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Gabrielle Abate, SPT

• 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




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.

• 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

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.


Parkinson’s disease is a progressive neurological condition that often results in a high risk of falls due to disordered motor control and postural instability. Research involving this population has focused on challenging impaired systems, and has demonstrated that using motor learning principles individuals with Parkinson’s disease are capable of learning motor tasks. In unimpaired populations self-controlled practice has consistently been shown to have positive effects on learning motor skills. Using this type of practice method, learners are given control over a certain aspect of the practice condition. To determine learning effects, controls are “yoked,” or matched to, self-controlled practice conditions.

Clinical Scenario

Mr. Parker is a 65 year old retired entrepreneur who presents to outpatient physical therapy with a 9 year history of Parkinson’s disease classified as Stage III on the Hoehn and Yahr scale. His past medical history is unremarkable with the exception of reporting two falls in the past month while walking in his home. Current medication includes Levadopa.

On examination, key findings were consistent with a typical Parkinsonian presentation including rounded shoulders and a forward head posture. He had diminished sensation on the plantar surface of his feet and reduced ROM and strength bilaterally. Balance and proprioception were decreased. The patient required minimal assist with bed mobility and transfers and presented with hypokinetic movement patterns. Gait assessment with close supervision and assistive device use revealed reduced stride length and speed, festination and freezing, reduced head, trunk, and arm movement, decreased hip and knee flexion during swing, and decreased ankle dorsiflexion at heel strike.

Mr. Parker’s goals include decreasing caregiver burden and difficulty with ADLs, improving strength in his lower extremities, improving balance to reduce falls and promote adherence to his HEP, and accompanying his wife of 40 years on long walks around their retirement community.

PICO Question

In patients with Parkinson’s disease (Stages II-IV Hoehn and Yahr) are self-controlled practice conditions during functional activity training an effective motor learning technique for improving balance and reducing the risk of falls?

Search Strategy & Results

Limits: English language & Humanssearch-strategy


(self-controlled feedback) AND motor learning


self-controlled AND balance


Self-controlled feedback AND balance

Evidence Appraisal & Study Participants



In the first study by Hartman (2007) participants were required to balance on a stabilometer, attempting to maintain it in a horizontal position. After each practice phase, participants completed a questionnaire adapted from Chiviacowsky and Wulf (2002). The self-control group was asked when and why they did or did not request the balance pole. The yoked group was asked if they received the pole after the correct trials and if not when they would have preferred to have used the pole. The self-control group chose when and whether they used a balance pole during practice trials.

Acquisition Days 1 & 2: 10 – 30 sec trials; 15 sec rest periods

Retention Day 3: 10 – 30 sec trials; 15 sec rest periods

study-2a   study-2b   study-2c

In the second study by Wulf and Adams (2014) participants were asked to perform 3 balance tasks: Toe Touch, Head Turn, and Ball Pass using their dominant leg first. The choice group was able to choose the order of the tasks.

Acquisition Day 1: 3 exercises 5x each (R & L leg)

Retention Day 2: 3 exercises 2x each (R & L leg)


In the third study by Lewthwaite, et al. (2015) participants were once again required to balance on a stabilometer, keeping the platform as close to horizontal as possible. They were given feedback about their time in balance after each practice trial. The choice group was presented with two choices unrelated to the primary motor task to determine if it would have an impact on task learning.

Acquisition Day 1: 10 – 30 sec trials; 90 sec rest periods

Retention Day 2: 5 – 30 sec trials; 90 sec rest periods


In the fourth study by Yoon, et al. (2013) subjects had to maintain an upright position for 10 seconds on a stabilometer. The choice group chose when they wanted visual feedback from the monitor, while a third group, the control group, received none.

Acquisition Day 1: 10 trials/block x 4 blocks

Retention Day 2: 10 trials/block x 2 blocks


In the fifth study by Chiviacowsky, et al. (2012) participants with Parkinson’s disease balanced on a stabilometer while wearing a safety harness to prevent falls. At the end of practice on day 1 and after the retention test on day 2 a customized questionnaire was completed. Participants in the self-control group could request the pole on any trial     during the practice session.

Acquisition Day 1: 10 – 30 sec trials; 90 sec rest periods

Retention Day 2: 5 – 30 sec trials; 90 sec rest periods

*Participants in the yoked groups for all five studies were matched to self-controlled conditions.



Wulf & Adams (2014)

In comparison to the control group the choice group had fewer errors (indicating a greater time in balance) during both the practice and retention phases when given a choice as to the order of their tasks.







Lewthwaite, et al. (2015)                                   Chiviacowsky, et al. (2012)

The learning curves pictured above depict time in balance during practice and retention trials for unimpaired university students highlighted in green and individuals with Parkinson’s disease in yellow. In both studies the self-controlled group had longer times in balance compared to the yoked group. In individuals with Parkinson’s disease less time in balance is spent overall compared to healthier counterparts, as indicated by the time intervals on the y axis. However, as compared to those in the yoked group, in individuals with Parkinson’s disease time in balance immediately improved after the first trial. During the retention phase there was a small drop-off in learning during the first trial, but improvements in time in balance continued throughout the fourth trial. Although individuals with Parkinson’s disease tend to learn balance tasks more slowly, this study provides evidence that greater learning effects can occur when self-controlled practice conditions are utilized.

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

Hartman (2007)

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

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

Yoon, et al (2013)

The self-controlled group had significantly smaller left/right and anterior/posterior body sway amplitudes.

Evidence Summary

More effective learning occurs when participants have the opportunity to control some aspect of the practice condition, including the use of an assistive device or when they receive feedback.

Clinical Bottom Line

There is limited, low quality evidence that suggests that self-controlled practice conditions during functional activity training are an effective motor learning technique for improving balance and reducing the risk of falls in patients with Parkinson’s disease. Additionally, there is ample, higher quality evidence demonstrating more effective learning under self-controlled practice conditions relative to yoked conditions in unimpaired individuals.

Application of the Evidence

Although the evidence is limited, self-controlled practice conditions improved time in balance in study participants with Parkinson’s disease and should be implemented in Mr. Parker’s plan of care. Using a walking program to help improve his balance, Mr. Parker can choose when he receives kinesthetic feedback. He will be informed that he may touch the wall in the clinic as needed or when he chooses while maneuvering around and over a variety of objects and surfaces. Our goal will be to get him to eventually walk around his retirement community at least 20 minutes a day safely with an assistive device. As we work up to this goal, other forms of feedback will be provided as needed in order to ensure Mr. Parker’s safety and promote appropriate decision making processes during home and community ambulation.


  1. Hartman JM. Self-controlled use of a perceived physical assistance device during a balancing task. Percept Mot Skills. 2007;104:1005-1016.
  2. Wulf G, Adams N. Small choices can enhance balance learning. Hum Mov Sci. 2014;38:235-240.
  3. Lewthwaite R, Chiviacowsky S, Drews R, Wulf G. Choose to move: the motivational impact of autonomy support on motor learning. Psychon Bull Rev. 2015;22(5):1383-1388.
  4. Yoon J-G, Yook D-W, Suh S-H, Lee T-H, Lee W-H. Effects of self-controlled feedback on balance during blocked training for patients with cerebrovascular accident. J. Phys. Ther. Sci. 2013;25:27-31.
  5. Chiviacowsky S, Wulf G, Lewthwaite R, Campos T. Motor learning benefits of self-controlled practice in persons with Parkinson’s disease. Gait Posture. 2012;35(4):601-605.


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



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.


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. 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.