Background:

It is very common to see athletes in an outpatient setting.  Many times there is a specific cause for injury, but sometimes the major complaint is decreased performance with athletes.  Therefore, physical therapists have a role in improving performance and restoring athlete’s full capability in relation to their sport.  It is important to realize that this is well within the scope of physical therapy, and therapists need to have the tools to provide the proper training for high level athletes as well.

Case Scenario:

The patient is a 22-year-old baseball pitcher at a Division 2 college that presents to physical therapy with unexplained shoulder fatigue and decreased performance.  He reports no pain and denies any traumatic events that may be causing the decreased performance.  He complains that his arm feels “dead”, but upper quarter neuro screen was all normal and special tests for rotator cuff and impingement were all negative, except external rotation weakness.  The patient reports that his throwing velocity decreases dramatically after throwing 20-25 pitches, and also states that his college coach verified the decreased velocity with a radar gun.  His reported prior level of function was that he could maintain a throwing velocity for about 80-90 pitches.  He shows 4/5 weakness in internal rotation, external rotation, scaption, and scapular muscles which is more dramatic (3+ or 4-/5) after 8 min of moderate upper body cycling.  He continues to pitch but is limited to 25 pitch maximum by his coach, and he wants to return to unrestricted pitching and his program to improve throwing velocity for next season.  Increasing throwing velocity and strength to return to prior level is his main goal for therapy.  *Sports subscale on DASH:  14/20 moderate to severe disability related to sports.*

Clinical question:

What are the most effective exercise programs to improve muscle performance in overhead athletes in relation to throwing velocity?

Search Strategy:

Applied criteria for results:

• Inclusion Criteria: (1) Competitive athletes (high school or higher); (2) Repetitive throwing athletes; (3) Training programs with structured frequency/duration

• Exclusion Criteria: (1) Non-throwing athletes; (2) Adolescents (13 years and younger); (3) One time interventions/warm-ups

• Other limits: (1) Randomized control trials; (2) Published within the last 10 years

Evidence Appraisal and Key Results:

Evidence Summary:

This collection of studies shows different types of exercise programs that can target throwing velocity in a multitude of ways.  The higher level studies (6/10 quality score) show moderate evidence that adding heavy resistance or medicine ball exercises that focus on upper body strength and power to a normal sport specific training regimen increase throwing velocity more than basic strength training without any adverse effects.  There are also studies that show low-medium evidence (5/10 score) that closed kinetic chain activities are more beneficial than open kinetic chain training during off season workout.  Also, there are 3 workouts (Thrower’s ten, Keiser pneumatic, Plyometric) that can help increase throwing velocity in baseball players, although this study had the smallest effect size.  This specific study’s control group did no activity.  Therefore, the study may be suggesting that any type of strength training improves throwing velocity, rather than these 3 programs being the most effective exercise choices.  Finally, there is one low quality study (4/10 score) that shows very low evidence that medicine ball training improves throwing velocity.  This study is considered low evidence because it does not measure throwing velocity directly.  However, the study does show a significant increase in power measurements in the upper body.  Therefore, it is possible that those results would correlate to increase in throwing velocity because the arm speed is faster during throwing.

Clinical Bottom Line:

Overall, the studies show that most exercise programs that have a strength, power, and stability focus will improve throwing velocity the most.  There is no recommendation for specific exercises that can be made, but the program should be sport specific with a power, strength, and stability aspect for the upper body.  However, the studies that show the biggest increases also have a lower body and core component.  Therefore, a total body view toward exercises targeting throwing velocity may be the most efficient because the lower body and core may help to improve the other aspects involved the throwing motion.

Application to Case:

Limitations/Considerations:

o   A few studies consist of all females.

o   Does not provide clear understanding how males respond

o   Focus on handball players

o   Differences in throwing mechanics, size of ball, etc.

o   No adverse effects reported in an athletic population.

o   Very cheap, and extremely cost effective.

o   Easy to apply because studies were done with normal training activities.

Prescribing Exercise:

Based on the combined results, the best prescription would be a combination of upper body medicine ball, closed chain and scapular stability, and heavy resistance exercises.  Doing this in conjunction with his normal lower body and core routine would be the most beneficial.  The most effective dosage is 3 times a week for 6 weeks with 1-2 throwing sessions/week (25-30 pitches) and maintain baseball activities.  It is important to pick sport specific movements related to baseball to achieve the highest effect possible for the patient.  Combining exercises from the studies gives the best result, and that provides the power, strength, and stability focus to achieve the highest possible muscular performance.

References:

1.)    Hermassi S, Chelly MS, Tabka Z, Shephard RJ, Chamari K. Effects of 8-Week in-Season Upper and Lower Limb Heavy Resistance Training on The Peak Power, Throwing Velocity, and Sprint Performance of Elite Male Handball Players. Journal of Strength and Conditioning Research. 2011;25:2424-2433.

2.)    Escamilla RF, Ionno M, deMahy MS, et al. Comparison of Three Baseball-Specific 6-Week Training Programs on Throwing Velocity in High School Baseball Players. Journal of Strength and Conditioning Research. 2012;26:1767-1781.

3.)    Ignjatovic AM, Markovic ZM, Radovanovic DS. Effects of 12-Week Medicine Ball Training on Muscle Strength and Power in Young Female Handball Players. Journal of Strength and Conditioning Research. 2012;2011;26:2166-2173.

4.)    Prokopy MP, Ingersoll CD, Nordenschild E, Katch FI, Gaesser GA, Weltman A. Closed-Kinetic Chain Upper-Body Training Improves Throwing Performance of NCAA Division I Softball Players. Journal of Strength and Conditioning Research. 2008;22:1790-1798.

5.)    Raeder C, Fernandez-Fernandez J, Ferrauti A. Effects of Six Weeks of Medicine Ball Training on Throwing Velocity, Throwing Precision, and Isokinetic Strength of Shoulder Rotators in Female Handball Players. Journal of Strength and Conditioning Research. 2015;29:1904-1914.

Introduction: The CDC defines concussion as “a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells and creating chemical changes in the brain,” and estimates up to 3.8 million instances of Sport-Related Concussion (SRC) per year.  Additionally, due to the variability in symptom presentation, the subjective nature of symptom reporting, and widespread misunderstanding about what a concussion actually is, there is an increased need for more objective assessments for detecting SRC in real-time.

Clinical Scenario: A 17 year-old female varsity soccer captain suffers a head injury early in the 2^nd quarter of the game.  She does not lose consciousness, is able to walk off the field and is A&O x3.  She is, however, reporting nausea, grogginess and tinnitus.  Her parents and coaches are pushing to have the athlete return to the game, as she is one of the star athletes.  Feeling pressured, and anxious to return to play, the athlete informs the Athletic Trainer that she feels “ok” and can return to the game.  The Athletic Trainer, seeing mixed signs and symptoms, decides to further screen the athlete for concussion before making a decision on return to play.

PICO: In the school-aged athlete, how accurate are standardized assessments in detecting concussion immediately following head injury?

Search Strategy:

• Inclusion Criteria: (1) Studies must be relevant to school-aged athletes (<25yo); (2) Concussion Assessment must be applicable to sideline evaluations or immediately post-injury.
• Exclusion Criteria: (1) Concussion Assessments given only >24 hours post-injury (studies were included if they included both < and > 24 hours)
• Keywords: The following key words were used in various combinations to search PubMed, CINAHL, and PEDro Databases: Visual Motor, Sports, Concussion, Sideline, Sport Concussion Assessment.

Results:
 

Limitations:

• Majority Male Samples
• Sport studied was majority football
• Lack of agreed upon reference standards used, with inconsistent reporting on how concussion diagnosis was confirmed.
• Index screening commonly done after athlete was concussion was diagnosed on the sideline.
• Inconsistent reporting on environment in which baseline and post-season measures were taken.

Clinical Bottom Line:  There is consistent Level 2-3 evidence that the SCAT3 is a moderately reliable tool for detecting concussion.  Baseline testing is still recommended for the SCAT3, as there has not been enough research to back the use of normative data.  There is consistent Level 3 evidence that the King-Devick Test is a reliable tool for detecting concussion in the presence of both a concussive-force injury, and an accumulation of sub-concussive impacts.  The King-Devick Test is a quick and low-cost assessment; however, due to lower levels of evidence and small sample sizes, further study is needed to confirm reliability and validity.

Application of the Evidence:  As there have been no adverse effects reported with either sideline test, I would proceed with screening my athlete.  Given the lower Test-Retest Reliability of the SCAT3, as well as the subjective and self-reported nature of some of the components, paired with the pressure from the coach and parents to return to play, I would not choose the SCAT3 for this athlete.  I believe The King-Devick Test provides a more objective and more reliable screening in this case.

References:

1. Seidman D, Burlingame J, Yousif L et al. Evaluation of the King–Devick test as a concussion screening tool in high school football players. Journal of the Neurological Sciences. 2015;356(1-2):97-101. doi:10.1016/j.jns.2015.06.021.
2. Chin E, Nelson L, Barr W, McCrory P, McCrea M. Reliability and Validity of the Sport Concussion Assessment Tool-3 (SCAT3) in High School and Collegiate Athletes. The American Journal of Sports Medicine. 2016;44(9):2276-2285. doi:10.1177/0363546516648141.
3. King D, Hume P, Gissane C, Clark T. Use of the King–Devick test for sideline concussion screening in junior rugby league. Journal of the Neurological Sciences. 2015;357(1-2):75-79. doi:10.1016/j.jns.2015.06.069.
4. Galetta K, Brandes L, Maki K et al. The King–Devick test and sports-related concussion: Study of a rapid visual screening tool in a collegiate cohort. Journal of the Neurological Sciences. 2011;309(1-2):34-39. doi:10.1016/j.jns.2011.07.039.
5. Yengo-Kahn A, Hale A, Zalneraitis B, Zuckerman S, Sills A, Solomon G. The Sport Concussion Assessment Tool: a systematic review. Neurosurgical Focus. 2016;40(4):E6. doi:10.3171/2016.1.focus15611.

Background

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

Clinical Scenario

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

PICO

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

Search Strategy

Results

Hielkema et. Al, 2011³

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

Morgan et. Al, 2015⁴

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

Morgan et. Al, 2016⁵

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

Zhang et. Al, 2015⁶

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

Mahoney et. Al, 2001⁷

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

Heathcock et. Al, 2015⁸

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

Limitations

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

Clinical Bottom Line

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

Application to Case

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

Acknowledgements

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

References

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

Background:

Stroke is the leading preventable cause of disability in the US, however a superior rehabilitation technique has yet to be established to best aid this population in recovery.  The idea of self-control or regulation, referring to the ability to monitor and control our own behaviors, emotions and thoughts in accordance to the demand of the situation, has become a topic of discussion.   Recent literature in 2015 found that absolute self-controlled feedback in addition to limited self-controlled feedback has been successful in enhancing motor learning in the upper extremity on young, healthy adults ^6,7.  In a study by Lim et al, novice Taekwondo students performed significantly better in acquisition and retention when they controlled their feedback scheduling for a serial task, suggesting that having the ability to regulate feedback can have a positive impact both initially and throughout learning⁷.  Furthermore, Tsai et al took it one step further and found that by decreasing the amount of self-controlled feedback received, participants had to increase attention to decisions about feedback and use of feedback, leading to greater acquisition, retention and overall learning⁶.  In spite of these positive correlations in healthy populations, high quality studies with consistent outcome measures and adequate population sizes addressing this therapeutic intervention have scarcely begun to graze the surface of stroke rehabilitation.

Clinical Case

The patient of interest is 65-year-old male who recently suffered a R MCA stroke. PMH includes hypocholesteremia, HTN, BMI: 28, family history of prostate cancer.  His PLOF was independence in all ADLs and IADLs and recreational activity and he worked as a Grounds and Maintenance manager for National parks.

• Key Relevant Exam Findings:
  • LUE PROM WFL; LUE 1/5 globally.
  • Impaired sensation to light touch and proprioception globally on LUE as well as flaccid paralysis
  • Max A x1 to perform upper and lower body dressing
• FIM on IE: 69.
• Patient Goals: Return to PLOF (driving the RV, working in the national parks, playing bridge)

PICO Question

“Does self-controlled feedback impact upper extremity motor re-learning in adult patients following a stroke”?

Search Strategy

Results

Systematic Reviews
Molier et al, 2010 & Subramanian et al, 2010.

• Population, Interventions, Outcomes: The Moiler SR assessed 23 studies, and the Subramanian SR assessed 9 with an overlap of 6 studies. For both of the SRs, the interventions were combinations of aspects of feedback, being nature, timing, and frequency, and types of feedback such as auditory, visual, or sensory.  Outcome measures were classified into two major themes that will be used throughout the rest of the studies.  Motor functions are objective measures whereas motor activities are more quality of mov’t.
• Results: Nature of feedback, meaning KR or KP, was used in all studies assessed by Molier et al with more evidence suggesting a positive effect on MF. Furthermore, Subramanian found that 3 of the 9 studies saw improvements in MF and MA when KP was used. Delivery was only described in one study with no reference to frequency or timing in any article.  Additionally, there were no definitive results on benefits of types of feedback (For example visual combined with auditory feedback) due to multiple types being assessed at once.

Intervention 1
Liu et al, 2016.

• Population, Interventions, Outcomes: The Lui study followed 86 first-stroke survivors who where divided into SR-mCIMT, mCIMT or a control group. Over 2 weeks, participants performed 10 daily talks for 10, 1 hours sessions.   Motor activity outcomes were assessed across groups.
• Results: In all Motor Activities, SR-mCIMT was significantly better than control groups, however, in ¾ outcomes assessed, mCIMT was also significantly superior to control groups.

Intervention 2
Popović et al, 2014.

• Population, Interventions, Outcomes: The Popovic study followed 20 stroke survivors who participated in either no feedback or feedback mediated exercise 5x/wk for 3 weeks. The feedback was presented in a way to make the individual be competitive within themselves and against others in the study.  For example, a positive auditory cue was given when a trial was performed successfully. Motor activities and intrinsic factors outcomes were recorded over both groups.
• Results:
  • Received Therapy Time: All patients in FME reached metric maximum time of treatment; NFE improved but did not reach maximum.
  • Intrinsic Motivation Inventory: significant results for only interest/enjoyment and perceived confidence subscales (p< 0.01 for FME).
  • Modified Drawing Test: Smoothness improvement coefficients and speed were significantly different (P<0.01) in FME.
  • Positive correlation between scores on the perceived competence subscale and: the smoothness metric scores (p < 0.05), and pt. speed P < 0.05). Speed metric is also positively correlated with RTT (p < 0.05).

Intervention 3
Boyd et al, 2006.

• Population, Interventions, Outcomes: The Boyd study followed 30 participants, 10 Basal Gangliar strokes, 10 Sensorimtor cortex strokes, and 10 healthy controls. Participants performed serial reaction time and continuous tracking tasks for three days with retention testing on the 4^th   Participants were either given explicit or not given explicit information during the intervention.  Motor activities and intrinsic factors outcomes were assessed in all populations, both with or without explicit knowledge provided.
• Results: Retention: Implicit learning for both continuous and discrete tasks was interrupted by EI for stroke groups, but not HC (p= 0.028); these interferences and benefits were retained at retention.
  • Effect of Task: Overall the groups performed slightly better in CT (p= 0.004) than SR (p= 0.029), with EI continuing to negatively impact the stroke groups.
  • Overall, all EI groups demonstrated at least minimal implicit learning for both tasks, suggesting that learning was not stopped, but limited by EI.

Limitations

As far as limitations are concerned, the obvious were present such as limited high quality studies, small sample sizes, inconsistent control groups and lack of blinding.  Several studies had 1 month follow-ups, however that seems inadequate given the nature of stroke recovery.  In addition, there was a wide variety of interventions, outcome measures and combinations of feedback provided simultaneously, making it challenging to generalize for this populations.

Clinical Bottom Line

At this time, there is limited evidence that directly demonstrates or suggests that self-controlled feedback has a positive correlation on upper extremity motor relearning in adult stroke patients.

However, what can be established is that:

• Individuals suffering from stroke do not process explicit information as do healthy aged matched controls; in fact, it interferes with implicit learning
• Location, chronicity, and severity may play a large role in how feedback is processes

Case Application

First and foremost, it is important to determine the individual’s learning preference and readiness to begin learning after stroke because it is crucial to have them be an active participant in their rehabilitation to remain motivated. The Popovic article demonstrates how positive feedback and competition has a positive correlation with problem solving. The Boyd on the other hand article nicely demonstrates how explicit information can negatively impact motor relearning, so it’s important to not over cue the patient during treatment.   Given the summative results of the selected literature, the Lui article with SR-mCIMT has the most clinical significance and application of the usage of self-controlled feedback so I would prescribe self-regulated mCIMT in combination with feedback mediated exercise for 1 hr/day for 5 days a week for the duration of the pt.’s rehab stay to best aid and facilitate motor relearning.

References

• Molier BI, Asseldonk EHFV, Hermens HJ, Jannink MJA. Nature, timing, frequency and type of augmented feedback; does it influence motor relearning of the hemiparetic arm after stroke? A systematic review. Disability and Rehabilitation. 2010;32(22):1799-1809. doi:10.3109/09638281003734359.
• Subramanian SK, Massie CL, Malcolm MP, Levin MF. Does Provision of Extrinsic Feedback Result in Improved Motor Learning in the Upper Limb Poststroke? A Systematic Review of the Evidence. Neurorehabilitation and Neural Repair. 2009;24(2):113-124. doi:10.1177/1545968309349941.
• Liu, K. P. Y., Balderi, K., Leung, T. L. F., Yue, A. S. Y., Lam, N. C. W., Cheung, J. T. Y., Fong, S. S. M., Sum, C. M. W., Bissett, M., Rye, R. and Mok, V. C. T. (2016), A randomized controlled trial of self-regulated modified constraint-induced movement therapy in sub-acute stroke patients. Eur J Neurol, 23: 1351–1360. doi:10.1111/ene.13037.
• Popović MD, Kostić MD, Rodić SZ, Konstantinović LM. Feedback-Mediated Upper Extremities Exercise: Increasing Patient Motivation in Poststroke Rehabilitation. BioMed Research International. 2014;2014:1-11. doi:10.1155/2014/520374.
• Boyd LA, Winstein CJ. Explicit information interferes with implicit motor learning of Both continuous and discrete movement tasks after stroke. Journal of Neurologic Physical Therapy. 2006;30(2):46–57. doi:10.1097/01.npt.0000282566.48050.9b.
• Tsai M-J, Jwo H. Controlling absolute frequency of feedback in a self-controlled situation enhances motor learning. Perceptual and Motor Skills. 2015;121(3):746–758. doi:10.2466/23.pms.121c28x7.
• Lim S, Ali A, Kim W, Kim J, Choi S, Radlo SJ. Influence of self-controlled feedback on learning a serial motor skill 1 , 2. Perceptual and Motor Skills. 2015;120(2):462–474. doi:10.2466/23.pms.120v13x3.
• http://www.heart.org/HEARTORG/

Introduction: Hemispatial neglect is associated with poor rehabilitation outcomes, increased falls, depression, and decreased independence in everyday activities. Neglect is difficult to ameliorate and therefore more treatments are required to address neglect. Prism adaptation therapy has become a promising rehabilitation technique. It uses prism lenses that laterally shift the visual field to the right to bring spatial awareness to the neglected side.

Clinical Scenario: A 40-year-old female was admitted to the hospital 6 weeks ago with left sided weakness and altered consciousness. Initial NIH stroke scale on admission was 15. MRI with angiogram revealed an infarct to the right middle cerebral artery. Procedures were done and her status improved since her initial hospitalization. Currently, the patient has been in rehab for 3 weeks now and made improvements overall however, the patient has not improved in her ability to learn to adapt to her environment. She is unable to return to work, sit for long periods without left side support, and unable to ambulate and scan her environment on the left side.

PICO: Since neglect is a primary impairment affecting safety during functional tasks, prism adaptation therapy may be a promising treatment to help her negotiate her environment in a safe manner. In adults (> 19 years old) with hemi-neglect post stroke, is prism adaptation therapy effective in improving functional outcome?

Search Strategy: 

Inclusion criteria: (1) be an experimental study, (2) include participates older than 18 years of age, (3) include participants with right sided stroke with left hemineglect/unilateral neglect, (4) include prism adaptation therapy as an intervention, (5) assess functional/daily life activity tasks.

Exclusion criteria: (1) included participants with hemianopia without stroke, (2) included participants with a previous neurological or psychiatric disease, (3) compared prism adaptation therapy with another treatment intervention for stroke.

The keywords, ‘prism adaptation,’ ‘prism,’ and ‘neglect,’ were used in combination with each other to search for articles in CINAHL, OVID, and PubMed.

Results:

Abbreviations: N=number; SR= systematic review; RCT= randomized controlled trial; SE= significant effects; PA= prism adaptation; DB=downs and black; L= left; R= right; M= middle; C= center; Ex= experimental group; CO= control group; Tx= Treatment; BIT= Behavior Inattention test; BG= between group; f/u= follow up; NLD= Netherlands; ITA= Italy; M-F= Monday-Friday; WS= within subjects; BS= between subjects; BSIE= between subject interaction effect; AL(C)= Albert Line Cancellation; AUS= Australia; FIM= functional independence measure; CBS= Cathering Bergego Scale; TUG= time up and go; SSA= subjective straight ahead pointing; deg= degree; BB= balance board; CoP= center of pressure; ML= mediolateral; AP= anterioposterior; H/V sway= horizontal/vertical; EO= eyes open; EC= eyes closed.

Limitations:

• Functional outcomes varied between subjects
• Small studies, no blinding
• No control group, no randomization
• Statistical analysis was not measured or only provided for certain measures
• Results can only be generalized to short term effects
• No standardization in interventions or measures
• Significant results were found in studies with different interventions
• Neglect comprises of heterogeneous set of symptoms therefore no test can capture symptoms in all patients

Clinical Bottom Line: There is good to fair evidence with mixed results that suggest prism adaptation therapy may improve daily function in patients with hemi-neglect post stroke when measured with functional outcome measures. Due to the high variability between studies, more consistent research is needed to address the effects of prism adaptation training on functional outcome.

Application to Clinical Case Scenario: Published studies vary in study type, interventions, outcome measures, and research quality. However, due to the easy administration and low risk of PA, there is evidence of promising effects on functional outcome. Prism adaptation is worth a try especially since the patient has made improvements overall and is unable to negotiate her environment in a safe manner.

Intervention: Prism lens with optical shift > 10 degrees with 100 pointing tasks to two targets without visual feedback. Then > 30 pointing tasks to two targets without lenses to measure adaptation after effect. Treatment time will be 10-30 min five times a week in addition to individualized stroke intervention in rehab.

Functional task: ambulation and sitting balance

Functional outcome: FIM and TUG

References:

1. Champod AS, Frank RC, Taylor K, Eskes GA. The effects of prism adaptation on daily life activities in patients with visuospatial neglect: A systematic review. Neuropsychol Rehabil. 2016:1-24. doi: 10.1080/09602011.2016.1182032 [doi].
2. Keane S, Turner C, Sherrington C, Beard JR. Use of fresnel prism glasses to treat stroke patients with hemispatial neglect. Arch Phys Med Rehabil. 2006;87(12):1668-1672. doi: S0003-9993(06)01263-9 [pii].
3. Mancuso M, Pacini M, Gemignani P, et al. Clinical application of prismatic lenses in the rehabilitation of neglect patients. A randomized controlled trial. Eur J Phys Rehabil Med. 2012;48(2):197-208. doi: R3312526 [pii].
4. Nijboer TC, Olthoff L, Van der Stigchel S, Visser-Meily JM. Prism adaptation improves postural imbalance in neglect patients. Neuroreport. 2014;25(5):307-311. doi: 10.1097/WNR.0000000000000088 [doi].
5. Nys GM, de Haan EH, Kunneman A, de Kort PL, Dijkerman HC. Acute neglect rehabilitation using repetitive prism adaptation: A randomized placebo-controlled trial. Restor Neurol Neurosci. 2008;26(1):1-12

Clinical Scenario:

The patient is a 72 year old female diagnosed with a left CVA 8 months prior.  Initially at diagnosis, patient spent 4 days within an acute care hospital and 2 weeks within an acute rehabilitation setting before being discharged to her own home. Following discharge, patient participated in 8 weeks of outpatient physical and occupational therapy to continue to improve independence around her home. Since that time, she has not participated in any further rehabilitation program.

On examination, patient displayed abnormal synergistic patterns with right AROM movements and noted difficulty isolating movements without decreasing speed of movement. With right shoulder flexion AROM, patient displayed flexion synergy pattern (shoulder elevation, shoulder flexion and abduction in conjunction with elbow flexion) to the level of her shoulder. When patient was asked to demonstrate extending her arm in front of her to reach for a cup, patient demonstrated decreased speed in movement, slight dyscoordination of movement, and forward trunk flexion in order to obtain the object.  Patient states her goals are to improve overall arm function, such as being able to reach into a cabinet without difficulty, as well as hand function for activities such as cooking.

PICO:

In adults presenting with moderate to severe upper extremity impairments (Fugl-Meyer assessment score <50) following chronic stroke (>6 months), is robotic therapy more effective than conventional therapy in improving upper extremity function?

Search Strategy:

Databases Searched: PubMed, CINAHL, and Web of Science

Inclusion Criteria: participants experienced a single CVA at least 6 months ago, participants presented with moderate (if not severe) deficits in upper extremity function meaning Fugl-Meyer scores were no greater than 50, participant age range was 40-70 years old, robotic system provided hepatic feedback but allowed for active movement by participant, English was the main language, all articles were published in the past 10 years

Exclusion criteria: severe spasticity in involved limb (Modified Ashworth Scale 3 or higher), minor deficits in involved limb (Fugl-Meyer score 55 or higher), age <40 years old, and a robotic system that was EMG driven and therefore controlling all aspects of patient’s arm movement (ie patient only performing passive movements).

Search terms used for all 3 databases: upper extremity function, chronic stroke, and robotic therapy

Results:

Limitations:

• Small sample sizes
• Robotic system’s not compared to one another; hard to determine which features of the system are leading to improvements in motor recovery
• Conventional therapy not clearly defined in all studies
• Statistically significant differences between groups very minimal

Clinical Bottom Line:

• There is both Level I and II evidence demonstrating minor but present change in upper extremity motor recovery with the use of robotic and conventional therapy for individuals with chronic deficits in UE function as a result of CVA
• Greater improvements in scores were noted with robotic therapy immediately after intervention however at follow up robotic therapy was not superior to conventional therapy in most studies
• Two studies found significance when robotic therapy was applied in addition to conventional therapy

Application to Clinical Case Scenario:

• Two factors to take into consideration: Cost effectiveness knowing that a robotic exoskeleton is rather expensive, however robotic systems allow repetitive task movements at a higher intensity and with greater precision (more so than what a therapist may be able to provide over extended period of time).
• If arm exoskeleton is available in clinic, robotic therapy could be combined with traditional therapeutic interventions for maximal upper extremity motor recovery
• Treatment:  First couple of weeks utilizing robotic exoskeleton alone: robotic system should provide hepatic feedback to maximize motor learning.  Remaining weeks: conventional therapy with emphasis on functional tasks such as reach and grasp or fine motor movements such as pinch.
• Goal: Gross motor movements are refined with robotic exoskeleton during those first initial weeks with progression to gross motor movements against gravity without the exoskeleton as well as fine motor movements or any other movement the patient wanted to achieve during final weeks prior to discharge.

References:

1. Brokaw E, Nichols D, Holley R, Lum P. Robotic therapy provides a stimulus for upper limb motor recovery after stroke that is complementary to and distinct from conventional therapy. Neurorehabil Neural Repair. 2014;28(4):367-376.
2. Klamroth-Marganska V, Blanco J, Campen K, et al. Three-dimensional, task-specific robot therapy of the arm after stroke: A multicentre, parallel-group randomised trial. The Lancet Neurology. 2014;13(2):159-166. doi: http://dx.doi.org.libproxy.temple.edu/10.1016/S1474-4422(13)70305-3.
3. Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: Systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96. http://dx.doi.org/10.1682/JRRD.2010.10.0210
4. Reinkensmeyer DJ, Wolbrecht ET, Chan V, Chou C, Cramer SC, Bobrow JE. Comparison of 3D, Assist-as-Needed Robotic Arm/Hand Movement Training Provided with Pneu-WREX to Conventional Table Top Therapy Following Chronic Stroke. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2012;91(11 0 3):S232-S241. doi:10.1097/PHM.0b013e31826bce79.
5. Susanto EA, Tong RKY, Ockenfeld C, Ho NSK. Efficacy of robot-assisted fingers training in chronic stroke survivors: A pilot randomized-controlled trial. Journal of NeuroEngineering and Rehabilitation. 2015;12:42. http://go.galegroup.com.libproxy.temple.edu/ps/i.do?p=AONE&sw=w&u=temple_main&v=2.1&it=r&id=GALE%7CA412502874&sid=summon&asid=e6e160c574c1931cbce913c8d1827e73.

Clinical Scenario

• He currently is able to ambulate for 3 minutes without needing to rest due to fatigue.
• The patient is a motivated, young, and athletic individual who is adamant about returning to walking, and hopefully skiing, as soon as possible. With such a great interest in the field of engineering, he inquires about assistive technology rehabilitation programs as a potential enhancement to his therapy plan of care.

Clinical Question:

What brain-computer interface technology is available for the purpose of improving ambulation capabilities in patients with incomplete SCI?

Search Strategy

• Inclusion criteria: patients diagnosed with SCI; use of BCI for purpose of gait-specific neurorehabilitation
• Exclusion criteria: brain-computer interface for upper extremity, non-motor/cognitive functions; BCI within only virtual reality environment; BCI using invasive procedures such as brain or spinal implants

Evidence Summary Table 

Outcomes Summary

• In Do et. al, the control or maximum value using this computerized analysis was 0.498, while the actual average cross-correlation value across the 5 sessions was 0.815. This indicates that the cross-correlations were significant with an empirical p-value of less than .001. The subject, diagnosed with a T6 ASIA B spinal cord injury, even gained accurate control of the system in their first attempt.
• A similar cross-correlation analysis was used in both King et. al studies.  The 2014 study resulted in a p-value of less than .001 for almost all experimental sessions and the 2015 study resulted in a p-value of less than .01 in all sessions. Both of these studies illustrate purposeful device control of the BCI- FES system in walking and idling states.
• Lastly, Lopez-Larraz et.al calculated the decoding accuracy of each session, by dividing the number of trails in which the BMI correctly decoded the intention of motion by the number of trials in which the subject triggered the system on their own. The average decoding accuracy for the successful sessions completed by 3 SCI subjects was about 77% across 120 trials in 4 sessions.

• The BCI-RoGO demonstrated a 100% response rate with no omissions. The false alarm rate was 2 or less per session, with an average of .8. Although few in number, false alarms do carry risk of bodily harm to the patient.
• The BCI-FES system also resulted in no omissions, but the false alarm rate was a bit higher than in the RoGO study. Fortunately, the false alarm rate decreased as the patient became more accustomed to operating the BCI system.
• In the BCI-exoskeleton study, instead of measuring the omissions and false alarms, authors reported on the number of movement triggers generated by the system during “rest” or “preparation” intervals because in this protocol, the system physically impeded the exoskeleton from moving during these time frames. In the successful sessions, movements were triggered falsely in 40% of the trials during the “preparation” interval and in 63% of the trials during the “rest” interval.

• The interventions included 2 BCI gait systems, virtual reality and traditional body-weight supported gait training techniques.
• Only 1 of the 8 patients in the study had an incomplete spinal cord injury, but all were chronic cases of 3 years or greater since time of injury.
  • All patients had previously been enrolled in traditional physical rehabilitation programs but had not exhibited any level of sensory or motor improvement in the years they were followed prior to enrollment in the study.
• In addition to manual testing, surface EMG recordings were taken and the post-study results revealed that all patients exhibited some degree of motor improvement, indicated by their ability to voluntarily control at least 1 muscle below the neurological level of injury.
  • Proximal muscles surrounding the hip joint were reported to have the most gains, however there were also improvements in the knee and ankle joints.
  • By the end of the 12 months, the  ASIA B classified patient moved to an ASIA C classification and interestingly, the 7 complete spinal cord injury patients also changed to an incomplete classification by the end of the study.
• All patients showed significant improvement in assisted walking skills over the last 5 months of training, assessed with the Walking Index for SCI.
  • The patient with an incomplete injury improved their score by 4 levels and it has been suggested by previous analyses that just 1 level of improvement on this measure may be considered a real difference in a clinical context (Burns et al, 2011).

Clinical Bottom Line:

• Recent evidence has demonstrated the feasibility of using brian-computer interface-based technology as a neurorehabilitation technique for the improvement of gait in patients with chronic spinal cord injury.
• The quality and amount of evidence available is limited.
• The evidence’s value is therefore “proof-of-concept” and the results engender areas of interest for future study, rather than provide significant findings for current rehabilitative use.
• Theory of neuroplastic effects: The authors of this research argue that these systems may bring about neuroplastic effects on residual or partially spared motor pathways in incomplete SCI patients. The hypothesis is that such technologies couple the behavioral activation of the supraspinal gait areas and the spinal cord gait central pattern generator to promote Hebbian learning, which could improve outcomes beyond those of standard gait therapy.

Application to case scenario:

• Because the patient has expressed interest in novel therapeutic gait training methods that may be more beneficial to him, the physical therapist has completed a search on the NIH website for ongoing studies for which he may be appropriate.  Due to the lack of current evidence on BCI technologies, and considering his more recent onset of injury and therefore greater potential for motor recovery, the physical therapist advocates that the patient continues with his current inpatient physical therapy in combination with his research participation.

References

1. Do AH, Wang PT, King CE, Chun SN, Nenadic Z. Brain-computer interface controlled robotic gait orthosis. J Neuroeng Rehabil. 2013;10:111-111.
2. Donati ARC, Shokur S, Morya E, et al. Long-term training with a brain-machine interface-based gait protocol induces partial neurological recovery in paraplegic patients. Sci Rep. 2016;6:30383-30383.
3. López-Larraz E, Trincado-Alonso F, Rajasekaran V, et al. Control of an ambulatory exoskeleton with a brain-machine interface for spinal cord injury gait rehabilitation. Frontiers in Neuroscience. 2016:1-15.
4. King CE, Wang PT, McCrimmon CM, Chou CCY, Do AH, Nenadic Z. Brain-computer interface driven functional electrical stimulation system for overground walking in spinal cord injury participant.Conf Proc IEEE Eng Med Biol Soc. 2014;2014:1238-1242.
5. King CE, Wang PT, McCrimmon CM, Chou CCY, Do AH, Nenadic Z. The feasibility of a brain-computer interface functional electrical stimulation system for the restoration of overground walking after paraplegia. J Neuroeng Rehabil. 2015;12:80-80.

Background

• Extracorporeal Membrane Oxygenation (ECMO) is used as a temporary life support in patients with end stage pulmonary and/or cardiac failure. Due to the limited number of organs available for children, ECMO can be used as a method to extend the life of a suitable candidate allowing them more time on the transplant list.
• Historically, ECMO was the strongest negative predictor of one-year survival post-lung transplant with a major contributing factor being secondary complications associated with prolonged immobility and bed rest. With advances in technology, awake and ambulatory ECMO is now a feasible option.
• Two main types of ECMO:
  • Veno-Venous (VV) ECMO                               Veno-Arterial (VA) ECMO

Case Scenario & PICO

Case: 10-year old female admitted to the hospital secondary to CF exacerbation. Conditioned continued to worsen until she reached respiratory failure and was placed on mechanical ventilation. Despite FiO2 at 100%, patient remained hypercapnic and hypoxic resulting in medical sedation and implementation of VV-ECMO. Patient was placed on the urgent bilateral lung transplant (BLTx) list.

PICO: Do pediatric patients awaiting a lung transplant (LTx) have improved functional outcomes and reduced hospital length of stay if they receive ambulatory ECMO as a bridge to LTx compared to those who receive traditional non-ambulatory ECMO?

Search Strategy

Databases Searched: PubMed, CINAHL, OAIster

Inclusion Criteria: English language, Human subjects, All age groups, Ambulatory ECMO, ECMO as a bridge to heart and/or lung transplant

Exclusion Criteria: Clinical Commentary/Narrative Review, Duplicate in Systematic Review, Non-ambulatory ECMO, Intervention focused on post-transplant ambulatory ECMO, Ambulatory ECMO awaiting a non-lung transplant.

Results

Limitations

• Low quality evidence
• Small sample sizes
• Time and type of PT interventions varied across studies

Clinical Bottom Line

• There is limited, low quality evidence that suggests that ambulatory ECMO improves functional outcomes and reduces hospital LOS in pediatric patients awaiting a lung transplant.
• Ambulatory ECMO is complex and high-risk and should only be performed within a multidisciplinary team in hospitals with ample experience to ensure optimal safety.

Application to Case

• Initiate the conversation with the medical team regarding the benefits associated with immediate PT following ECMO initiation. It will be a multidisciplinary team effort to provide active rehabilitation while on ECMO in order to guarantee safety.
• POC: Initiate PT immediately following initiation of ECMO progressing from PROM while patient is weaning off medical sedation (avoiding ROM of affected limb) –> active exercises in bed –> resistance exercises –> task specific exercises including ambulation until organ transplant.

Acknowledgments

Richard Lauer, PhD and TU DPT class of 2017

References

1. Bain JC, Turner DA, Rehder KJ, et al. Economic outcomes of extracorporeal membrane oxygenation with and without ambulation as a bridge to lung transplantation. Respir Care. 2016;61(1):1-7. doi: 10.4187/respcare.03729 [doi].

2. Hayes D,Jr, Galantowicz M, Preston TJ, Lloyd EA, Tobias JD, McConnell PI. Tracheostomy in adolescent patients bridged to lung transplantation with ambulatory venovenous extracorporeal membrane oxygenation. J Artif Organs. 2014;17(1):103-105. doi: 10.1007/s10047-013-0738-9 [doi].

3. Lowman JD, Kirk TK, Clark DE. Physical therapy management of a patient on portable extracorporeal membrane oxygenation as a bridge to lung transplantation: A case report. Cardiopulm Phys Ther J. 2012;23(1):30-35.

4. Polastri M, Loforte A, Dell’Amore A, Nava S. Physiotherapy for patients on awake extracorporeal membrane oxygenation: A systematic review. Physiother Res Int. 2015. doi: 10.1002/pri.1644 [doi].

5. Wong JY, Buchholz H, Ryerson L, et al. Successful semi-ambulatory veno-arterial extracorporeal membrane oxygenation bridge to heart-lung transplantation in a very small child. Am J Transplant. 2015;15(8):2256-2260. doi: 10.1111/ajt.13239 [doi].

VV-ECMO and VA-ECMO Pictures: http://tele.med.ru/book/cardiac_anesthesia/text/gr/gr031.htm

By: Erika Shumock, SPT

Background

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

Case Scenario

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

Search Strategy

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

Results: Pain

Results: Function

Weaknesses/Limitations

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

Clinical Bottom Line

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

Clinical Application

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

References

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

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

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

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

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

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

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