn’t seen her physician because she is afraid of surgery, but believes physical therapy could help her.

Key Exam Findings:
– No pain with c/s ROM (neg. Spurlings, neg. Cervical distraction)
– Mild hyposensitivity in median nerve distribution
– Mild weakness in R thenar opposition to 5th digit
– No significant muscle wasting of thenar eminence
– ULNDT ROM R<L
– Positive Carpal Compression Test
– Positive Tinel’s Sign

Outcome Measures:
– NPRS: 7/10 pain with activity
– BCTQ Function: 23/40 (Moderate)
– BCTQ Symptom Severity: 28/55 (Moderate)

PICO: In adults with carpal tunnel syndrome, is surgery more effective than conservative treatment in improving pain and function?

Search Strategy:
Inclusion Criteria: (1) Adults >18 years who have been diagnosed with CTS clinically or with electro-diagnostics (2) At least one intervention that is non-surgical or conservative and can be performed by a physical therapist (3) At least one intervention that is considered surgical (4) At least one of the following outcome measures used: CTSAQ, BCTQ, NPRS
Exclusion Criteria: (1) Surgery compared solely to conservative treatment that cannot be administered by a physical therapist i.e. steroid injections

Appraisal Table:

Results:
* Only 3 out of the 5 articles studied outcomes in short term and long term follow-ups. Of the 2 that did not, one had a follow-up of 6 months³ and the other had a follow-up of 5 years⁴. I chose to include the 6 month follow-up in the short term and the 5 year follow-up in the long term. Thus, there are 4 articles that look at each the short term and the long term.

**The authors of the study that found results on function favoring surgery in the short term state that the results of that analysis are likely not clinically meaningful².
***All interventions studied on outcomes of both pain and function, in both the short term and the long term had positive significant within-group changes. This means that each intervention was associated with significant improvements over time.

Limitations:

• Definition of conservative treatment varied across the studies
• Generalizability:
  • Various populations studied
  • EMG used as an outcome measure
    • Two studies ^4,5 excluded people with normal EMG findings despite them having clinical symptoms
    • Ucan et. al. stated that 2 people included in their study had EMG improvements over time, but still had functional limitations and clinical symptoms⁵
  • Exclusion of those with severe CTS

Clinical Bottom Line:

There is limited and inconsistent evidence to conclude that surgery is more effective than conservative treatment on improving pain and function in adults with CTS. Because of this, it is suggested that conservative treatment, as it is effective, less-invasive, and less-costly, be the first line of management for this diagnosis.

Application to Case Scenario:

• Conservative Treatment¹: 30 minute sessions, 1x per week, for at least 3 weeks
  • Manual Therapy – directed at sites of potential entrapment of median nerve
    • Nerve/Tendon Gliding – 5-10 min. in 2 sets of 5 min. with 1 min. rest between
      
    • Lateral Glides to C-spine
    • Soft Tissue Mobilization – treated according to pain on palpation or reproduction of symptoms
      
  • Splinting/Rest – in neutral position, at night, for up to 6 weeks

References:

1. Fernandez-de-las Peñas C, et. al. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain. 2015; 16(11): 1087-1094.
2. Jarvik J, et. al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial. Lancet. 2009; 374: 1074-1081.
3. Elwakil T, et. al. Treatment of carpal tunnel syndrome by low-level laser versus open carpal tunnel release. Lasers Med Sci. 2007; 22: 265-270.
4. Ettema A, et. al. Surgery versus Conservative Therapy in Carpal Tunnel Syndrome in People Aged 70 Years and Older. Plast. Reconstr. Surg. 2006; 118: 947.
5. Ucan H, et. al. Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome. Rheumatol Int. 2006; 27: 45-51.

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].