Introduction

  • Falls are the leading cause of fatal and non-fatal injuries in older adults aged 65 years and older.
  • Every year, nearly 3 million fall-related injuries are treated in emergency departments across the U.S.
  • Fear of falling, decreased physical activity, and limited community participation are common psychosocial implications associated with falls.

PICO Question

In community-dwelling adults aged 65 years or older is supervised group-based exercise compared to a non-exercise intervention effective in reducing number of falls and fear of falling?

Clinical Case

  • Patient is a 71 year-old female living independently in the community with a history of falls.
  • Chief complaint is feeling unsteady when walking and increased difficulty getting up from a chair.
  • Previous medical history is consistent with hypertension, osteoporosis, and asthma.
  • Goals are to improve her strength, balance, and confidence when walking outdoors.
  • Patient reports having 3 falls in the past year.
  • FES-I: 40/64

Search Strategy

  • Databases searched: PubMed, CINAHL, PEDro
  • Search Terms: “group exercise” OR “community group exercise” AND “physical therapy” OR “physiotherapy” AND “older adult” AND “falls prevention”
  • Inclusion criteria: community-dwelling older adults ambulating independently, intervention consisted of a group-based activity designed/supervised by a health care provider, control group consisted of a non-exercise intervention, outcome measures included reports on number of falls and/or fear of falling, and articles were published between January 2011 through August, 2016.
  • Exclusion criteria: disease specific populations (i.e. stroke, Parkinson’s disease, multiple sclerosis), older adults living in a long-term care facility or similar institution, intervention consisting of a group-based activity not designed or supervised by a health care provider, and lack of a non-exercise control group.

Flow Chart

  • 469 articles identified (PubMed, CINAHL, PEDro, hand search)
    • 186 duplicates eliminated
      • 283 titles and abstracts screened
        • 262 articles not relevant
          • 21 full text evaluated
            • 16 articles excluded
              • 5 articles included

Results

Table Summary

Clinical Bottom Line

There is inconsistent evidence that supports supervised group-based exercise is more effective compared to a non-exercise intervention in decreasing number of falls and fear of falling in community-dwelling older adults aged 65 years or older.

Limitations

  • Group exercise intervention was not standardized across studies.
  • Therapists delivering interventions varied across studies.
  • Supplemental home exercise programs.
  • Non-exercise comparisons varied across studies.
  • Majority of outcome measures were based on self-report.
  • Not all studies collected data at long-term follow-up.

Application

  • Community-dwelling older adults can potentially benefit from physical therapist supervised group-based exercise as a falls prevention intervention.
  • Supervised group-based exercise promotes increased physical activity in structured exercise sessions.
  • Individuals with multiple comorbidities may also benefit from an individualized intervention delivered in groups with similarly matched impairments to promote a safe environment in the community that allows for both exercise and social interaction.
  • Supervised group-based exercise can be a more cost effective falls prevention intervention compared to a traditional individual exercise intervention.
  • It is theorized that group-based exercise can promote increased patient satisfaction and exercise adherence.
  • The lack of adverse events reported in the evidence suggest that supervised group exercise can be a viable intervention for an individual with a history of falls and fear of falling.

Acknowledgements

Heidi Ojha, PT, DPT, OCS, FAAOMPT

References

1. Halvarsson A, Franzen E, Faren E, Olsson E, Oddsson L, Stahle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling – a randomized controlled trial. Clin Rehabil. 2013;27(5):450-458. doi: 10.1177/0269215512462908 [doi].

2. Iliffe S, Kendrick D, Morris R, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Technol Assess. 2014;18(49):vii-xxvii, 1-105. doi: 10.3310/hta18490 [doi].

3. Lee HC, Chang KC, Tsauo JY, et al. Effects of a multifactorial fall prevention program on fall incidence and physical function in community-dwelling older adults with risk of falls. Arch Phys Med Rehabil. 2013;94(4):606-15, 615.e1. doi: 10.1016/j.apmr.2012.11.037 [doi].

4. Martin JT, Wolf A, Moore JL, Rolenz E, DiNinno A, Reneker JC. The effectiveness of physical therapist-administered group-based exercise on fall prevention: A systematic review of randomized controlled trials. J Geriatr Phys Ther. 2013;36(4):182-193. doi: 10.1519/JPT.0b013e3182816045 [doi].

5. Perula LA, Varas-Fabra F, Rodriguez V, et al. Effectiveness of a multifactorial intervention program to reduce falls incidence among community-living older adults: A randomized controlled trial. Arch Phys Med Rehabil. 2012;93(10):1677-1684. doi: 10.1016/j.apmr.2012.03.035 [doi].

For further questions please contact: patricia.garcia@temple.edu

Introduction:

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

Clinical Scenario:

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

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

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

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


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

searchstrategy

 

Appraisal Table:

appraisal-table

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

pain

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

Limitations:

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

Clinical Bottom Line:

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


Application to Case Scenario:

  • Conservative Treatment1: 30 minute sessions, 1x per week, for at least 3 weeks
    • Manual Therapy – directed at sites of potential entrapment of median nerve
      • Nerve/Tendon Gliding – 5-10 min. in 2 sets of 5 min. with 1 min. rest between
        ulndt
      • Lateral Glides to C-spine
      • Soft Tissue Mobilization – treated according to pain on palpation or reproduction of symptoms
        stm stm2
    • Splinting/Rest – in neutral position, at night, for up to 6 weeks

References:

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

Case Scenario: 

A 50 year old male presents to physical therapy with a chief complaint of numbness and tingling as well as decreased sensation in his distal lower extremities, which he states has gradually gotten worse over the past 3 months. The patient has a 10 year history of Type II Diabetes, which he admits he does not manage well. When asked, the patient was unsure of his HbA(1c) and reports not measuring his glucose levels regularly or observing his feet for integumentary changes. After seeing his primary care practitioner last month, he was referred to an endocrinologist. The endocrinologist has recently prescribed him Lyrica for the nerve pain. The patient reports that the prescription makes drowsy and dizzy, and that “he’d really rather not take it”. The patient denies any acute trauma or injury, night pain, or changes in bowel or bladder. He is a construction worker in the local union and is on his feet for most of the work day. He states that the decreased sensation as well as the numbness and tingling in his toes is impacting his ability to perform at work, particularly climbing ladders at construction sites. He also says that he used to golf every other Saturday, but has not been able to because of the symptoms he is experiencing in his feet. His goal for physical therapy are to find the cause of his pain, and to be able return to golfing 2x/month, as well as safely climbing the ladder at work. After educating the patient on the importance of managing glucose levels through adhering to medications and through exercise and a healthy diet, the patient also made it a goal to exercise more, monitoring glucose levels after every meal, improve his diet, and monitor skin changes.

 

Outcomes:

HbA(1c)- 6.8%

NPRS: Average 5/10

PSFS: Golf- 3, Stand for >1 hour

Activities-Specific Balance Confidence Scale: 70%

 

Presentation:

Sitting posture examination appears within normal limits. When transferring from sit to stand, patient takes increase time to stand and weight bear through both lower extremities. Patient appears unsteady while standing and weight is transferred over right lower extremity. Lumbar active range of motion: within functional limits for flexion, extension, and right and left lateral flexion. Although, during these screens, patient was unsteady and had to use a “step-recovery” strategy to regain mild loses of balance. Lower quarter neuro examination consisting of dermatomes, myotomes, and deep tendon reflexes revealed decreased sensation along L5 and S1 (bilaterally), decreased deep tendon reflex (1+) left S2, and grossly normal myotomes. Slump test elicited no neural signs. When testing sensation using the Semmes-Weinstein Monofilaments, patient did not sense the 4.31 monofilament on the plantar surface of both lower extremities, which correlates to decreased protective sensation and diminished light touch. Supine examination revealed overall gross tightness in bilateral hamstrings, iliopsoas, and ITB. Central PAs over lumbar spine reproduced no pain or neural signs. Upon observation of plantar surface of feet, stage I ulceration was visible on both the heel and great toe of the left lower extremity.

 


Search Strategy & Results

Inclusion Criteria, Article must include:

  • Adults (>45 years old)
  • Patients with Type II Diabetes
  • Intervention includes interval training, OR aerobic AND resistance training, but not solely resistance training
  • Utilizes HbA(1c) as a clinical marker/outcome measure

 

Exclusion Criteria, Article cannot include:

  • Patients (<45 years old)
  • Patients with Type I Diabetes
  • Articles examining outcomes of resistance interval training
  • Article did not use HbA(1c) as a clinical marker/outcome measure

 

Databases Searched:

  • PubMed
    • Search terms: “high intensity interval training” OR “aerobic interval training” AND “hemoglobin)” AND “diabetes”
      • Madsen SM, Thorup AC, Overgaard K, Jeppesen PB. High intensity interval training improves glycaemic control and pancreatic beta cell function of type 2 diabetes patients. PLoS One. 2015;10(8):e0133286. doi: 10.1371/journal.pone.0133286 [doi]
      • Mitranun W, Deerochanawong C, Tanaka H, Suksom D. Continuous vs interval training on glycemic control and macro- and microvascular reactivity in type 2 diabetic patients. Scand J Med Sci Sports. 2014;24(2):e69-76. doi: 10.1111/sms.12112 [doi].

pubmed-search

 

  • CINAHL
    • Search terms: “high intensity interval training” OR “aerobic interval training” AND “HbA(1c)” AND “diabetes”
      • Terada T, Friesen A, Chahal BS, Bell GJ, McCargar LJ, Boule NG. Feasibility and preliminary efficacy of high intensity interval training in type 2 diabetes. Diabetes Res Clin Pract. 2013;99(2):120-129. doi: 10.1016/j.diabres.2012.10.019 [doi].

cinahl-search

 

  • Web of Science
    • Search terms: “type II diabetes” AND “aerobic interval training” OR “high intensity interval training” AND “HbA(1c)
      • Alvarez C, Ramirez-Campillo R, Martinez-Salazar C, et al. Low-volume high-intensity interval training as a therapy for type 2 diabetes. Int J Sports Med. 2016;37(9):723-729. doi: 10.1055/s-0042-104935 [doi].
      • Karstoft K, Winding K, Knudsen SH, et al. The effects of free-living interval-walking training on glycemic control, body composition, and physical fitness in type 2 diabetic patients: A randomized, controlled trial. Diabetes Care. 2013;36(2):228-236. doi: 10.2337/dc12-0658 [doi].
      • Balducci S, Zanuso S, Cardelli P, et al. Effect of high- versus low-intensity supervised aerobic and resistance training on modifiable cardiovascular risk factors in type 2 diabetes; the italian diabetes and exercise study (IDES). PLoS One. 2012;7(11):e49297. doi: 10.1371/journal.pone.0049297 [doi].wos-search

 


Evidence Summary and Appraisal

Author Date and Country Patient Group Outcomes

Key Results

Study Weaknesses
Mitranum, 2014, Thailand 45 adults with T2DM HbA1C%, BMI, fasting blood glucose, triglycerides

 

Health related physical fitness measures, vascular reactivity

Both continued and interval exercise training groups showed decreases in fasting glucose concentration and improvements in lipid profiles. However, only the interval group had a statistically significant decrease in HbA1C levels when compared to the sedentary group.

 

Interval training may be a safe, efficient, and effective strategy for the secondary prevention of chronic cardiovascular complications of T2DM.

Patients included in the study were of older age, sedentary, and on anti-hyperglycemic medications. Therefore, the results of the study may not be generalizable to the whole population of patients with T2DM.

 

Overall, the number of subjects in each intervention group may be considered small.

Terada, 2013, Alberta 15 adults with T2DM HbA1C%, BMI, fasting blood glucose, triglycerides

 

Subjective exercise experience scale, self-efficacy scales

In both exercise intervention groups, fasting blood glucose, HbA1c, triglycerides, and body weight did not change from baseline to post intervention. There was no significant differences between interventions, which indicates the similar effectiveness of both types of interventions after accounting for baseline differences.

 

Both interventions are feasible and provide high satisfaction to participants in patients with well controlled T2DM.

Findings need to be interpreted with caution given the small sample size and the presence of significant baseline differences in some characteristics despite random assignment.

 

The presence of a run-in phase required the attendance of 5/6 sessions to be eligible for the study and this could have resulted in a selection bias by favoring participants who were more likely to be compliant to the intervention. This selection of more compliant individuals strengthens internal validity but may weaken external validity.

 

There was relatively low HbA1C at baseline, as well as lack of statistical power to detect meaningful differences, which may be responsible for lack of change.

Karstoft, 2013, Denmark 32 subject with T2DM HbA1C%, BMI, fasting blood glucose, triglycerides

 

VO2max, blood pressure

Walking exercise can be implemented as a free-living training method in T2DM. Interval walking training is superior to energy expenditure matched continuous walking training in regards to physical fitness body composition, and glycemic control.

 

BMI showed improvements in the IWT between pre- and post, as well as between CWT and CON groups.

T2DM self-paced walking speed is low, and potentially too low to improve health-related outcomes.

 

There was large variability in the HBA1c changes in the IWT group. If a single subject with rapidly progressing, severe disease, who experienced serious deterioration in classic glycemic control variables after the training intervention was removed from statistical analysis, significant improvements in HbA1c were encountered in the IWT group. Additionally, a higher baseline HbA1C is associated with smaller training-induced reduction in HbA1C, which is evident that exercise responsiveness may be influenced by the underlying state of glycemic control.

Madsen, 2015, Denmark 23 patients, 10 with T2DM and 13 matched healthy controls HbA1C%, BMI, fasting blood glucose, triglycerides

 

Pancreatic beta-cell function, total fat, abdominal fat mass

Among the T2D patients there was significant reductions of average fasting glucose concentration and HbA1C (clinically significant). In the control group, there was no significant change.

 

This study provides results that HIIT improves overall glycemic control and pancreatic beta-cell function in T2DM patients and HIIT is a health beneficial exercise strategy for these patient. Additionally, all subjects fulfilled the HIIT intervention, indicating that it could be integrated as a future exercise strategy in inactive T2DM patients.

This study did not consider conducting the intervention with different duration of HIIT interventions.

 

More focus should also be addressed on more long-term HIIT intervention as well as individualized specific needs to address the intrasubject heterogeneity.

Balducci, 2012, Italy 606 subjects randomized to a control group, low intensity group, or high intensity group. HbA1C%, BMI, fasting blood glucose, triglycerides

 

Cardiovascular risk factors, physical fitness

There was a reduction in primary endpoint HbA1C, and although slightly, was significantly higher in HI than LI subjects. When compared with the CON group changes over baseline in both the LI and HI subgroups were significantly more marked for HbA1C and BMI.

 

In low fitness individuals, such as sedentary subjects with T2DM, training at LI is just as effective as training at HI improving modifiable CVD risk factors and reducing CVD burden. Intensity is of less importance than volume and type of training when exercise is applied as a form of therapy.

With a larger duration of the study, significant differences between the two subgroups would have emerged due to the progressively more pronounced difference in the duration of aerobic training and number of series of resistance training.

Only supervised exercise was performed at LI or HI, and working at HI in the absence of supervision is not recommended for safety reasons in individuals with T2DM. Due to the high volume of unsupervised physical activity achieved by both subgroups, only 1/3 of total PA was performed at different intensities. Differences in intensity in low-fitness individuals may not translate into absolute differences in aerobic and resistance workloads which are enough to produce a clinically significant difference in HbA1c.

Alvarez, 2016, Chile Adult overweight or obese (BMI between 25 and 35 kg/m2) with established diagnosis of T2DM for at least 12 months. HbA1C%, BMI, fasting blood glucose, triglycerides

 

 

Blood pressure, changes in current medication

There was significant interactions between inter- and intra-intervention in fasting glucose, HbA1C, BMI and triglycerides during 12 week follow-up.

 

The current low volume HIT program resulted in glycemic control improvements similar to those observes with a greater volume of exercise (>150min/week), and occurred even with a reduction in daily dosage of diabetes medications. Given that most T2DM patients are sedentary or insufficiently active, and lack of time is most frequently cited barrier to regular exercise participation, these findings are important implication for a public health perspective.

 

This particular study investigated only overweight or obese women with less than 5 years of diagnosis and no disease-related complications, which makes it hard to generalize to other populations.

 

There was only no control for dietary changes during the study and for physical activity during daily life after the intervention.

Author, Year Country CEBM Level of Evidence PEDro Scale

Study Design 

 

Trenda, 2013 Alberta Level 2 8/10 Randomized control trial
Alvarez, 2016 Chile Level 2 7/10 Randomized control trial
Mitranum, 2014 Thailand Level 2 7/10 Randomized control trial
Karstoft, 2013 Denmark Level 2 6/10 Randomized Control Trial
Balducci, 2012 Italy Level 2 5/10 Randomized control trial
Madsen, 2015 Denmark Level 3 3/10

Non-randomized control trial/cross-sectional

 

 

There is moderate-level evidence that suggests that high intensity interval training is an effective method for lowering the HbA1C levels in adults with Type 2 Diabetes. As the overall benefits of high intensity interval training are becoming more evident, it was prudent to justify its presence in the management of Type 2 Diabetes. However, it is difficult to draw a cohesive conclusion, as the studies examined utilize a variety of training protocols. Additionally, 4/6 studies compared high intensity training to continuous or low intensity, whereas 1 study compared high intensity to a non-exercise control group, and a final study compared the Type 2 Diabetes group to a healthy control group. This makes it challenging to draw a consistent parallel between the current published literature and the stance practitioners should take when prescribing exercise for patients with Type 2 Diabetes. Although many of the studies presented statistically significant results in favor of high intensity interval training, only one study was able to produce clinically significant results when comparing high intensity interval training to continuous training. In patients with already well-managed Type 2 Diabetes, training at either high or low intensities did not seem to make an effect on HbA1C values. The American College of Sports Medicine along with the American Diabetes Association recommend >150 minutes of low-moderate exercise per week for the management of Type 2 Diabetes. HIIT provides these patients the same benefits, but the training protocols require less time and allow for periodic rest breaks. Overall, it is conclusive that both high intensity interval training and low intensity interval training can be utilized in

the management of Type 2 Diabetes. But, what sets high intensity interval training apart from other intervention is that it is more efficient, cost effective, and less time consuming, making it more favorable and potentially leading to higher adherence rates. There a variety of different forms of HIIT, which makes it utility in practice extremely practical and can be utilized in all physical therapy settings, and when prescribed from a health care practitioner, specifically a physical therapist, it can be safely performed in the home as a part of a home exercise program.

 


Application of Evidence

Sample Protocol:

VARIABLE WEEKS 0-4 (3x/week) WEEKS 5-9

(3x/week)

WEEKS 10-13

(3x/week)

WEEKS 14-16

(3x/week)

Exercise Intensity (% Age heart rate reserve) 90-100 90-100 90-100 90-100
Exercise Duration (s) 30-34 38-44 46-50 52-58
Number of exercise bouts 8 10 12 14
Recovery Intensity (% Age predicted heart rate reserve) <70% <70% <70% <70%
Recovery Duration (s) 120 108 100 96
Number of recovery bouts 9 11 13 15
Total Time Commitment/day 22-22.5 min 26.1-27.1 min 30.9-31.7 min 36.1-37.5 min

High intensity interval training can be easily implemented into practice across all physical therapy settings. There is a large number of forms of high intensity training that can be utilized in practice. Depending on the technology available, 70-90% VO2max, 70-90% max HR, or Borg Rate of Perceived Exertion Scale can be used to ensure the patient is exerting themselves at the appropriate intensity. One of the protocols used in the reported studies can be used or modified to best suit the patient.

Depending on their preferred method of exercise, interventions can be tailored to best suit the desires/preferences of the patient. As presented in the literature, training programs can implement any form of exercise, from walking, cycling, and jogging. Other forms could include circuit training, such as plyometrics, or skipping rope. The main goal of treatment although, is to reach a particular pre-determined intensity, whether determined through heart rate, VO2 max, or RPE.

Based on our patient’s presentation, he will benefit from comprehensive and progressive balance training. Exercises can be taught to the patient in the clinic, but then can be completed at home a part of a home exercise program. Due to the flexibility of the training programs and its feasibility to be completed outside of the clinic, the patient should only have to be seen at the time of training progressions, in the absence of adverse events.


References 

1. Alvarez C, Ramirez-Campillo R, Martinez-Salazar C, et al. Low-volume high-intensity interval training as a therapy for type 2 diabetes. Int J Sports Med. 2016;37(9):723-729. doi: 10.1055/s-0042-104935 [doi].

2. Karstoft K, Winding K, Knudsen SH, et al. The effects of free-living interval-walking training on glycemic control, body composition, and physical fitness in type 2 diabetic patients: A randomized, controlled trial. Diabetes Care. 2013;36(2):228-236. doi: 10.2337/dc12-0658 [doi].

3. Madsen SM, Thorup AC, Overgaard K, Jeppesen PB. High intensity interval training improves glycaemic control and pancreatic beta cell function of type 2 diabetes patients. PLoS One. 2015;10(8):e0133286. doi: 10.1371/journal.pone.0133286 [doi].

4. Mitranun W, Deerochanawong C, Tanaka H, Suksom D. Continuous vs interval training on glycemic control and macro- and microvascular reactivity in type 2 diabetic patients. Scand J Med Sci Sports. 2014;24(2):e69-76. doi: 10.1111/sms.12112 [doi].

5. Terada T, Friesen A, Chahal BS, Bell GJ, McCargar LJ, Boule NG. Feasibility and preliminary efficacy of high intensity interval training in type 2 diabetes. Diabetes Res Clin Pract. 2013;99(2):120-129. doi: 10.1016/j.diabres.2012.10.019 [doi].

6. Balducci S, Zanuso S, Cardelli P, et al. Effect of high- versus low-intensity supervised aerobic and resistance training on modifiable cardiovascular risk factors in type 2 diabetes; the italian diabetes and exercise study (IDES). PLoS One. 2012;7(11):e49297. doi: 10.1371/journal.pone.0049297 [doi].

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

 

search

 

Evidence Appraisal and Key Results:

picture1

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 2nd 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.

strategy

Results:
results  scat3

king-devick-graph

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
  • 4th 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

gggg

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

zhang

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

search-strategyinformation

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).

results

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 4th   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.

last

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.

untitled

Results:

table

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:

Author, Year, Country Patient Population Study Type/Level of Evidence Outcomes Key Results
Brokaw

(2014)

United States

N=12 subjects

Adults, mean age of 57 y.o. Presenting with residual UE impairments(FMA 22.4(7.4)) after single CVA at least 1 year ago

Randomized cross over study design, Level II evidence

Pedro: 5/11

FMA1

ARAT2

Box and Block

Test (B&B)

FMA: Within group difference: (p A3: 0.26, B4: 0.51), Between group comparison not significant (p=0.68)

ARAT: Within group analysis (p A: 0.018, B:0.84), no significance of treatment type and order (p=0.15) meaning robotic therapy was superior in both groups

B&B: significance between treatment type and order (p=0.024), within group difference only significant for Group A at follow up (p=0.044)

Reinkensmeyer

(2012)

United States

N=26

Adults, mean age of 60 y.o

Presenting with residual UE impairments (FMA score 10-35) after single CVA occurring at least 11 months ago

Randomized controlled trial,

Level II evidence

Pedro: 6/11

FMA

MAL5

Box and Block

Test (B&B)

Improvements in scores greater for robotic therapy but scores not statistically significant

FMA: 24.1/27.4**/26.5

22.9/23.8**/23

MAL: 0.20/0.30**/0.30

           0.20/0.20**/0.20

B&B: 0.50/2.0**/1.9

0.30/0.60/0.80

Susanto

(2015)

China

N=19

Adults between the age of 41-65 y.o.

Presenting with moderate upper limb deficits (FMA score 20-50) after single CVA 6-24 months prior

Pilot Randomized Controlled Trial,

Level II evidence

Pedro: 7/11

ARAT

WMFT6

FMA

Both groups showed improvements in scores: only robotic group was able to maintain significant increase in score at 6 month follow up:

ARAT: 17.3/31.3**/28.33**

             20.8/28.5**/27.4

WMFT: 11.22/20.11**/17.67

               12.7/16.8/15.6

FMA: 31.89/37/38

         34.60/40.3**/37.3

Between group comparison: significant score change in robotic group for WMFT. No significance noted at 6 month follow up however.

Klamroth Marganska

(2014)

Switzerland

N=73

Adults between the age of 42-72 y.o.

Presenting with moderate to severe arm paresis (FMA score of 8-38) after single CVA at least 6 months prior

Multicenter, parallel group randomized controlled trial

Level II evidence

Pedro: 7/11

FMA

WMFT

Robotic therapy group showed quicker gains in scores for motor function recovery, however scores similar between groups at 34 week follow up

FMA: change in score for robot group significant (p=0.041) after 8 weeks.   Mean score change between groups not statistically significant.

WMFT: no significance noted between robot and control group (p=0.212) after 24 sessions/8 weeks

Norouzi-

Gheidari

(2012)

Canada

Adults who have experienced single CVA presenting with moderate UE impairments

Participated in prior study involving robotic and conventional therapy

Systematic review and meta-analysis

Level I evidence

PRISMA checklist: 18/27

FMA

FIM7

FMA: no significant difference among studies (p=0.28) when both groups received interventions for same length of time. Significance (p=0.004) when additional robotic therapy applied.

FIM: No statistical significance between groups for improvements in ADL’s (either same duration/intensity or additional robotic therapy)

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

case-scenario-slide

  • 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 

results-1

results-2

results-3

results-4

results-5 

Outcomes Summary

outcomes-1

  • 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.

 

outcomes-2

  • 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.

 

outcomes-3

  • 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.