Physical Therapy EBP 2016

Title: Effectiveness of Aquatic Therapy in Treating Women Diagnosed With Fibromyalgia Compared to Land-based Therapy or Usual Care.

Introduction: Fibromyalgia syndrome (FMS) is characterized by widespread musculoskeletal pain and fatigue. More commonly diagnosed in females than males between ages of 30-50 yrs old. Symptoms include: lack of energy, fatigue, weakness, sleep and cognitive disturbances, stiffness, tender points, IBS, tension type headaches, anxiety and/or depression. According to ACR diagnostic criteria, person must experience symptoms for more than 3 month, and feel tenderness in at least 11 of 18 tender points. There is no cure for FMS, however light exercises with stretching, jogging, swimming, aerobic, have been shown to help with pain and psychological factors by reducing sedentary life styles.

Case Scenario: Patient is a 36 years old female presenting to an outpatient Physical Therapy clinic with complains of joint pain in bilateral knees, shoulders, elbows and lower back pain. She reports fatigue on exertion and low stamina. Patient was diagnosed with fibromyalgia 2.5 years ago. She reports she doesn’t know how exactly her symptoms started but suspects that she never fully recovered after a flu virus 3 years ago. Patient feels stiffness and pain in the morning which gets a little better as the day goes but then gets worse in the evening again. Patient reports her pain goes up to 5-6/10 at worst, 2-3 at best and 3 currently. Taking warm baths and meditating sometimes helps ease the pain a little, but the pain is mostly there all the time. She has good and bad days where pain fluctuates and she noticed that too much physical activity increases her symptoms. Patient is currently unemployed due to the fact that she is unable to perform her work requirements because of the pain and fatigue that she is experiencing every day. Her occupation is a massage therapist which requires moderate physical activity level. Patient reports feeling depressed at times due to her symptoms and is unable to participate in recreational activities. She gets tired very easily with minimal activity which she tries to limit during her bad days. Patient enjoys walking her dog but is unable to walk for more than 2 blocks due to exertional fatigue which makes her very upset. Patient gained 20 pounds over the last 2 years due to limited physical activity. Patient denies any changes in bowel or bladder movement and reports no numbness or tingling in her lower or upper extremities. She is currently taking Lyrica for her symptoms which was prescribed by her Rheumatologist but is still not getting adequate relief with the medicine. No other health issues have been identified. Patient was referred to Physical Therapy for evaluation and treatment to help with her fibromyalgia symptoms. Patient did not have Physical Therapy in the past and believes that it could be beneficial for her. Patient goals for the therapy are to decrease her pain level, increase strength, minimize exertional fatigue so she can walk her dog for more than 2 blocks, and increase her stamina.

During Physical Examination patient displayed weakness in all major upper and lower extremity muscles with grades 3-4/5, bilateral tightness in hamstrings and gastroc-soleus, and minor tightness in bilateral IT band. Lumbar active ROM is limited and painful in all directions. She was tender to the touch around lower back and sacral area and displayed decreased lumbar lordosis. Patient’s back and hip extension was examined in a standing position due to inability to lay prone because of the tenderness in her knees. During examination patient was tender to the touch in bilateral knees, shoulders and elbows. Her shoulders active ROM was within normal limits. Patient presented with slight fatigue during examination and was irritated due to her pain.

Outcomes:

NPRS: Worst 5-6/10, Best 2-3, Now 3

Physical activity: Exertional fatigue/able to walk no more then 2 blocks

MMT: weakness in all major UE/LE muscles with grades 3-4/5

Palpation: Tenderness in bilateral knees, shoulders, elbows, and lower back and sacral area

Patient will benefit from skilled aquatic physical therapy 3 times a week for 12 weeks to increase her strength, minimize exertional fatigue, decrease pain, increase hamstring, gastoc-soleus and IT band flexibility, and improve her quality of life. Aquatic physical therapy is recommended due to the fact that patient experiences increase in symptoms after too much physical activity therefore taking a slower exercise approach in a warm pool can be beneficial.

PICO: Is aquatic therapy an effective treatment option to manage physical and psychological symptoms in patients with Fibromyalgia compared to non-aquatic therapy?

Database search: Pubmed, CINAHL, PEDro

Search Terms: “Fibromyalgia and Aquatic Therapy”

Inclusion criteria: Women with FMS; include aquatic therapy intervention and a control group; have at least one of the two outcome measures: pain and/or psychological wellbeing.

4 articles came from Pubmed and 1 article from PEDro. CINAHL had same articles as Pubmed.

Clinical Bottom Line: Based on the research there is consistent evidence that aquatic therapy is an effective treatment option to treat pain and psychological wellbeing in patients with Fibromyalgia compared to other therapies or usual care. However, when comparing aquatic therapy to other therapies there was no significant difference between groups for pain level and better results for psychological well being favoring aquatic therapy. When comparing aquatic therapy to usual care results showed significant difference in pain and psychological wellbeing favoring aquatic therapy.

Limitations: Small sample size. No blinding of the subjects, assessors or therapist. Only one study had blinding of the assessors. All five RCTs were done outside of the United States. Short therapy duration. Only one study was long term. A future need for longer term studies considering chronic nature of FMS.

Application of the evidence to case scenario: Aquatic therapy 2 times per week for 8 weeks. Progress to once a week aquatic therapy and once a week land based therapy for manual stretching and advanced strengthening exercises. Continue with aquatic therapy at least once a week for psychological well being, pain, and fatigue symptoms.

References:

1. Sevimli D, Kozanoglu E, Guzel R, Doganay A. The effects of aquatic, isometric strength-stretching and aerobic exercise on physical and psychological parameters of female patients with fibromyalgia syndrome. J Phys Ther Sci. 2015 Jun;27(6):1781-6. doi: 10.1589/jpts.27.1781. Epub 2015 Jun 30. PubMed PMID: 26180320; PubMed Central PMCID: PMC4499983.
2. Munguía-Izquierdo D, Legaz-Arrese A. Exercise in warm water decreases pain and improves cognitive function in middle-aged women with fibromyalgia. Clin Exp Rheumatol. 2007 Nov-Dec;25(6):823-30. PubMed PMID: 18173915
3. Munguía-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2008 Dec;89(12):2250-7. doi: 10.1016/j.apmr.2008.03.026. PubMed PMID: 19061736.
4. Assis MR, Silva LE, Alves AM, Pessanha AP, Valim V, Feldman D, Neto TL, Natour J. A randomized controlled trial of deep water running: clinical effectiveness of aquatic exercise to treat fibromyalgia. Arthritis Rheum. 2006 Feb 15;55(1):57-65. PubMed PMID: 16463414.
5. Tomas-Carus P, Gusi N, Häkkinen A, Häkkinen K, Leal A, Ortega-Alonso A. Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial. J Rehabil Med. 2008 Apr;40(4):248-52. doi: 10.2340/16501977-0168. PubMed PMID: 18382819.

Background

• Extracorporeal Membrane Oxygenation (ECMO) is used as a temporary life support in patients with end stage pulmonary and/or cardiac failure. Due to the limited number of organs available for children, ECMO can be used as a method to extend the life of a suitable candidate allowing them more time on the transplant list.
• Historically, ECMO was the strongest negative predictor of one-year survival post-lung transplant with a major contributing factor being secondary complications associated with prolonged immobility and bed rest. With advances in technology, awake and ambulatory ECMO is now a feasible option.
• Two main types of ECMO:
  • Veno-Venous (VV) ECMO                               Veno-Arterial (VA) ECMO

Case Scenario & PICO

Case: 10-year old female admitted to the hospital secondary to CF exacerbation. Conditioned continued to worsen until she reached respiratory failure and was placed on mechanical ventilation. Despite FiO2 at 100%, patient remained hypercapnic and hypoxic resulting in medical sedation and implementation of VV-ECMO. Patient was placed on the urgent bilateral lung transplant (BLTx) list.

PICO: Do pediatric patients awaiting a lung transplant (LTx) have improved functional outcomes and reduced hospital length of stay if they receive ambulatory ECMO as a bridge to LTx compared to those who receive traditional non-ambulatory ECMO?

Search Strategy

Databases Searched: PubMed, CINAHL, OAIster

Inclusion Criteria: English language, Human subjects, All age groups, Ambulatory ECMO, ECMO as a bridge to heart and/or lung transplant

Exclusion Criteria: Clinical Commentary/Narrative Review, Duplicate in Systematic Review, Non-ambulatory ECMO, Intervention focused on post-transplant ambulatory ECMO, Ambulatory ECMO awaiting a non-lung transplant.

Results

Limitations

• Low quality evidence
• Small sample sizes
• Time and type of PT interventions varied across studies

Clinical Bottom Line

• There is limited, low quality evidence that suggests that ambulatory ECMO improves functional outcomes and reduces hospital LOS in pediatric patients awaiting a lung transplant.
• Ambulatory ECMO is complex and high-risk and should only be performed within a multidisciplinary team in hospitals with ample experience to ensure optimal safety.

Application to Case

• Initiate the conversation with the medical team regarding the benefits associated with immediate PT following ECMO initiation. It will be a multidisciplinary team effort to provide active rehabilitation while on ECMO in order to guarantee safety.
• POC: Initiate PT immediately following initiation of ECMO progressing from PROM while patient is weaning off medical sedation (avoiding ROM of affected limb) –> active exercises in bed –> resistance exercises –> task specific exercises including ambulation until organ transplant.

Acknowledgments

Richard Lauer, PhD and TU DPT class of 2017

References

1. Bain JC, Turner DA, Rehder KJ, et al. Economic outcomes of extracorporeal membrane oxygenation with and without ambulation as a bridge to lung transplantation. Respir Care. 2016;61(1):1-7. doi: 10.4187/respcare.03729 [doi].

2. Hayes D,Jr, Galantowicz M, Preston TJ, Lloyd EA, Tobias JD, McConnell PI. Tracheostomy in adolescent patients bridged to lung transplantation with ambulatory venovenous extracorporeal membrane oxygenation. J Artif Organs. 2014;17(1):103-105. doi: 10.1007/s10047-013-0738-9 [doi].

3. Lowman JD, Kirk TK, Clark DE. Physical therapy management of a patient on portable extracorporeal membrane oxygenation as a bridge to lung transplantation: A case report. Cardiopulm Phys Ther J. 2012;23(1):30-35.

4. Polastri M, Loforte A, Dell’Amore A, Nava S. Physiotherapy for patients on awake extracorporeal membrane oxygenation: A systematic review. Physiother Res Int. 2015. doi: 10.1002/pri.1644 [doi].

5. Wong JY, Buchholz H, Ryerson L, et al. Successful semi-ambulatory veno-arterial extracorporeal membrane oxygenation bridge to heart-lung transplantation in a very small child. Am J Transplant. 2015;15(8):2256-2260. doi: 10.1111/ajt.13239 [doi].

VV-ECMO and VA-ECMO Pictures: http://tele.med.ru/book/cardiac_anesthesia/text/gr/gr031.htm

By: Erika Shumock, SPT

Background

Knee OA is a common diagnosis causing chronic pain, decreased physical function, and diminished quality of life.  Research has demonstrated that physical therapy is effective at improving pain and function in adults with knee OA, but long term follow ups have demonstrated that these improvements are not being maintained.  As our population ages and rates of obesity rise we expect to continue to see an increase in knee OA, and add to this that up to 42% of Americans with health insurance were considered underinsured in 2014.  Booster sessions are aimed at improving patients long term benefits from PT by allowing the therapist to monitor patients over a longer period of time and encourage more compliance with home exercises.  For the purposes of this research booster sessions are considered any physical therapy that is delivered after the initial course of consecutive treatments.

Case Scenario

The patient is a 63 year old female with bilateral knee OA, BMI = 44.4, with a chief complaint of worsening knee pain that began insidiously 15 years ago. Her outcome measures were as follows; LEFI = 33/80, 30 second sit to stand test = 3.  When observing her gait she ambulates with a single point cane, decreased step length, decreased cadence, decreased hip flexion during swing, maintains knee flexion throughout patter.  The patients goals include walking four blocks to go shopping and playing with her grandchildren without pain.

Search Strategy

The inclusion criteria for my literature search were as follows; all articles must (1) include adult patients with knee OA, (2) include one group that receives exercise therapy in consecutive sessions followed by a home exercise program, (3) include one group that receives exercise therapy with “booster sessions” of supervised therapy provided at time intervals separated from the consecutive sessions of the initial episode of care, and (4) provide outcomes including pain and/or Western Ontario McMaster Universities Osteoarthritis Index.

Results: Pain

Results: Function

Weaknesses/Limitations

The two most recent randomized control trials that had identical study design found that a combination of manual therapy and Booster sessions had a negative impact outcomes, that the interactions between these two factors is not well understood.  The initial period of care was not standardized across studies.  A number of the studies were underpowered to test group interactions.  The number of booster sessions was not standardized between groups/studies.  None of the research provided data on a long term follow up after the conclusion of booster sessions.

Clinical Bottom Line

Two of the five articles demonstrated a significant difference between groups on outcomes for pain.  One of the four articles demonstrated a significant difference between groups on the WOMAC.  I recommend that future research  explore the possible negative interaction between manual therapy and booster sessions, the most effective dosage of booster sessions, and include a long term follow up after cessation of PT.

Clinical Application

The patients plan of care will be as follows: 8 sessions in the first 9 weeks, 2 sessions at 5 months, 1 session at 8 months, and 1 session at 11 months.  Treatment focus in the first 8 weeks will focus on decreasing the patient’s pain and increasing her weight bearing tolerance.  The patient will also perform aerobic exercise consisting of cycling and treadmill walking.  As her pain decreases and her weight bearing tolerance increases I will begin to progress her aerobic exercise and add weight bearing resistive training.  The patients home exercise program will be performed 3-4 times per week, and consist of 3 exercises to be performed in the home.  The patient will also be advised to begin a home walking program in which the patient will be asked to walk outside for 20 minutes 4 times per week.

References

1. Abbott JH, Chapple CM, Fitzgerald GK, et al. The incremental effects of manual therapy or booster sessions in addition to exercise therapy for knee osteoarthritis: A randomized clinical trial. J Orthop Sports Phys Ther. 2015;45(12):975-983. doi: 10.2519/jospt.2015.6015 [doi].

2. Bennell KL, Kyriakides M, Hodges PW, Hinman RS. Effects of two physiotherapy booster sessions on outcomes with home exercise in people with knee osteoarthritis: A randomized controlled trial. Arthritis Care Res (Hoboken). 2014;66(11):1680-1687. doi: 10.1002/acr.22350 [doi].

3. Fitzgerald GK, Fritz JM, Childs JD, et al. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: A multi-center, factorial randomized clinical trial. Osteoarthritis Cartilage. 2016;24(8):1340-1349. doi: 10.1016/j.joca.2016.03.001 [doi].

4. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376. doi: 10.1002/14651858.CD004376.pub3 [doi].

5. Mahon M. 31 million people were underinsured in 2014; many skipped needed health care and depleted savings to pay medical bills. www.commonwealthfund.org. Updated 2015. Accessed September 28th, 2016.

6. Pisters MF, Veenhof C, van Meeteren NL, et al. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review. Arthritis Rheum. 2007;57(7):1245-1253. doi: 10.1002/art.23009 [doi].

7. Veenhof C, Koke AJ, Dekker J, et al. Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: A randomized clinical trial. Arthritis Rheum. 2006;55(6):925-934.

Background:

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

Clinical Case:

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

PICO Question:

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

Search Strategy:

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

Results:

Limitations:

Clinical Bottom Line:

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

Application to Case:

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

References:

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

Background:

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

Clinical Case:

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

PICO:

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

Search Strategy:

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

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

Exclusion criteria were as follows:

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

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

Results:

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

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

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

Clinical Bottom Line and Application to Case:

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

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

Limitations:

Limitations include the following:

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

References:

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

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

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

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

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

Introduction:

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

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

Clinical Case & PICO:

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

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

PICO:

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

Search Strategy:

Inclusion criteria:

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

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

Results:

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

Clinical Bottom Line:

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

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

Application to Case:

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

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

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

Limitations:

-Has a small sample size for all randomized control trials

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

-Lack of long-term follow-up

References:

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

Background:

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

4

Case Scenario:

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

PICO Question:

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

Search Strategy:

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

Article 1- Lekskulchai et al, 2001:

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

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

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

Article 2-Heathcock et al, 2009:

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

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

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

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Article 3- Heathcock et al, 2008:

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

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

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

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Article 4- Cameron et al, 2005:

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

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

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

Article 5- Koldewijn et al, 2009:

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

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

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

Clinical Bottom Line:

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

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Limitations:

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

Application:

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

Resources:

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

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

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

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

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

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

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