Introduction:

  • Femoroacetabular impingement (FAI) is a bony abnormality of the acetabulum (pincer impingement) or the femoral head/neck junction (cam impingement)
  • This condition is common in young adults and can be congenital, or caused by repetitive motions
  • FAI is becoming recognized as a leading cause of hip pain, and surgical techniques for this condition have increased dramatically over the past decade
  • People in the field believe FAI may be over-diagnosed

oincer-2

 

The chart below represents a consensus for the diagnosis and treatment of individuals with symptomatic FAI

diagnosis

Clinical case scenario:

  • 30 year old active female with right anterolateral hip and groin pain. Imaging reveals a pincer type impingement with a partial superior anterior labral tear
  • The patient reports pain with ascending stairs and crossing legs (right over left). Increased hip adduction is demonstrated during functional activities, and she has a positive impingement and FABER test
  • This patients goals include return to running, however, she is reluctant to try physical therapy because she was told by her physician that she will most likely need surgery

PICO Question:

  • In adults (<18 years) with FAI and labral pathology, what is the effect of conservative management on decreasing pain and increasing functional ability?

Search strategy:

  • Databases searched: PubMed, CINAHL, Medline (via EBSCOhost)
  • Inclusion criteria: Adults: age >18 years, A diagnosis of femoroacetabular impingement and/or labral tear, patients are symptomatic, conservative treatment was received, outcome measures were used to assess pain/function
  • Exclusion criteria: Age < 18 years, patients are asymptomatic, hip surgery was received
  • 5 articles were included in my CAT. There is limited research on the conservative management of FAI/labral pathology (most research has focused on surgery as this has been seen to be the gold standard)

search-strategy ss-results

 

Results:

cart-1

chart-2

 

Clinical bottom line:

Multiple low level studies have shown that conservative treatment can play an important role in decreasing pain and increasing function in those presenting with symptomatic FAI

Limitations:

  • Limited research on FAI/labral treatments with low quality evidence overall
  • Small sample sizes and lack of long-term follow-up
  • Lack of control groups for majority of studies
  • Physician influence on the participants expectations of physical therapy and decision to choose surgery (based on whether or not they were examined by an orthopedic surgeon, or if they had already been pre-listed to receive surgery)

Application to case:

  • My patient is a candidate for physical therapy. I will see her 2-3x/week and then progress to more of an independent program
  • It is important to keep in touch with her other health care providers so everybody is on the same page during the treatment
  • Education is key: I will educate my patient on her condition, the treatment plan/prognosis, and the current research
  • The chart below is based off current research and what’s considered “the most effective treatments” for this condition

activities

Suggestions for future research:

  • Longer term follow-up studies to document lasting effects of conservative treatment and surgery
  • Investigate patient responses in order to determine who would be successful with conservative care versus surgery
  • Studies that directly compare physical therapy outcomes to surgical outcomes (there are currently RCT’s in the making that are directly comparing surgery to conservative management, therefore, it is very important to stay up to date with the literature)

* People in the field have noted that this diagnosis of FAI may be following similar trends to other conditions such as shoulder impingement. In the past the diagnosis and surgical treatment for shoulder impingement greatly increased, but then after years of research they found these individuals do great with an active treatment program and physical therapy (a lot of us have seen/successfully treated patients with shoulder impingement!). My point being, stay up to date with the research, FAI is currently a hot topic that is gaining considerable attention in the literature and medical community. When a patient presents to us in the clinic with this “diagnosis” we want to be able to educate and provide them with evidence based care.

Acknowledgements:

Bill Egan, PT, DPT, OCS, FAAOMPT

TU DPT Class Of 2017

References:

1. Emara K, Samir W, Motasem el H, Ghafar K.A. Conservative treatment for mild femoroacetabular impingement. Journal of Orthopaedic Surgery (Hong Kong), 19 (1) (2011).

2. Hunt D, Prather H, Harris Hayes M, Clohisy JC. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R. 2012 Jul;4(7):479-87. doi: 10.1016/j.pmrj.2012.03.012.

3. Smeatham A, Powell R, Moore S, Chauhan R, Wilson M. Does treatment by a specialist physiotherapist change pain and function in young adults with symptoms from femoroacetabular impingement? A pilot project for a randomised controlled trial. Physiotherapy. 2016 Feb 27.

4. Wright AA, Hegedus EJ, Taylor JB, Dischiavi SL, Stubbs AJ. Non-operative management of femoroacetabular impingement: A prospective, randomized controlled clinical trial pilot study. J Sci Med Sport. 2016 Sep;19(9):716-21. doi: 10.1016/j.jsams.2015.11.008. Epub 2016 Jan 6.

5. Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum tears: A case series. J Orthop Sport Phys Ther. 2011 ;41:346-53.

Background:

  • More than 795,000 people suffer from a cerebral vascular accident (CVA) each year
    • Ischemic strokes account for approximately 87% of all CVA’s
  • Leading cause of disability in the United States
  • CVA’s cost an estimated $34 billion each year
    • Includes medication costs, health care services, and missed work days
  • Repetitive Transcranial Magnetic Stimulation (rTMS) is a device that uses an electromagnet to stimulate small areas of the brain
    • This is achieved by low or high frequency magnetic pulses that send an electric current across the brain tissue
  • Low frequency stimulation has inhibitory effects
    • Transcallosal Disinhibition: By inhibiting the non-lesioned hemisphere the theory is that competition between hemispheres is decreased and it allows for more cortical excitability due to the non-lesioned hemisphere no longer inhibiting the affected hemisphere.
  • High frequency stimulation has excitatory effects

picture1

Image source: www.practicalpainmanagement.com

Case Scenario:

  • Hank is a 66 y.o. male diagnosed with a left middle cerebral artery thrombotic infarction 2 weeks ago.  He underwent surgery for recanalization of his left MCA and was placed on anticoagulants. Hank has a past medical history of hypertension, diabetes mellitus II, and peripheral vascular disease.

    Upon exam Hank was A&O x 3, able to follow commands, and provide social history. He is a retired school teacher who enjoys working on antique cars in his free time. Hank lives at home in a 1 story house with his wife and was previously independent with all ADLs and IADLs. He denies any pain but states, “I just can’t really feel my left hand very well.”  Hank is 6’1” and 182 lbs and right hand dominant.

     

    Hank is very hopeful that PT will “get his arm moving like it used to” so he has the upper extremity strength and hand dexterity to continue working on his cars.

picture2

Image Source: www.radiologyassistant.nl

Key Exam Findings:

  • Right upper extremity demonstrates a flexion synergy pattern with AROM
  • Manual muscle tests of the right upper extremity
    • Shoulder flexion 3/5
    • Elbow flexion 2/5
    • Elbow extension 2/5
    • Decreased grip strength
  • Diminished sensation to light touch in right upper extremity throughout C6-T1 dermatomes

PICO Question:

Does repetitive transcranial magnetic stimulation before activity training enhance upper extremity motor recovery in adults s/p CVA?

Search Strategy:

The following limits were applied: Published within the past 10 years, human species, English language, Meta-analyses, Systematic Reviews, RCTs

try

Inclusion Criteria, article must include:

  • Adults (>18 years old) who present with upper extremity paresis after stroke
  • At least one intervention arm that consisted of repetitive transcranial magnetic stimulation to either the ipsilesional or contralesional hemisphere
  • At least one intervention arm that consisted of motor/activity training after stimulation
  • Assessment of at least one of the following outcome measures:
    • Fugl- Meyer Assessment
    • Wolf Motor Function Test
    • 9 Hole Peg Test
    • Grip strength
    • Upper limb force production

Exclusion Criteria, article cannot include:

  • Stimulation to areas of the brain other than M1 or the premotor cortex
  • Other non-invasive brain stimulation techniques

Evidence Summary Table:

Author, Date, and Country Patient Population Study Type and Level of Evidence Outcomes Conclusion Study Weaknesses
Hao, 2013

China

Patients of any age or sex after stroke, regardless of the duration of illness or severity of the initial impairment Systematic Review

Level I

PRISMA: 23/27

Motor Outcomes: Jebsen-Taylor Hand Function Test, Pegboard Task, Wolf Motor Function Test, Action Research Arm Test –Use of rTMS for patients with stroke is not recommended until its efficacy is verified in high-quality, large scale RCT’s

Subgroup analysis: Contralesional rTMS displayed a moderate effect size on motor outcomes

Small number of subjects across all articles reviewed with sample sizes ranging from 10 to 123.

Stimulation parameters varied across studies.

No studies included with long term follow-up.

Inclusion criteria for participants was not very strict, for example a study with pediatric patients was included.

Meta-Analysis for motor function was only performed on 4 of 19 studies.

 

Hsu, 2012

Taiwan

Adults diagnosed with stroke Systematic Review

Level I

PRISMA: 20/27

Wolf Motor Function Test, Nine-Hole Peg Test, Grip Strength  

–rTMS suggests a clinically positive effect on motor recovery in the affected upper limb of patients with stroke

Low frequency rTMS over the contralesional hemisphere being more effective in enhancing upper limb motor recovery based on subgroup analysis

Small number of subjects across all articles reviewed

Many articles reviewed report a wide variety of long term outcomes, if any (from 2 weeks to 1 year),

Outcome measures, experimental designs, inclusion criteria, and rTMS protocols varied between articles.

 

Etoh, 2013

Japan

Adults with chronic stroke; either first or second unilateral stroke Randomized Double-Blind Crossover Study

Level II

PEDro: 6/10

Fugl-Meyer Assessment, Action Research Arm Test, Simple Test for Evaluating Hand Function Low frequency inhibitory rTMS to the contralesional hemisphere facilitated the effects of repetitive facilitation exercises (100 reps of 5 to 8 exercises) in improving the motor function of the affected upper limb in patients with chronic stroke Very small sample size.

“Sham” stimulation still involved actual use of the rTMS coil and it is possible that there was some stimulation to the motor cortex or the sensory cortex that may have confounded the results.

No long term follow-up.

Generalizability limited to those with unilateral chronic stroke

 

Seniow, 2012

Poland

Adults diagnosed with stroke with onset of symptoms <3months Randomized Control Trial
Level II

PEDro: 9/10

Fugl-Meyer Assessment, Wolf Motor Function Test  

Contralesional inhibitory stimulation to the primary motor cortex by low frequency rTMS is not yet an evidence-based method during early rehab for patients with stroke

There were statistically significant differences in both groups from pre test to post test scores, however there were no significant between group differences

 

 

 

Small sample size, The article stated that those in the experimental group received more PT posttreatment, There was loss to follow-up in both groups potentially skewing the data, though an intention to treat analysis was performed.

Generalizability limited to those in early rehabilitation post stroke

Wang, 2014

Taiwan

Adults with chronic stroke Randomized Control Trial

Level II

PEDro: 9/10

Fugl-Meyer Assessment, Wolf Motor Function Test, Medical Research Council Scale (grip strength and shoulder flexion) Inhibitory rTMS to the contralesional premotor cortex or primary motor cortex facilitated restoration of motor function in patients with chronic stroke

The patients assigned to the contralesional M1 and contralesional  dorsal premotor cortex groups showed significant improvements in MRC, FMA, and WMFT scores post-rTMS compared with those of the sham groupwith stimulation to M1 demonstrating larger effect sizes than stimulation to the dorsal premotor cortex.

 

 

 

Small sample size with a very homogeneous sample of only right handed patients and those with an MCA infarct – not very generalizable. There was no control group for the premotor cortex stimulation. Stimulation to the dorsal premotor cortex was only 3 cm away from the M1 stimulation area, while simultaneously stimulating M1 was attempted to be controlled there may have been some overlap.

Generalizability limited to those with chronic stroke.

 

Clinical Bottom Line:

There is moderate to high-quality evidence that suggests low frequency, inhibitory repetitive magnetic transcranial stimulation (rTMS) to the contralesional hemisphere may be an effective intervention in facilitating upper extremity motor recovery in those with chronic stroke. However, more research is needed to determine this treatments effectiveness in other stroke populations.

rTMS is an emerging intervention in stroke rehabilitation, and the current evidence varies greatly in terms of acuity of stroke, type of stimulation administered, hemisphere stimulated, and type of motor training performed after rTMS intervention. These variations across studies made it more difficult to draw a consistent conclusion from all articles reviewed.

Application to Case Scenario:

  • The literature does not suggest that rTMS will have a significant effect on the patient in my case scenario based on the acuity of his stroke as he is 2 weeks s/p CVA.
    • POC for my patient:
      • Interventions will include:
        • Weight bearing exercises through the affected upper extremity
        • Reaching tasks
        • Active assisted range of motion exercises
        • Goal of progressing to strength training and fine motor skill training
    • Discharge plan for outpatient PT

Acknowledgements: Dr. Richard Lauer, PhD

References:

1.  Hao Z, Wang D, Zeng Y, Liu M. Repetitive transcranial magnetic stimulation for improving function after stroke. Cochrane Database Syst Rev. 2013;(5):CD008862.

2. Hsu WY, Cheng CH, Liao KK, Lee IH, Lin YY. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: a meta-analysis. Stroke. 2012;43(7):1849-57.

3. Etoh S, Noma T, Ikeda K, et al. Effects of repetitive trascranial magnetic stimulation on repetitive facilitation exercises of the hemiplegic hand in chronic stroke patients. J Rehabil Med. 2013;45(9):843-7.

4. Seniów J, Bilik M, Leśniak M, Waldowski K, Iwański S, Członkowska A. Transcranial magnetic stimulation combined with physiotherapy in rehabilitation of poststroke hemiparesis: a randomized, double-blind, placebo-controlled study. Neurorehabil Neural Repair. 2012;26(9):1072-9.

5. Wang CC, Wang CP, Tsai PY, Hsieh CY, Chan RC, Yeh SC. Inhibitory repetitive transcranial magnetic stimulation of the contralesional premotor and primary motor cortices facilitate poststroke motor recovery. Restor Neurol Neurosci. 2014;32(6):825-35.

For further questions please contact: brooke.walters@temple.edu

Background

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

PubMed

(self-controlled feedback) AND motor learning

Ovid

self-controlled AND balance

CINAHL

Self-controlled feedback AND balance

Evidence Appraisal & Study Participants

study-information

Interventions
study-1

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)

study-1

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

study-4a

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

study-5a

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.

Results

study-2-learning-curve

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.

study-3-learning-curvestudy-5-learning-curve

 

 

 

 

 

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.

References

  1. Hartman JM. Self-controlled use of a perceived physical assistance device during a balancing task. Percept Mot Skills. 2007;104:1005-1016. http://pms.sagepub.com/content/104/3/1005.full.pdf.
  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. http://link.springer.com/article/10.3758%2Fs13423-015-0814-7.
  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. https://www.jstage.jst.go.jp/article/jpts/25/1/25_JPTS-2012-251/_pdf.
  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.

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

  • Motor imagery (MI) or Mental imagery is the mental representation of movement without any body movement6
  • Mental practice (MP) is the voluntary rehearsal of imagery scenes or tasks6
  • Healthy individuals have shown the enhancement performance of various motor tasks because of MI practice, especially in high level athletes6
  • It is widely accepted that MI practice is similar to physical practice except for the absence of neuromuscular output during imagery practice
  • Neuroimaging findings show functionally equivalent, overlapping brain regions for motor preparation and execution in both MP and Physical Practice (PP)

Case Study

Sharon is a 35 year old female boutique manager who sustained a moderate TBI 2 years ago. Initial Glascow Coma scale was an 8 but then increased to 13 after 2 hours. Prior to her injury she was an avid competitive roller blader and was independent with all tasks.

  • She spent 1 month in the acute care hospital, 2 months in acute rehab and 8 weeks in a transitional/OP program
  • She lives in a single level home with 2 STE, she has her husband and 2 teenage daughters.
  • Functional limitations: mod I with most ADL’s and IADL’s, can only walk 100ft on uneven surfaces limited by fatigue
  • Participation Limitations: Unable to grocery shop for > a couple items
  • Cognition: Rancheros Los Amigos Score is a 7, she has some impairment in problem solving and judgment making it difficult for her to be safe
  • Mini Mental State Exam: 24

She had heard about MI from a friend and was wondering if it could help her to get back to being independent with all functional tasks.

Goals: Return to PLOF, get back to shopping, walk to her friends house

Search Strategy

Search Terms: TBI + MI, TBI +MI+ PT

Inclusion: Moderate to severe TBI, MI

Exclusion: PTSD, music therapy

  • 478 Articles Identified in PubMed, CINAHL and Google Scholar
  • 1 Duplicate Removed
  • 477 Records Screened
  • 127 Abstracts Screened
  • 85 Articles Excluded Based on Relevance
  • 42 Full Texts Screened
  • 5 Articles Included

Results

Author, Date and Country Patient Group Study Type & Level of Evidence Outcomes MI Intervention/

Examination

Key Outcomes
1Oostra, Kristine et al. 2012 Belgium TBI pt’s undergoing rehab vs HC’s matched for age, gender, and level of education. Inclusion: no posttraumatic amnesia moderate to severe TBI Prospective cohort study in University Hospital Rehab, CEBM Level 4 The MI Questionnaire-RS

TDMI screening test

Temporal Congruence Stepping Test

Walking Trajectory Group

MIQ-RS: assess visual & kinesthetic modalities of MI ability

TDMI: Time to imagine vs time to execute action

TCST: compares real &imagined movement times

WT: quantify imagery of gait & demonstrates relationship between imagined & actual gait

TDMI- significant correlation between number of imagined stepping movements & duration: TBI group performed less

•TBI pt’s retain ability for MI & benefit from MI training to improve motor preparation, execution of movement & functional ability

2 Wondrusch, C et al. 2013, Switzerland Inclusion: Stroke, PD, MS, TBI, >18 y.o., MMSE >20, Speak German

Exclusion: >1 of above diagnoses, previous experience with MI

Case Series with pre-post design, CEBM Level 4 After MIIP Training:

MI Questionnaire

(MI-Q)

Mental Chronometry

(MC)

MI-Q:

Part A: Assess declarative knowledge of MI

Part B: Assess procedural knowledge with self perception of skills to perform MI

Part C: Assess pt satisfaction

MC: Measure congruency between time needed to imagine and time to perform movement

MI-Q:

A: Improved significantly after MIIP training

B: Increased but not significantly

C: 7/11 pt’s report high satisfaction

•MIIP is feasible intervention for TBI pts who understand concept of MI

3Franck Di Rienzo et al. 2014 France MI Studies Included: Stroke 49, PD 24, SCI 13, Amputation 14 Systematic Review, CEBM Level 1 Temporal Congruency

Vividness of Visual Imagery Questionnaire

The Vividness Movement Imagery Questionnaire

Transcranial Magnetic Stimulation

•Neurophysiological recordings showed specific changes in cerebral activations during MI which, mirrored structural & functional reorganizations due to neuroplasticity.

•MI capacities may not be deteriorated by neurologic diseases resulting in motor incapacities, but adjusted to the current state of the motor system.

•MI shares common neural and psychological bases with PP

•Both acute and progressive neurologic disorders impact brain motor networks, potentially eliciting changes in MI capacities.

4D’Arcy, Ryan et al. 2015 Canada Trevor Greene (TG) a 41 year old Canadian Soldier (45 at start of study), suffered a severe TBI, 53 year old with no motor impairment Case Control, longitudinal follow up >6 years, CEBM Level 4 Repeat fMRI monitors ongoing functional changes during recovery •fMRI showed expanded activation patterns in motor regions in TG compared to control

•During LL task motor activation increased significantly overtime which correlated with motor recovery

•MF recovery can occur >6 years after severe TBI.

•TG’s MF recovered (maxàmin A).

•Brain imaging results showed significant plasticity-related neural activation gains.

•As predicted LL activation increases closely with recovering the ability to walk.

5Liu, K. et al. 2004 China 2 Stroke pt’s: 1) 65-year-old Chinese female 2) 66-year-old Chinese male Case study, CEBM Level 4 Pt specific tasks i.e clean bathroom, cook they were doing on a daily basis prior to stroke (Likert Scale, 1=max A, 7= Independent) 3 week MI program

•1) pt’s self regulation technique

•2&3) procedural performance of task, engage mentally in performing task, visualize problems if task was carried out, describe how to fix problems, mental rehearsal of task, perform task

•MI able to promote stroke pt’s relearning of functional tasks. MI also appeared to promote the attentional function of pts.

•MI may   enhance task relearning after BI

 

 

 

Study Limitations

  • Future Research: Bigger sample sizes, blinding, random control trials, population specific to TBI, a gold standard outcome measures that evaluates MI ability

Application

  • Good cognition, avid high level roller blader
  • Used MIQ-RS to assess her ability to use MI
  • Want pt in functional but relaxed position6
  • Use first person perspective (internal MI)6
  • Physical practice of task
  • Gains may be higher in cognitive phase of motor skill6
  • HEP 10-15 minutes 3 x week6
  • Mx results by self report and improving function

Clinical Bottom Line

       Advantages

  • Cost effective tool
  • Various settings
  • If get tired from PP, MI can give them a rest
  •            Disadvantages
    • Requires future research
    • Takes variable time to teach pt how to do it
  • Neurophysiologic findings reveal that neuroplasticity occurs in individuals with a neurological insult3
  • Ability to do MI is preserved in individuals with moderate to severe TBI
  • May have less vividness compared to “normal” control1
  • PICO: In adults who suffered a moderate to severe TBI is mental imagery effective in improving function?

Acknowledgements

Anne Galgon,PT, PhD, NCS

References available upon request

Further questions contact : jane.carpenter@temple.edu

Background

  • According to a report by PricewaterhouseCoopers, 1 in 5 Americans owns some type of wearable technology
    • 1 in 10 Americans wears it daily
  • 90% of US mobile users are in possession of their phone 24hrs/day so it is easy to download a fitness app and track your physical activity any time
  • Fitness and healthy lifestyle trend in past few years is correlated with increased sales of wearable technology and usage of fitness apps
    • Even President Obama is keeping up with the trend and has been spotted wearing a Fitbit (Photo Source: Getty)

picture2

Case Scenario

  • A 56 year old female presents to the clinic with L knee OA. She has a BMI of 31 kg/m2 which is considered obese. She is currently performing 40 min/week of moderate intensity physical activity which is significantly below the recommended 150 min/week. Her goals include increasing her physical activity, decreasing pain, and losing weight. She is considering buying a fitbit or downloading a fitness app to help achieve her goals.

PICO Question

  • Are the use of mobile activity trackers effective in the promotion of physical activity in the general population including the obese and overweight population?

Search Strategy

  • Inclusion criteria: at least one intervention group that used a mobile activity tracker, step count as an outcome measure, and a study population of the general population including overweight or obese population

la_stephs-ebp

 

Summary of Evidence

table-of-evidence

Results

  • Change in Step Count (3 RCTs included)
    •  Key for graph (see below)
      • The studies are listed on the x-axis and # of steps are listed on the y-axis
      • Blue bars represent the control groups and green bars represent the interventions
      • The brackets and stars note significant between group differences in the studies
    • Cadmus et al.
      • Only the Fitbit group had significant increases in physical activity
      • No significant between group differences
    • Glynn et al.
      • Interaction with the smartphone app was significantly more effective than no access to the app/deactivated app
    • Wang et al.
      • Significant greater effect of Fitbit plus text reminders over the use of Fitbit alone but only at week 1
        •  Physical activity changes were short term and not maintained through the remainder of study period

results-change-in-steps

  • Average Steps – Harries et al. (RCT)
    • Key for graph (see below)
      • The interventions are listed on the x-axis and the average # of steps are listed on the y-axis
      • The blue bar represents the group that received no feedback from the smartphone app, green represents individual feedback, and purple represents social feedback
      • The brackets and stars represent significant between group differences
    • Results
      • Both the individual and social feedback groups took significantly more steps than the no feedback group
      • Individual feedback alone can be just as effective as social feedback

feedback-results

  • Urban Youth and Fitbit – Schaefer et al. (Cohort Study)
    • Key for graph (see below)
      • The study period is listed on the x-axis and the average step counts are listed on the y-axis
    • 11-12 years olds from a middle school in the city
    • Initially highly active and logged a lot of steps
    • Participation was not sustained by the end of 6 months
    • Many barriers for participation
    • Results (Graph is directly from Schafer et al.’s study)
      • The trend on graph showed a slight increase over time, but this was not statistically significant
      • The study did not report any other quantitative data
      • Due to the high drop out rate and lack of participation, Fitbit may not be appropriate for this age group
        • Fitbits are more often targeted towards health conscious adults

urban-youth-results

Limitations

  • Small sample sizes
  • Insufficient follow up duration and did not examine long term sustainability
    • 4 of 5 studies only 6-8 weeks long
  • Varied interventions and comparison groups
  • Difficult to compared effectiveness mobile activity tracker alone
    • Few of the studies included additional effects of SMS text reminders and social feedback

Clinical Bottom Line

  • There is limited moderate-level evidence that suggest mobile activity tracker is effective in the promoting physical activity in the general population
  • Clinically meaningful during short duration but results are often not sustained and may even decrease with time
  • Further research is needed to examine long term sustainability of mobile activity tracker and if other factors such as competition will motivate participants

Application to Case

  • Recommend trying a fitness app or Fitbit to start moving
  • Goal: 7,000 steps/day initially
    • Progress to 10,000 steps/day
  • Incorporate competition and challenges with friends or other clients in the clinic
  • Include other interventions such as group exercise

Acknowledgements

Dr. Heidi Ojha, PT, DPT, OCS, FAAOMPT and TU DPT Class of 2017

References

1.Cadmus-Bertram LA, Marcus BH, Patterson RE, Parker BA, Morey BL. Randomized Trial of a Fitbit-Based Physical Activity Intervention for Women. American journal of preventive medicine. 2015;49(3):414-418. doi:10.1016/j.amepre.2015.01.020.

2.Glynn LG, Hayes PS, Casey M, et al. Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial. The British Journal of General Practice. 2014;64(624):e384-e391. doi:10.3399/bjgp14X680461.

3.Wang JB, Cadmus-Bertram LA, Natarajan L, et al. Wearable Sensor/Device (Fitbit One) and SMS Text-Messaging Prompts to Increase Physical Activity in Overweight and Obese Adults: A Randomized Controlled Trial. Telemedicine and e-Health. 2015;21(10):782-792. doi:10.1089/tmj.2014.0176.

4.Sara E. Schaefer, Cynthia Carter Ching, Heather Breen & J. Bruce German (2016) Wearing, Thinking, and Moving: Testing the Feasibility of Fitness Tracking with Urban Youth, American Journal of Health Education, 47:1, 8-16, DOI: 10.1080/19325037.2015.1111174.

5.Harries T, Eslambolchilar P, Rettie R, Stride C, Walton S, Woerden HCV. Effectiveness of a smartphone app in increasing physical activity amongst male adults: a randomised controlled trial. BMC Public Health. 2016;16(1). doi:10.1186/s12889-016-3593-9.

CHF/ Background

Briefly, chronic/ congestive heart failure causes blood to move through the heart and body at a slower rate. As a result, the pressure within the heart increases and the chambers overtime may compensate with anatomical and pathological changes in attempt to adequately supply the heart and body with oxygen and nutrients. There are two main classifications; diastolic CHF and systolic CHF. Systolic HF causes stretching of the heart chambers over tim
e decreasing the hearts ability to pump blood and diastolic HF which causes thickening/ stiffening of the muscular walls of the chambers resulting in the hearts inability to fill. The Signs/symptoms of heart failure include congested lungs, shortness of breath, dizziness, confusion, fatigue, dry hacking cough or wheezing, fluid retention, and rapid or irregular heartbeat. Chronic heart failure can be caused by CAD, MI, cardiomyopathy, and conditions which can chronically overwork the heart such as uncontrolled hypertension, valve disease, thyroid disease, kidney disease, diabetes, or heart defects present at birth.

chf-picture

https://g.co/kgs/pJVVJ8

What’s the difference between cardiac rehabilitation and “usual care” that CHF patient’s may receive?

  • Cardiac rehab is a medically supervised program that includes formal exercise training, education on heart-healthy living and lifestyle (such as pharmacological education and nutrition), and often counseling to reduce stress.
  • Usual care does NOT incorporate formal exercise training upon discharge. It mainly focuses on education on heart-healthy living and lifestyle, and counseling to reduce stress and discharge upon symptom stabilization.

Clinical Scenario/ PICO

  • The patient is a 56-year-old male presenting with a three-year history of left ventricular CHF NYHA (New York Heart Association) class 2 now newly classified as a NYHA class 3 with potential right ventricular involvement. Upon admission to the hospital, the patient weighed 236 pounds with a BMI of 34.9. His wife drove him to the hospital this morning (9/2/2016) due to complaints of moderate chest pain, perceived heart palpitations, breathlessness, fatigue, sweating, and dizziness upon awakening. The patient had a history of uncontrolled hypertension prior to CHF diagnosis. Upon auscultation, there is slight crackles at the base of his lungs
  • I included the outcome measure of relative VO2max into my search since literature suggests that it is a strong prognostic indicator in chronic heart failure associated with a lower risk of all-cause mortality or all-cause hospitalization. The determinants of VO2max include central (heart rate, stroke volume, cardiac output) and peripheral (muscle oxygen extraction) components. Each of these factors responds favorably to exercise training.
  • PICO: Is cardiac rehabilitation training effective vs. control in prevention of all-cause mortality and hospitalizations with improvement of VO2max for patients with chronic/congestive heart failure?

Search strategy

I searched PubMed, Pedro and CINAHL and found a total of 204 articless. I ruled out articles based on irrelevance to my PICO question, compounding treatments, lack of control groups, and of course those that did not fit my inclusion criteria listed here resulting in a total of 5 articles.

Inclusion criteria: Chronic heart failure, Average Ejection Fraction ≤ 40%, Age ≥ 40 years’ old, Class ≥ II NYHA CHF, clinical signs and symptoms of heart failure, at least one exercise intervention prescription, control group: usual care without formal exercise plan, assessment of at least one of the following outcome measures (Re-hospitalization, All-cause mortality, VO2 MAX, Exercise capacity).

Results:

  • Hospitalization: 3/5 studies assessed hospitalization and all found between-group statistical significance between intervention and control groups
  • Mortality Rate: 3/5 studies assessed mortality rate and all found between-group statistical significance between intervention and control groups
  • VO2: 5/5 studies looked at VO2 and found between-group statistical significance in VO2max between intervention and control groups

Clinical Bottom line

  • There is consistent, high-level evidence that exercise therapy demonstrates improvement in all-cause mortality, hospitalizations, and/or VO2 across RCTs in patients with CHF NYHA class II-IV in comparison to those receiving “usual care.”
  • Formal exercise programs are often not prescribed to CHF patients by health care professionals due to fear of hard-events such as hospitalization and death; however, the evidence presented in the literature indicates the exact opposite.

Limitations

As for limitations, more research needs to focus on the intensity, frequency and duration of exercise therapy. More research needs to include patients with comorbidities since they tend to accumulate in this population and also to further assess the risk benefit ratio of formal exercise with CHF and multiple comorbidities.

Application to case

  • A greater emphasis on formal exercise training to improve clinical outcomes in patients with CHF NYHA class 2-4 upon discharge needs to be established ubiquitously. Specifically, the study Belardinelli demonstrated short/ long-term improvements in VO2max as well as prevention of all-cause mortality and hospitalizations with supervised, (cardiologist & exercise therapist) moderate aerobic training at 60-70% VO2max twice weekly for 10 years. Supervision leads to good adherence and ensures exercise intensity and duration for the levels prescribed. A Coronary Club may represent an efficient model for long-term cardiac rehabilitation programs.
  • We want to avoid the vicious cycle that can occur with CHF patients. When patients are discharged from the hospital to home they are often NOT prescribed a formal exercise program. The problem with this model is that it promotes a sedentary lifestyle in patient’s already at risk for depression and comorbidities. This can lead to further loss of functional independence and therefore exacerbation of CHF and adverse outcomes, recycling them back into the hospital. We as physical therapists and experts in movement can be the advocates for these patients to get them into a supervised exercise program to reduce the risk of hospitalizations and all-cause mortality by improving their functional capacity.

References:

Belardinelli R, Georgiou D, Cianci G, Purcaro A. 10-year exercise training in chronic heart failure: A randomized controlled trial. J Am Coll Cardiol. 2012;60(16):1521-1528. https://www.ncbi.nlm.nih.gov/pubmed/22999730

Ahmad T, Fiuzat M, Mark DB, et al. The effects of exercise on cardiovascular biomarkers in patients with chronic heart failure. Am Heart J. 2014;167(2):193-202.e1. https://www.ncbi.nlm.nih.gov/pubmed/24439980

Maria Sarullo F, Gristina T, Brusca I, et al. Effect of physical training on exercise capacity, gas exchange and N-terminal pro-brain natriuretic peptide levels in patients with chronic heart failure. Eur J Cardiovasc Prev Rehabil. 2006;13(5):812-817.            https://www.ncbi.nlm.nih.gov/pubmed/term=Effect+of+physical+training+on+exercise+capacity,+gas+exchange+%09and+N-terminal+pro-brain+natriuretic+peptide+levels+in+patients+with+chronic+heart+failure

Swank AM, Horton J, Fleg JL, et al. Modest increase in peak VO2 is related to better clinical outcomes in chronic heart failure patients: Results from heart failure and a controlled trial to investigate outcomes of exercise training. Circ Heart Fail. 2012;5(5):579-585.            https://www.ncbi.nlm.nih.gov/pubmed/term=Modest+increase+in+peak+VO2+is+related+to+better+clinical+outcomes+in+%09chronic+heart+failure+patients

Erbs S, Höllriegel R, Linke A, et al. Exercise training in patients with advanced chronic heart failure (NYHA IIIb) promotes restoration of peripheral vasomotor function, induction of endogenous regeneration, and improvement of left ventricular function. Circ Heart Fail. 2010;3(4):486-494. https://www.ncbi.nlm.nih.gov/pubmed/term=Exercise+training+in+patients+with+advanced+chronic+heart+failure+%09(NYHA+IIIb)+promotes+restoration+of+peripheral+vasomotor+function%2C+induction+of+endogenous+%09regeneration%2C+and+improvement+of+left+ventricular+function.

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:

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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.