Gabrielle Abate, SPT

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

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

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

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

Results:

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

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

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

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

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

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

Background

• Therapeutic alliance (TA)- collaboration and affiliation between patient and therapist

• Associated with better outcomes in general medicine and psychotherapeutic practices

• Is the same pattern present in physical therapy? What specific outcomes are affected?

http://www.folklife.si.edu

Case Scenario and PICO

25 year old mother and student referred to PT for chronic low back pain over 6 months.

• No red flags present, 42% dysfunction on Oswestry, AROM limited by pain

• Patient fearful she will not improve

The treating PT after evaluation focuses sessions on reassuring patient, including minimal exercise. The facility manager, also a PT, says future sessions should involve more therapeutic exercise to maximize results.

For patients with musculoskeletal pain, does enhanced therapeutic alliance predict improved outcomes compared to limited therapeutic alliance or exercise alone?

Search Strategy

Inclusion Criteria: Article Type: Systematic review, RCT. Date range: 2011 – Present. Age group: Adult >18, Outcomes: pain, function. Providers: PT, MD,RN.  Intervention: Therapeutic  Alliance, Motivational Enhancement

Results

Clinical Bottom Line

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Mixed quality evidence including high and low quality studies indicates that Enhanced Therapeutic Alliance

• applies best to chronic low back pain patients

• causes increased pain tolerance even without therex

• correlates with better outcomes in function, pain reduction and perceived treatment effect

Limitations

• Poor design of lower quality RCT’s

• Multiple and under studied outcome measures

• Lack of power analysis

• Lack of replication

• Use of VAS

• Use of high tech sham treatment

Application

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Specifically target therapeutic alliance in Chronic LBP populations using a Motivational Enhancement approach including:

• Collaborative goal setting

• Affirming symptoms

• Adjusting exercises if patient is resistant

• Seeing patient one-on-one until alliance is built & therapeutic exercise program well tolerated

• Using an Alliance Survey, such as the  Working Alliance Theory of Change Inventory

References 

1. Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S., Rashiq, S., Magee, D.J. and Gross, D.P., 2014. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy,94(4), pp.477-489.
2. Hall, A.M., Ferreira, P.H., Maher, C.G., Latimer, J. and Ferreira, M.L., 2010. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy.
3. Ferreira, P.H., Ferreira, M.L., Maher, C.G., Refshauge, K.M., Latimer, J. and Adams, R.D., 2013. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy, 93(4), pp.470-478.
4. Vong, S.K., Cheing, G.L., Chan, F., So, E.M. and Chan, C.C., 2011. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Archives of physical medicine and rehabilitation,92(2), pp.176-183.
5. Tse, M.M., Vong, S.K. and Tang, S.K., 2013. Motivational interviewing and exercise programme for community‐dwelling older persons with chronic pain: a randomised controlled study. Journal of clinical nursing, 22(13-14), pp.1843-1856.

Introduction:

• Physical Manifestations such as hypokinetic movements can lead to an increased risk of falls in the Parkinson’s Population. BIG Therapy was created to address this specific limitation.
• LSVT BIG Therapy
  • Training Protocol
    • High amplitude movements performed at high intensity (≥ 8 on RPE)
    • Minimum 4x/wk for 4 weeks with strict HEP
    • Certification needed

Clinical Case & PICO Question:

• Eileen is a 65 y/o female with a PMH of Idiopathic Parkinson’s Disease dx 11yrs, pt rated 3 on Hoehn and Yahr Scale, R humeral Fx 2 months ago secondary to fall. Meds include Siminet 4x/d & ASA as necessary.
• Impairments on eval: Frequent faller (6 times in the last year), Diminished stride length, Freezing gait when turning
• PICO: Can targeting the hypokinetic movements through BIG Therapy reduce the risk of falls in individuals with PD as opposed to traditional therapy techniques?

Search Strategy:

• 3 Databases: PubMed, CINAHL, PEDro
  • Search Terms: BIG therapy AND Parkinson’s Disease AND Parkinson’s Disease AND Physical Therapy AND Falls
  • Inclusion Criteria: English, Full text, Humans, Adults >18, Idiopathic PD <5 on H&Y scale, minimum dosage of 1 therapy session per week for a minimum of 4 weeks, Used TUG as a primary or secondary outcome measure.

Results: Studies in Red involve BIG Therapy, Studies in white are traditional therapy.

Limitations:

Small sample sizes, lacking of blinding of patients and therapists, unable to generalize results to entirety of Parkinson’s population, ceiling effect of outcome measure chosen

Clinical Bottom Line:

Level 2 and 4 evidence exists that suggests LSVT BIG Therapy can help improve motor functions that assist in the decrease of falls risk in PD populations. Level 2 evidence also exists that demonstrates a direct decrease in falls for those participating in traditional therapy that focuses on resistance and/or balance training in individual or group settings. At this time, more research is required to determine whether LSVT BIG Therapy has a direct correlation to reduction in falls risks. Another important area to focus is whether the intensity of an exercise program can effect a patient’s fall risk.

Application:

Based on the evidence provided the best treatment method for Eileen at this time would be to participate in traditional strength and balance training with principles of BIG therapy included throughout.

BIG Therapy limitations: Cost, Time, UE involvement

Recommended Program:
Sessions 2-3x/wk for ~1hr: Primary treatment of UE ROM
Repeated functional movements: Sit-to-stand, lunging (all directions), bed mobility. Progress: supported to unsupported
Balance training: Reactive, Anticipatory, Sensory Integration
Progressive bodyweight activities including: Squats, H/T raises, BIG walking
Key Factor: All activities performed at RPE ≥ 7 – resting when needed

References:

1. Ebersbach G, Ebersbach A, Edler D, et al. Comparing exercise in Parkinson’s Disease – the berlin LSVT BIG study. Movement Disorders. 2010;25(12):1902-1908.

2. Goodwin V, Richards S, Henley W, Exings P, Taylor A, Campbell J. An exercise intervention to prevent falls in people with parkinson’s disease: A pragmatic randomized controlled trial. J Neurol Neurosurg Psychiatry. 2011;82:1232-1238.

3. Ebersbach G, Ebersbach A, Grust U, Wegner B, Gandor F, Kuhn A. Amplitude-oriented exercise in parkinson’s disease: A randomized study comparing LSVT-BIG and a short training protocol. J Neural Transm. 2015;122:253-256.

4. Janssens J, Malfroid K, Nyffeler T, Bohlhalter S, Vanbellingen T. Application of LSVT BIG intervention to address gait, balance, bed mobility, and dexterity in people with parkinson disease: A case series.Phys Ther. 2014;94(7):1014-1023. doi: 10.2522/ptj.20130232 [doi]

5. Morris M, Menz H, McGinley J, et al. A randomized controlled trial to reduce falls in people with parkinson’s disease. Neurorehabilitation and Neural Repair. 2015;29(8):777-785