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.

Background:

Foam rolling has become an increasingly popular form of self myofascial release among athletes and fitness enthusiasts. Advocates believe it corrects muscular imbalances, alleviates muscle soreness, relieves joint stress, and improves range of motion. However, despite these beliefs literature on foam rolling is quite rudimentary.

Clinical Case:

The patient is a 40 year old female presenting to physical therapy with chief complaints of intense muscle soreness in her right leg and an inability to straighten her leg without pain after her last gym session 4 days ago. She is an avid bootcamp enthusiast and reports that she has had recurring injuries since beginning bootcamp, but this is the worst she has experienced. Upon physical exam, she ambulates with an antalgic gait with decreased gait speed, decreased strength and limited range of motion secondary to pain in her right lower extremity. She rates her pain as a 3/10 at rest that increases to 6/10 when doing functional movements such as squatting or climbing stairs. Her goals include decreasing her pain, increasing her flexibility and learning how to help prevent future injuries at the gym.

PICO Question:

In adults (>18 years) participating in exercise, does foam rolling increase range of motion and decrease muscle soreness after activity as compared to no intervention?

Search Strategy:

A literature search was conducted using the databases PubMed, CINAHL, PEDro. The search terms included the following in each database: “foam roller” AND “foam rolling” AND “self myofascial release”. Articles considered for inclusion met the following criteria: peer reviewed, English language, articles published within the last 10 years, healthy adults, RCTs, studies that measured the effects of a foam roller on joint ROM, acute muscle soreness and/or DOMS, studies that compared an intervention program using a foam roll to a control group, and studies focused on the lower extremities. Articles were excluded if self myofascial release consisted of a roller massager or trigger point therapy, subjects were adolescents, studies focused on upper extremities, or if the outcomes were muscle performance measures. As a result, five articles were included.

Results:

Limitations:

Clinical Bottom Line:

• Based on limited, low level evidence, foam rolling acutely increases range of motion and decreases muscle soreness after exercise in healthy, physically active adults
• Foam rolling shows benefit being used both prior to and after activity with no adverse events
• At this time there is no standardized protocol for foam rolling

Application to Case:

• Patient’s goal: Decrease soreness, increase flexibility, learn how to prevent future injury!
• To deter DOMS and maintain ROM, patient will foam roll:
  • Prior to exercise to acutely increase ROM
  • Post-exercise to decrease muscle soreness
• Perform every time she exercises since it shows short term results
• Would not progress sets or reps (unless patient preference) because there is no standardized foam rolling procedure

References:

1. Barnes, MF. The basic science of myofascial release: Morphologic change in connective tissue. J Bodywork Move Ther 1: 231–238, 1997.
2. Pearcey GE, Bradbury-Squires DJ, Kawamoto JE, Drinkwater EJ, Behm DG, Button DC. Foam rolling for delayed-onset muscle soreness and recovery of dynamic performance measures. Journal of athletic training. 2015 Jan;50(1):5-13.
3. MacDonald GZ, Button DC, Drinkwater EJ, Behm DG. Foam rolling as a recovery tool after an intense bout of physical activity. Med Sci Sports Exerc. 2014 Jan 1;46(1):131-42.
4. Junker DH, Stöggl TL. The foam roll as a tool to improve hamstring flexibility. The Journal of Strength & Conditioning Research. 2015 Dec 1;29(12):3480-5.
5. MacDonald GZ, Penney MD, Mullaley ME, Cuconato AL, Drake CD, Behm DG, Button DC. An acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force. The Journal of Strength & Conditioning Research. 2013 Mar 1;27(3):812-21.
6. Bushell JE, Dawson SM, Webster MM. Clinical relevance of foam rolling on hip extension angle in a functional lunge position. The Journal of Strength & Conditioning Research. 2015 Sep 1;29(9):2397-403.

Background:

The incidence of plagiocephaly among infants in the United States has been steadily increasing.  Strategies to treat plagiocephaly include orthotic helmet therapy, conservative therapy such as repositioning or stretching, or simply waiting to see if the condition resolves on its own.

Clinical Case:

The patient is a 3 month old infant, referred to Early Intervention after his pediatrician made a diagnosis of torticollis and positional plagiocephaly.  Examination of the patient’s head indicates a moderate ipsilateral ear shift, and severe posterior quadrant flattening.  The patient’s Cranial Vault Asymmetry Index is 10, indicating severe plagiocephaly.  There is no evidence of developmental delay.

PICO:

Is orthotic helmet therapy more effective than physical therapy, repositioning therapy, or no treatment at all in treating plagiocephaly in infants?

Search Strategy:

The terms “plagiocephaly” and “helmet” were searched in the PubMed, CINAHL, and PEDRO databases.  Inclusion criteria were as follows:

• The articles were published in the past 6 years.
• The subjects were infants younger than 12 months diagnosed with positional or deformational plagiocephaly with or without torticollis.
• With the exception of the above diagnosis, the infants were otherwise healthy.
• The studies evaluated the effectiveness of an orthotic helmet in treating plagiocephaly in infants.
• The articles used measurements of skull asymmetry as an outcome measure.
• The articles were in English.

Exclusion criteria were as follows:

• The subjects were given a cranial cup, shaping pillow, or other device that was not an orthotic helmet.
• The subjects were diagnosed with craniosynostosis or other type of skull deformity.
• The subjects were older than 12 months at the initiation of helmet therapy.
• Subjects received osteopathic manipulations.

Applying the above criteria, 124 articles were found.  3 duplicates were removed.  121 articles were screened, and 99 were removed as irrelevant.  22 articles were full text screened.  Of these, 17 were excluded as irrelevant. Ultimately, 5 articles were included.

Results:

Is Orthotic Helmet Therapy (H) More Effective Than No Treatment (N) in Treating Skull Asymmetry? 

Is Orthotic Helmet Therapy (H) More Effective Than Repositioning Therapy or Physical Therapy (PT) in Treating Skull Asymmetry?

Is Orthotic Helmet Therapy (H) More Effective Than No Treatment For Motor Delays (N)?

Clinical Bottom Line and Application to Case:

There is limited, low-level evidence which does not clearly establish whether helmets are more effective in treating plagiocephaly in infants than either no treatment or conservative treatment such as physical therapy or repositioning therapy in terms of quantitative measurements of skull shape or achievement of developmental milestones.

The ultimate decision about whether to pursue helmet therapy should be determined by the parent after education is provided regarding the current status of research.

Limitations:

Limitations include the following:

• There is limited standardization in outcome measure reporting, and in the ultimate determination of when plagiocephaly is considered to be resolved or “cured”.
• Intervention and comparison groups are similar across all studies, but are not standardized.
• Many of the studies allowed infants to switch from intervention to comparison group based on parental preference.

References:

van Wijk RM, van Vlimmeren LA, Groothuis-Oudshoorn CG, Van der Ploeg CP, Ijzerman MJ, Boere-Boonekamp MM.  Helmet therapy in infants with positional skull deformation: randomised controlled trial.  BMJ. 2014 May 1;348

Lipira AB, Gordon S, Darvann TA, Hermann NV, Van Pelt AE, Naidoo SD, Govier D, Kane AA.  Helmet versus active repositioning for plagiocephaly: a three-dimensional analysis. Pediatrics. 2010 Oct;126(4):e936-45. doi: 10.1542/peds.2009-1249. Epub 2010 Sep 13.

Kluba S, Kraut W, Calgeer B, Reinert S, Krimmel M.  Treatment of positional plagiocephaly–helmet or no helmet?  J Craniomaxillofac Surg. 2014 Jul;42(5):683-8.

Wilbrand JF, Lautenbacher N, Pons-Kühnemann J, Streckbein P, Kähling C, Reinges MH, Howaldt HP, Wilbrand M.  Treated Versus Untreated Positional Head Deformity.  J Craniofac Surg. 2016 Jan;27(1):13-8.

Steinberg JP, Rawlani R, Humphriew LS, Rawlani V, Vicari FA.  Effectiveness of Conservative Therapy and Helmet Therapy for Positional Cranial Deformation.  Plast Reconstr Surg. 2015 Mar;135(3):833-42

Introduction:

-An important factor in stroke rehabilitation includes repetition of specific movements to improve functional mobility and balance.

-Wii technology provides an alternative form of repetitive task training in an interactive enriched environment for patients to improve functional mobility and balance.

Clinical Case & PICO:

-55 y.o. male Starbucks Manager who suffered from cerebral vascular accident in the right middle cerebral artery

• Ambulates 10’ with hemi-walker with max assist for balance at a self-selected speed of 0.2 m/s,
• Unable to perform TUG at this time due to inability to maintain standing balance without assistance
• Scored 3/56 on Berg Balance Test
• Goal is to return to work and participate in outdoor activities with family.

PICO:

Is using Nintendo Wii an effective intervention for stroke patients to improve balance compared to the conventional physical therapy (CPT)?

Search Strategy:

Inclusion criteria:

• Articles published within past 10 years only
• Randomized control trials
• Systematic reviews
• Systematic reviews with meta-analysis

• 66 articles identified in: PubMed, CINAHL, and Medline
• 25 removed from inclusion criteria and 3 removed from duplication
• 38 records screened
• 20 not relevant
• 18 full text screened
• 13 full text excluded
• 5 articles included

Results:

1-Berg Balance Scale 2-Timed up and Go 3-Functinal Reach Test 4-Wolf Motor Functional Test
5-10 Meter Walk Test 6-Functional Ambulatory Capacity 7-Barthel Index 8-Dyamic Gait Index
*R = correlation coefficient
**Statistical significance is (p<0.05)
ꭞGames used in this study includes the following: Hula Hoop, Bubble Blower, and Sky Slalom
ꭞꭞWii Fit program was used this study
ꭞꭞꭞGames used in this study includes the following: Tightrope Walking, Penguin Teeter-Tooter Seesaw, Balance Skiing, Rolling Marble Board, and Balance Wii

Clinical Bottom Line:

-The use of Nintendo Wii is an effective way to improve static and dynamic balance in post-stroke patients however, there is no significant difference between the Nintendo Wii and conventional physical therapy.

-Both level 1 and level 2 studies state that combining the Nintendo Wii and conventional physical therapy will produce the best results.

Application to Case:

-Since the Wii is just as effective as CPT, it would be an appropriate intervention to incorporate into the patient’s plan of care.

-Pt will participate in 45-60 minutes of CPT which will include static and dynamic balance training using stable ground, foam boards, and interventions from the berg balance scale, gait training using LRD, and specific tasks oriented to training ADLs for 5x/week in addition to 30-45 min of Wii for 3x/week for 6 weeks. Games will include ski slalom, ski jump, Wii sports, soccer heading, hula hoop, and penguin slide game.

-Physical therapist will give less assistance as patient improves in balance and increase the difficulty in Wii games.

Limitations:

-Has a small sample size for all randomized control trials

-Balance data was acquired using less sensitive outcome measurements instead of a stabilometry which would give the best quantitative data

-Lack of long-term follow-up

References:

1. Cheok G, Tan D, Low A, Hewitt J. Is nintendo wii an effective intervention for individuals with stroke? A systematic review and meta-analysis. J Am Med Dir Assoc. 2015;16(11):923-932. doi: 10.1016/j.jamda.2015.06.010 [doi].
2. Dos Santos LR, Carregosa AA, Masruha MR, et al. The use of nintendo wii in the rehabilitation of poststroke patients: A systematic review. J Stroke Cerebrovasc Dis. 2015;24(10):2298-2305. doi: 10.1016/j.jstrokecerebrovasdis.2015.06.010 [doi].
3. Lee HY, Kim YL, Lee SM. Effects of virtual reality-based training and task-oriented training on balance performance in stroke patients. J Phys Ther Sci. 2015;27(6):1883-1888. http://libproxy.temple.edu/login?url=http://search.ebscohost.com.libproxy.temple.edu/login.aspx?direct=true&db=cmedm&AN=26180341&site=ehost-live&scope=site. doi: 10.1589/jpts.27.1883.
4. Morone G, Tramontano M, Iosa M, et al. The efficacy of balance training with video game-based therapy in subacute stroke patients: A randomized controlled trial. Biomed Res Int. 2014;2014:580861. doi: 10.1155/2014/580861 [doi].
5. Yatar GI, Yildirim SA. Wii fit balance training or progressive balance training in patients with chronic stroke: A randomised controlled trial. J Phys Ther Sci. 2015;27(4):1145-1151. doi: 10.1589/jpts.27.1145 [doi].

Background:

Preterm birth is the birth of an infant before 37 weeks of pregnancy. In 2014, preterm birth affected about 1 of every 10 infants born in the United States.  Preterm birth is the greatest contributor to infant death.  Most preterm-related deaths occurring among babies who were born very preterm (before 32 weeks).  Preterm birth is the leading cause of long-term neurological disabilities in children.  Some problems that premature infants may face include: breathing problems, feeding difficulties, cerebral palsy, developmental delay, vision problems and hearing impairment.1

4

Case Scenario:

My patient is currently a 32 weeks gestational age female who was born at 26 weeks gestational age.  From the time of birth, the patient has been in the NICU of the local hospital. Upon evaluation, the patient has present grasp reflexes bilaterally (UE and LE), absent Babinski bilaterally, present rooting reflex bilaterally, one beat of clonus on the right lower extremity and two beats of clonus on the left lower extremity.  The patient has increased tone in all extremities, a 1 on the modified Ashworth scale in all extremities.  The patient has normal range of motion in all extremities and neck. The patient prefers right neck rotation while in supine but can tolerate left neck rotation if put in that position.  The patient had mostly stable vital signs throughout the treatment, with two O2 sat drops into the low 80s which the patient was able to independently recover from when treatment was paused. Throughout the examination and treatment, the patient had minimal fussing.

PICO Question:

In premature infants, what effect does physical therapy in the first 6 months of life have on motor development?

Search Strategy:

Three databases were searched: Pubmed, Cinahl and Ovid.  The key words “premature infants”, “physical therapy”, “neonatal intensive care unit” were used to search. The limits English language and article published from the year 2000 to the present were applied and and resulted in a total of 520 articles.  3 Duplicate articles were removed.  517 Titles were screened.  Articles were excluded if they did not relate to physical therapy, motor development or intervention within the first 6 months of life in premature infants.  501 articles were not relevant, leaving 16 articles for full text screening.  11 of those articles were excluding leaving 5 articles to include.

Article 1- Lekskulchai et al, 2001:

CEBM Level 2 of Evidence; RTC; PEDro = 7/10

The population in this study included 111 premature infants gestational age < 37 weeks (Thailand).  The interventions were individualized to the patient but included: positioning techniques, assisted kicking, promotion of eye following head movement, encouragement of weight bearing, assisted rolling, promoting reaching, encouragement of head righting.  In this study and all of the studies that were looked at, the physical therapist trained the primary care giver who performed the interventions with the infants.  The results of this study were that the intervention group showed significantly better results on the Test of Infant Motor Performance than the control group after 4 months.

Clinical bottom line: A developmental physical therapy program was found to be useful in promoting motor performance of preterm infants who were detected as being at risk for developmental delays during the early stage of life. 3

Article 2-Heathcock et al, 2009:

CEBM Level 2 of Evidence; RTC; PEDro = 5/10

The population in this study included 27 preterm infants gestational age < 33 weeks and weight < 2,500 g (United States).  For the intervention group, there was 3 categories of interventions: General movement of lower extremity (ex: attaching bells onto the infant’s sock and encouraging foot-toy interaction), Midline movement (ex: holding a toy in midline reach and encouraging infant to make contact to the toy with their foot), Distinct movement (ex: caregiver holds infant’s hip at 90 degrees and encouraging primarily knee motion to contact the toy).  The results of this study were that the intervention group had significantly more average number of foot-toy contact, mean foot-toy duration and percentage of infants that touched the toy more than 10 times at 8 weeks.

Clinical bottom line: Physical therapists can use feet-oriented play as an intervention technique with premature infants in the first 6 months of life to increase the rate of motor development. 2

2

Article 3- Heathcock et al, 2008:

CEBM Level 2 of Evidence; RTC; PEDro = 6/10

The population in this study included 26 preterm infants gestational age <33 weeks and weighted < 2,500g (United States). The intervention group received 3 categories of activities: General movement( ex: holding a toy attached to the infant’s sleeve so that any arm movement causes movement of the toy), Midline movement(ex: encouraging the infant to touch a toy held at midline), Distinct movement (ex: caregiver holds the infant’s upper arm and holds a toy over the infant’s hand, encouraging elbow movement).  The results of this study were that the intervention group had significantly more hand-toy contacts, longer hand-toy duration and number of infants that contacted the toy more than 5 times at 8 weeks.

Clinical bottom line: Physical therapists can use arm reaching activities as an intervention technique in premature infants in the first 6 months of life to help improve gross motor skills. 4

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Article 4- Cameron et al, 2005:

CEBM Level 2 of Evidence; RTC; PEDro = 6/10

The population in this study included 72 Preterm infants gestational age >24 weeks (United Kingdom).  After the start of the study, Twelve (20%) of the preterm sample were diagnosed with cerebral palsy, most of these infants from the treatment group. The effects of these infants may have balanced out the median Alberta Infant Motor Scale scores in the results.  The treatment group received individualized interventions including handling and positioning techniques, designed to promote symmetry and muscle balance and movement using postural support and facilitation techniques.  The results of this study were that there was no difference in the Alberta Infant Motor Scale between the intervention and control group at 4 months. However, this study also found that in the intervention group, infants with good parental compliance scored significantly better on the Alberta Infant Motor Scale than moderate or poor parental compliance.

Clinical bottom line: Physical therapy intervention increases motor performance, but not significantly, of infants born very preterm with very low birth weight at four months corrected age. Parental compliance to the intervention program significantly affected motor performance of the infants at four months corrected age. 5

Article 5- Koldewijn et al, 2009:

CEBM Level 2 of Evidence; RTC; PEDro = 6/10

The population in this study included 176 preterm infants gestational age <32 weeks and birth weight < 1,500g (Netherlands).  This study used the Infant Behavioral Assessment and Intervention Program.  The motor development strategies used in this program focus on midline orientation (ie. brining hands together and hands to mouth) and are also used to enhance postural control (ie. head and body righting in different positions) with the aim of addressing specific motor problems in preterm infants.  The results of this study were that the intervention group had significantly better results on the Behavioral Rating Scale but not on the Infant Behavioral Scale at 6 months.

Clinical bottom line: The Infant Behavioral Assessment and Intervention Program improved outcomes, though not significantly, of premature infants at 6 months corrected age. 6

Clinical Bottom Line:

There is moderately high level research that shows physical therapy in premature infants in the first 6 months of life can increase motor development in the short term

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Limitations:

The premature infants in all of these randomized controlled studies that have been shown to benefit from physical therapy are relatively healthy and do not have congenital abnormalities, genetic disorders, prenatal drug exposure, vision and hearing problems. Therefore, no effects of physical therapy are known for premature infants that may have some of these impairments listed.  All of these randomized controlled trials only study motor development effects in the short term and no long term effects have currently been studied.  None of the studies blinded the subjects or the physical therapist because it is not ethical. The therapists need to know the intervention in order to coordinate treatment between all of the infant’s health care providers to ensure the infant is receiving the optimal care. It would also be unethical to blind the subjects and the parents of the infants.  Many of the studies have a higher dropout rate or small sample sizes.  More research needs to be done to assess the effects of physical therapy in the long term, on premature infants with other health conditions and the cost effectiveness of physical therapy as an early intervention for premature infants.

Application:

My patient would be an appropriate candidate for motor development physical therapy because she was born at 26 weeks gestational age and currently does not have any other health conditions that would affect treatment.  I would start treatment now at 32 weeks gestational age since my patient is medically stable.  I would treat this patient 5 times a week for about 15 minutes a day, depending on tolerance and behavior.  My treatment plan would include extremity movement and postural techniques. Since my patient prefers right neck rotation while in supine, I would encourage left rotation actively and position her in left neck rotation when she is in supine. I would progress this to encouraging left cervical rotation while I have her supported in a sitting position. Since my patient has slight increase in tone in all extremities, I would encourage general movement of all extremities using a toy. I would progress this by using a toy to encourage midline movement of her extremities.  I would treat my patient for the remainder of her stay in the NICU.  When my patient is discharged from the NICU, I would educate and instruct her caregivers to continue the exercises.

Resources:

1.Preterm Birth. CDC. 2015. http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm

2.Heathcock J, Galloway J. Exploring Objects With Feet Advances Movement in Infants Born Preterm: A Randomized Controlled Trial.  Phys Ther. 2009;89:1027-1038. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928666/

3.Lekskulchai R, Cole J. Effect of a Developmental Program on Motor Performance in Infants Born Preterm.  Australian Journal of Physiotherapy. 2001; 47: 169-176.  http://www.sciencedirect.com/science/article/pii/S0004951414602646

4.Heathcock J, Lobo M, Galloway J. Movement Training Advances the Emergence of Reaching in Infants Born at Less Than 33 Weeks of Gestational Age: A Randomized Clinical Trail. Phys Ther. 2008; 88: 310-322. https://www.ncbi.nlm.nih.gov/pubmed/18096650

5.Cameron E, Maehle V, Reid J. The Effect of an Early Physical Therapy Intervention for Very Preterm, Very Low Birth Weight Infants: A Randomized Controlled Clinical Trail. Pediatric Physical Therapy. 2005; 107-119. https://www.ncbi.nlm.nih.gov/pubmed/16357661

6.Koldewijn K, Wolf M, Wassenaer A, Meijssen D, Sonderen L, Baar A, Beelen A, Nollet F and Kok J. The Infant Behavioral Assessment and Intervention Program for Very Low Birth Weight Infants at 6 Months Corrected Age. J Pediatr 2009; 154:33-38.  https://www.researchgate.net/publication/221692335_The_infant_behavioral_assessment_and_intervention_program_in_very_low_birth_weight_infants_Outcome_on_executive_functioning_behaviour_and_cognition_at_preschool_age

Please contact Laura Bishop at tuf66520@temple.edu for any further questions.

Background:

There are ~4 million ICU admissions per year with an average mortality rate of 8-19%, or about 500,000 deaths annually. These patients are at high risk for adverse outcomes due the severity of illness and the multiple and complex interventions given to them at the same time. “Critical care is a costly component of the national health care budget, with costs estimated to be $81.7 billion…These costs are largely explained by the length of stay (LOS) in the ICU”.1

Case Scenario:

Mr. B, a 78-year-old male, went into cardiac arrest while on a morning jog and was resuscitated via CPR by a Good Samaritan. He underwent a coronary artery bypass graft (CABG) after it was discovered that he suffered a myocardial infarction. He has been sedated and mechanically ventilated for the past 48 hours in the ICU and the physician lets you know he will be coming off of sedation today. Mr. B has a limited PMH and vitals are stable and safe for mobility at this time

Clinical Question:

In patients who are mechanically ventilated >24 hours, is early mobilization effective in significantly reducing the amount of time spent in the ICU?

Search Strategy and Results:

A literature search was performed to identify eligible randomized controlled trials (RCT), clinical trials, cohort studies and single-blind studies. Electronic searches of MEDLINE, CINAHL, and PUBMED using the key words “physical therapy” or “early mobilization” or “rehabilitation” and “ICU” or “critical care” and “mechanical ventilation” and “length of stay” were conducted. Only full reports in English were included. Inclusion criteria were as follows: Design: RCT, clinical trial, cohort study or single blind studies; Participants: Ages 19+, male or female, >24 hours on mechanical ventilation, patients in the ICU; Interventions: early mobilization or physical therapy including active or passive exercises in bed, side of bed, and/or ambulation, once or twice a day; Comparisons: usual care, delayed mobilization, as ordered by physician; Outcomes: ICU length of stay, ICU-acquired weakness (ICUAW) and adverse events.

Evidence Appraisal: 

Evidence Summary:

Clinical Bottom Line:

There is mixed and lower-quality evidence suggesting that early mobilization can significantly reduce the ICU length of stay

There were no significant adverse events reported in any of these studies suggesting that early mobilization in these patients is safe and feasible.

Application of the Evidence: 

The clinician needs to consider the patient’s prior level of function, goals, expectations and level of motivation. They also need to consider if the entire mobility team is on board including (but not limited to) the ICU nurse, physician, physical therapist, occupational therapist and respiratory therapist. In this particular case, Mr. B was previously very active and independent and is currently highly motivated to return home with his wife and eventually run again. The entire mobility team is also on board at this time. Due to Mr. B’s prior level of activity, we are choosing to implement the “Early Goal-Directed Mobilization” (EGDM) protocol 7 days per week at the level determined by the ICU Mobility Scale (which is outside the realm of this research). The EGDM protocol was used in the Hodgson et al 2016 study (as shown below):

https://twitter.com/iwashyna/status/717023531503058944

References: 

1. ICU outcomes (mortality and length of stay) methods, data collection tool and data. Philip R. Lee Institute for Health Policy Studies Web site. http://healthpolicy.ucsf.edu/content/icu-outcomes#ICU%20BACKGROUND. Accessed 09/23, 2016.

2. Dong Z, Yu B, Zhang Q, et al. Early rehabilitation therapy is beneficial for patients with prolonged mechanical ventilation after coronary artery bypass surgery. Int Heart J. 2016;57(2):241-246. doi: 10.1536/ihj.15-316 [doi].

3. Morris PE. Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: A randomized clinical trial. JAMA : the Journal of the American Medical Association. 06;315(24):2694; 2694-2702; 2702.

4. Hodgson CL, Bailey M, Bellomo R, et al. A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU. Crit Care Med. 2016;44(6):1145-1152. doi: 10.1097/CCM.0000000000001643 [doi].

5. Yosef-Brauner O, Adi N, Ben Shahar T, Yehezkel E, Carmeli E. Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness. Clin Respir J. 2015;9(1):1-6. doi: 10.1111/crj.12091 [doi].

6. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243. doi: 10.1097/CCM.0b013e318180b90e [doi].

Contact Andrea Dietrich at Andrea.Dietrich@temple.edu for further information.

References

1. Brumitt, J. Heiderscheit, B. Manske, R. Niemuth, P. Rauh, M. Lower extremity functional tests and risk of injury in division III college athletes. IJSPT. 2013; 8(3): 216-227.
2. 2. Dallinga J, Benjaminse A, Lemmink K. Which screening tools can predict injury to the lower extremities in team sports. Sports Med. 2012; 42(9): 791-815.
3. 3. Ivarsson et al. Psychological factors and sport injuries: meta-analysis for prediction and prevention. Sports Med. 2016. Doi: 10.1007/s40279-016-0578-x
4. 4. Lehr et al. Field-expedient screening and injury risk algorithm categories as predictors of non contact lower extremity injury. Scand J Med Sports. 2013; 23: e225-e232. Doi: 10.1111/sms.12062
5. 5. Walbright, D. Ojha, H. Validity of functional screening tests to predict lost-time lower extremity injury in a small cohort of female collegiate athletes. 2016. In preparation.

Research Performed by: Cara Fowler, SPT

Background:

Obtained from: http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/stroke_overview_slideshow/webmd_rm_illustration_of_stroke_causes_.jpg

Stroke is the number one cause of long-term disability in the United States.¹ Eight out of ten stroke survivors suffer from residual hemiparesis that results in a multitude of impairments including decreased balance, gait ability, and coordination.² Dynamic balance and gait dysfunction are the two prevalent impairments in individual’s post-hemiparetic stroke and place individuals at a higher risk of falling and results in impaired functional mobility.²

Virtual reality is a form of interactive simulation that immerses patient’s within a virtual environment that gives patient’s similar experiences to real-world events within a safe and controllable clinical environment.³ Virtual reality has been explored in the chronic stroke population to improve stroke outcomes in many aspects, including balance and gait.^3-7 Virtual reality has been theorized to increase patient’s motivation and adherence in a physical therapy program.³ Virtual reality also provides users with the ability to receive real time feedback based on their performances, increasing their knowledge of performance leading to more improvements in their performance.³ For these reasons, it may be a feasible option to integrate wishing a conventional physical therapy regimen in order to promote better outcomes.

Clinical Scenario:

Mrs. Anita Cooke is a 65-year-old female that is presenting to physical therapy with the chief complaint of right-sided weakness, primarily in her lower extremity, after suffering from a Left Anterior Cerebral Artery Stroke 12-months ago. For the two years prior to her stroke, Anita was enjoying her retirement from being a school teacher by going for daily walks around her neighborhood, watching her granddaughter three times per week, taking care of her home, and playing video games with her grandson. Prior to her stroke, Anita was independent in all ADLs and IADLs. Anita’s goals are to: 1) return to her prior level of function, 2) play with her granddaughter again, 3) improve her balance, 4) go for walks around her neighborhood again, and 5) increase her confidence in her ability to move around.

Anita’s physical therapy exam revealed that she had normal active and passive range of motion in her upper and lower extremities, normal cognition (as demonstrated by score of 25 on the MMSE), difficulty isolating movements in her right lower extremity, decreased dynamic balance, and decreased walking abilities. More specifically, Mrs. Cooke ambulated independently with a single point cane and asymmetric gait pattern with decreased cadence, decreased right foot clearance, and decreased step length with left lower extremity. Anita completed the following functional tests and measures with the corresponding scores:

• Timed Up and Go: 20 seconds with single point cane (patient had difficulty with sit to stand transfer and ambulated slowly) and 35 seconds with no Assistive Device
• Berg Balance Scale: 40/56
• 10-Meter Walk Test: gait speed = 0.5 m/s
• 6-Minute Walk Test: 50m with 5 rests of 15 seconds
• ABC Scale: 70

Clinical Question: 

In adult patients (> 18 years old) with chronic stroke resulting in hemiparesis, are virtual reality (VR) interventions in addition to conventional physical therapy (CPT) more effective than CPT alone in improving dynamic balance and gait outcomes?

Search Strategy:

A literature search was performed to identify all eligible randomized controlled trials. Electronic searches of PubMed, CINAHL, Embase, and MEDLINE was performed using the keywords ‘stroke’ or ‘chronic stroke’; and ‘balance’, ‘postural balance’, or ‘berg balance’; and ‘virtual reality’. Only full reports in English were included. On the basis of titles and abstracts, articles were determined relevant or irrelevant. The inclusion criteria were as follows: articles published within the last 10-years; Design – RCT; Participants – Adults age > 18, male or female, with chronic stroke (> 6 months) resulting in hemiparesis; Outcomes – Berg Balance Scale (BBS), Timed up and go (TUG), 10-m walk test (10MWT); Comparison – Conventional or standard rehabilitation; Intervention – intervention with virtual reality and conventional or standard rehabilitation. Pilot studies, systematic reviews, and meta analyses were excluded. Additional studies were excluded if they utilized Telerehabilitation in the home environment, video game consoles (Wii, Wii Balance Board, PlayStation, Xbox Kinnect, etc.) as virtual reality, and studies with acute or subacute stroke participants. These inclusion and exclusion criteria resulted in 5 papers being included in this review.

Results:

Evidence Summary:

• 3 of 5 articles reported on TUG performance; 2 of 3 studies exhibited moderate-level evidence that VR + CPT leads to significantly greater changes in TUG performance.
• 4 out of 5 articles reported on BBS performance; 3 of 4 articles offer moderate-quality evidence that the use of VR + CPT results in significantly better performance on the BBS.
• 3 out of 5 articles examined 10MWT performance; all 3 articles offer moderate-quality evidence that VR + CPT leads to statistically significant ↑ in gait speed.

Overall, 4 of 5 studies show that VR when combined with CPT has additive effects and improves balance and gait outcome measures when compared to CPT alone.

Clinical Bottom Line: 

There is limited, moderate-level evidence that suggests that virtual reality in addition to physical therapy is more effective than physical therapy alone in improving gait and balance outcome measures.

Limitations of the Evidence:

• Small sample sizes were utilized in all of the studies.
• There was an inconsistence across the studies of the blinding of therapists, raters, and participants.
• All samples utilized a sample of convenience, limiting the ability to generalize these results to the general stroke population.
• All studies utilized strict inclusion and exclusion criteria limiting the generalizability to the general stroke population.
  • All studies only included participants that were ambulatory with high cognitive abilities which does not depict all stroke survivor abilities.
• There was an inconsistence in control group demographics across all 5 studies.
• Not all studies utilized the same methods to implement standard physical therapy or virtual reality limiting our ability as providers to determine the best way to implement virtual reality in addition to normal physical therapy in a plan of care.
• All studies were completed outside of the United States.
• There is an inconsistence across available literature about what the definition of virtual reality is.
• A lot of studies had to be eliminated from this critically appraised topic due to their use of video gaming systems as methods to implement virtual reality within their study.

Recommendations for Future Research:

Overall, there are many opportunities for future research to improve research on virtual reality in chronic stroke patients. In future research, there should be a clearer definition in what constitutes virtual reality. Currently, there is such an inconsistent interpretation of what constitutes virtual reality and the implementation of virtual reality. Many current studies utilize video game consoles and televisions as virtual reality treatment; however, all studies that utilized video games consoles were excluded from this CAT, significantly limiting the available research. Future research should also standardize what constitutes conventional physical therapy treatment, as it is difficult to implement and generalize vastly different conventional physical therapy programs into one physical therapy program. In addition, in future research, larger sample studies should be utilized to increase the statistical power and significance of future research, leading to the ability to generalize this research to the general chronic stroke population. Future research should also implement long-term follow-up periods to determine the long-term retention effects of the additive effects of virtual reality treatment.

Conclusion and Application to Case Scenario:

This evidence supports the notion that virtual reality in additional to conventional physical therapy will significantly improve these balance and gait outcome measures. Based on the current literature, integrating the use of virtual reality into a conventional physical therapy treatment program proves to be more superior than utilizing standard physical therapy alone for balance and gait deficits in chronic stroke patients with residual hemiparesis. Overall, throughout this literature, there have been no adverse events associated with the use of virtual reality; based on this information, the benefits by far outweigh the potential harm. Although there are proven benefits of implementing virtual reality in conjunction to a conventional physical therapy program, it is expensive to invest in virtual reality technology; therefore, its utility may vary depending on patient volume, finances in any given clinic environment, and space in any given setting. By showing that there are no negative consequences to utilizing virtual reality in addition to conventional physical therapy for chronic stroke patients with residual hemiparesis, may prompt more clinics to integrate virtual reality in their treatment program.

In this scenario, Mrs. Cooke presents to an outpatient clinic with balance and gait deficits following a stroke that resulted in residual hemiparesis. This condition and these deficits fall within the scope of current virtual reality research and within a physical therapist’s scope of practice. Since this is the case, the physical therapist may elect to include virtual reality into Mrs. Cooke’s conventional physical treatment program. By integrating virtual reality into Mrs. Cooke’s treatment program, she will have the opportunity to interact with an environment that is similar to the real-world while in a controlled and safe situation. In addition, by including virtual reality in addition to a conventional physical therapy program, Anita will have the ability to receive real time feedback to provide further improvements in her balance and gait outcome measures.

Although most of these research studies have proven the effectiveness of the use of virtual reality in addition to an individualized conventional physical therapy treatment program, there are several gaps in the evidence that lead to difficult application to this clinical question and scenario. The largest gap in the application to this case scenario is that within research that there was no common method of implementing virtual reality therapy or in the standardization of conventional physical therapy throughout these studies. In addition, all of these research studies were performed outside of the United States. Lastly, although the intervention and comparison groups were fairly similar across all studies, there was a large diversity in population as they were not standardized throughout the research.

After reviewing the literature, it will be beneficial to integrate the use of virtual reality technology into a conventional physical therapy treatment program for Mrs. Cooke. Anita’s treatment program should include both an individualized conventional therapy treatment program that is based on both the neurodevelopmental and motor learning theory. Anita should participate in physical therapy four times per week, for a total of 70-minute sessions with 40-minutes being dedicated to conventional physical therapy and 30-minutes of virtual reality treatment with the IREX VR system.

Obtained from: http://www.gesturetek.com/images/press/media-oct29-09-3.jpg

Virtual Reality Training should utilize various games on the IREX VR system in order to encourage active lower-limb movement, weight shifting, and single-limb stance. This will facilitate improvement in balance, mobility, stepping and ambulation skills, while simultaneously increasing her strength and range of motion.The difficulty of the games should be increased as Mrs. Cooke makes improvements in order to maximize her ability to progress. Weight and therabands can be added to provide external resistance and make the games harder and promote increased muscle strength and endurance.

Obtained from: https://acewebcontent.azureedge.net/certifiednews/BalanceExer2.jpg

The conventional physical therapy should be designed to be patient-specific and progress from static balance training to dynamic balance training. Since Anita is independent in quiet static standing balance, Anita would benefit most from progressing from static balance activities within the first few sessions as soon as she is able to shift her weight in the anteroposterior and mediolateral planes while performing functional reaching tasks. Her PT program should also include strengthening for the gluteus medius to improve controlled mobility of the pelvis during the stance phase of gait because she is having difficulty walking, particularly on uneven ground. Anita’s program should also include gait training and dynamic balance on unstable surfaces, because one of her main goals is to be able to walk around her neighborhood again.

References:

1. Stroke facts. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/stroke/facts.htm. Updated 20152016.
2. National Stroke Association Web site. http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/hemiparesis. Accessed October 16, 2016.
3. Cho K, Lee W. Effect of treadmill training based real-world video recording on balance and gait in chronic stroke patients: a randomized controlled trial. Gait & Posture [serial online]. 2014;39(1):523-528. Available from: MEDLINE, Ipswich, MA. Accessed September 11, 2016.
4. Chi-Ho L, Yumi K, Byoung-Hee L. Augmented reality-based postural control training improves gait function in patients with stroke: Randomized controlled trial. Hong Kong Physiotherapy Journal [serial online]. December 2014;32(2):51-57. Available from: CINAHL, Ipswich, MA. Accessed September 11, 2016.
5. Kang H, Kim Y, Chung Y, Hwang S. Effects of treadmill training with optic flow on balance and gait in individuals following stroke: randomized controlled trials. Clinical Rehabilitation [serial online]. March 2012;26(3):246-255. Available from: CINAHL, Ipswich, MA. Accessed September 11, 2016.
6. Lloréns R, Gil-Gómez J, Alcañiz M, Colomer C, Noé E. Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke. Clinical Rehabilitation [serial online]. March 2015;29(3):261-268. Available from: Psychology and Behavioral Sciences Collection, Ipswich, MA. Accessed September 11, 2016.
7. Kim J, Jang S, Kim C, Jung J, You J. Use of virtual reality to enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled study. American Journal Of Physical Medicine & Rehabilitation / Association Of Academic Physiatrists [serial online]. September 2009;88(9):693-701. Available from: MEDLINE, Ipswich, MA. Accessed September 11, 2016.

Please contact Cara Fowler at cara.fowler@temple.edu with any additional questions you may have regarding this topic.