Physical Therapy EBP 2016

Background:

There are ~4 million ICU admissions per year with an average mortality rate of 8-19%, or about 500,000 deaths annually. These patients are at high risk for adverse outcomes due the severity of illness and the multiple and complex interventions given to them at the same time. “Critical care is a costly component of the national health care budget, with costs estimated to be $81.7 billion…These costs are largely explained by the length of stay (LOS) in the ICU”.1

Case Scenario:

Mr. B, a 78-year-old male, went into cardiac arrest while on a morning jog and was resuscitated via CPR by a Good Samaritan. He underwent a coronary artery bypass graft (CABG) after it was discovered that he suffered a myocardial infarction. He has been sedated and mechanically ventilated for the past 48 hours in the ICU and the physician lets you know he will be coming off of sedation today. Mr. B has a limited PMH and vitals are stable and safe for mobility at this time

Clinical Question:

In patients who are mechanically ventilated >24 hours, is early mobilization effective in significantly reducing the amount of time spent in the ICU?

Search Strategy and Results:

A literature search was performed to identify eligible randomized controlled trials (RCT), clinical trials, cohort studies and single-blind studies. Electronic searches of MEDLINE, CINAHL, and PUBMED using the key words “physical therapy” or “early mobilization” or “rehabilitation” and “ICU” or “critical care” and “mechanical ventilation” and “length of stay” were conducted. Only full reports in English were included. Inclusion criteria were as follows: Design: RCT, clinical trial, cohort study or single blind studies; Participants: Ages 19+, male or female, >24 hours on mechanical ventilation, patients in the ICU; Interventions: early mobilization or physical therapy including active or passive exercises in bed, side of bed, and/or ambulation, once or twice a day; Comparisons: usual care, delayed mobilization, as ordered by physician; Outcomes: ICU length of stay, ICU-acquired weakness (ICUAW) and adverse events.

Evidence Appraisal: 

Evidence Summary:

Clinical Bottom Line:

There is mixed and lower-quality evidence suggesting that early mobilization can significantly reduce the ICU length of stay

There were no significant adverse events reported in any of these studies suggesting that early mobilization in these patients is safe and feasible.

Application of the Evidence: 

The clinician needs to consider the patient’s prior level of function, goals, expectations and level of motivation. They also need to consider if the entire mobility team is on board including (but not limited to) the ICU nurse, physician, physical therapist, occupational therapist and respiratory therapist. In this particular case, Mr. B was previously very active and independent and is currently highly motivated to return home with his wife and eventually run again. The entire mobility team is also on board at this time. Due to Mr. B’s prior level of activity, we are choosing to implement the “Early Goal-Directed Mobilization” (EGDM) protocol 7 days per week at the level determined by the ICU Mobility Scale (which is outside the realm of this research). The EGDM protocol was used in the Hodgson et al 2016 study (as shown below):

https://twitter.com/iwashyna/status/717023531503058944

References: 

1. ICU outcomes (mortality and length of stay) methods, data collection tool and data. Philip R. Lee Institute for Health Policy Studies Web site. http://healthpolicy.ucsf.edu/content/icu-outcomes#ICU%20BACKGROUND. Accessed 09/23, 2016.

2. Dong Z, Yu B, Zhang Q, et al. Early rehabilitation therapy is beneficial for patients with prolonged mechanical ventilation after coronary artery bypass surgery. Int Heart J. 2016;57(2):241-246. doi: 10.1536/ihj.15-316 [doi].

3. Morris PE. Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: A randomized clinical trial. JAMA : the Journal of the American Medical Association. 06;315(24):2694; 2694-2702; 2702.

4. Hodgson CL, Bailey M, Bellomo R, et al. A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU. Crit Care Med. 2016;44(6):1145-1152. doi: 10.1097/CCM.0000000000001643 [doi].

5. Yosef-Brauner O, Adi N, Ben Shahar T, Yehezkel E, Carmeli E. Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness. Clin Respir J. 2015;9(1):1-6. doi: 10.1111/crj.12091 [doi].

6. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243. doi: 10.1097/CCM.0b013e318180b90e [doi].

Contact Andrea Dietrich at Andrea.Dietrich@temple.edu for further information.

References

1. Brumitt, J. Heiderscheit, B. Manske, R. Niemuth, P. Rauh, M. Lower extremity functional tests and risk of injury in division III college athletes. IJSPT. 2013; 8(3): 216-227.
2. 2. Dallinga J, Benjaminse A, Lemmink K. Which screening tools can predict injury to the lower extremities in team sports. Sports Med. 2012; 42(9): 791-815.
3. 3. Ivarsson et al. Psychological factors and sport injuries: meta-analysis for prediction and prevention. Sports Med. 2016. Doi: 10.1007/s40279-016-0578-x
4. 4. Lehr et al. Field-expedient screening and injury risk algorithm categories as predictors of non contact lower extremity injury. Scand J Med Sports. 2013; 23: e225-e232. Doi: 10.1111/sms.12062
5. 5. Walbright, D. Ojha, H. Validity of functional screening tests to predict lost-time lower extremity injury in a small cohort of female collegiate athletes. 2016. In preparation.

Research Performed by: Cara Fowler, SPT

Background:

Obtained from: http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/stroke_overview_slideshow/webmd_rm_illustration_of_stroke_causes_.jpg

Stroke is the number one cause of long-term disability in the United States.¹ Eight out of ten stroke survivors suffer from residual hemiparesis that results in a multitude of impairments including decreased balance, gait ability, and coordination.² Dynamic balance and gait dysfunction are the two prevalent impairments in individual’s post-hemiparetic stroke and place individuals at a higher risk of falling and results in impaired functional mobility.²

Virtual reality is a form of interactive simulation that immerses patient’s within a virtual environment that gives patient’s similar experiences to real-world events within a safe and controllable clinical environment.³ Virtual reality has been explored in the chronic stroke population to improve stroke outcomes in many aspects, including balance and gait.^3-7 Virtual reality has been theorized to increase patient’s motivation and adherence in a physical therapy program.³ Virtual reality also provides users with the ability to receive real time feedback based on their performances, increasing their knowledge of performance leading to more improvements in their performance.³ For these reasons, it may be a feasible option to integrate wishing a conventional physical therapy regimen in order to promote better outcomes.

Clinical Scenario:

Mrs. Anita Cooke is a 65-year-old female that is presenting to physical therapy with the chief complaint of right-sided weakness, primarily in her lower extremity, after suffering from a Left Anterior Cerebral Artery Stroke 12-months ago. For the two years prior to her stroke, Anita was enjoying her retirement from being a school teacher by going for daily walks around her neighborhood, watching her granddaughter three times per week, taking care of her home, and playing video games with her grandson. Prior to her stroke, Anita was independent in all ADLs and IADLs. Anita’s goals are to: 1) return to her prior level of function, 2) play with her granddaughter again, 3) improve her balance, 4) go for walks around her neighborhood again, and 5) increase her confidence in her ability to move around.

Anita’s physical therapy exam revealed that she had normal active and passive range of motion in her upper and lower extremities, normal cognition (as demonstrated by score of 25 on the MMSE), difficulty isolating movements in her right lower extremity, decreased dynamic balance, and decreased walking abilities. More specifically, Mrs. Cooke ambulated independently with a single point cane and asymmetric gait pattern with decreased cadence, decreased right foot clearance, and decreased step length with left lower extremity. Anita completed the following functional tests and measures with the corresponding scores:

• Timed Up and Go: 20 seconds with single point cane (patient had difficulty with sit to stand transfer and ambulated slowly) and 35 seconds with no Assistive Device
• Berg Balance Scale: 40/56
• 10-Meter Walk Test: gait speed = 0.5 m/s
• 6-Minute Walk Test: 50m with 5 rests of 15 seconds
• ABC Scale: 70

Clinical Question: 

In adult patients (> 18 years old) with chronic stroke resulting in hemiparesis, are virtual reality (VR) interventions in addition to conventional physical therapy (CPT) more effective than CPT alone in improving dynamic balance and gait outcomes?

Search Strategy:

A literature search was performed to identify all eligible randomized controlled trials. Electronic searches of PubMed, CINAHL, Embase, and MEDLINE was performed using the keywords ‘stroke’ or ‘chronic stroke’; and ‘balance’, ‘postural balance’, or ‘berg balance’; and ‘virtual reality’. Only full reports in English were included. On the basis of titles and abstracts, articles were determined relevant or irrelevant. The inclusion criteria were as follows: articles published within the last 10-years; Design – RCT; Participants – Adults age > 18, male or female, with chronic stroke (> 6 months) resulting in hemiparesis; Outcomes – Berg Balance Scale (BBS), Timed up and go (TUG), 10-m walk test (10MWT); Comparison – Conventional or standard rehabilitation; Intervention – intervention with virtual reality and conventional or standard rehabilitation. Pilot studies, systematic reviews, and meta analyses were excluded. Additional studies were excluded if they utilized Telerehabilitation in the home environment, video game consoles (Wii, Wii Balance Board, PlayStation, Xbox Kinnect, etc.) as virtual reality, and studies with acute or subacute stroke participants. These inclusion and exclusion criteria resulted in 5 papers being included in this review.

Results:

Evidence Summary:

• 3 of 5 articles reported on TUG performance; 2 of 3 studies exhibited moderate-level evidence that VR + CPT leads to significantly greater changes in TUG performance.
• 4 out of 5 articles reported on BBS performance; 3 of 4 articles offer moderate-quality evidence that the use of VR + CPT results in significantly better performance on the BBS.
• 3 out of 5 articles examined 10MWT performance; all 3 articles offer moderate-quality evidence that VR + CPT leads to statistically significant ↑ in gait speed.

Overall, 4 of 5 studies show that VR when combined with CPT has additive effects and improves balance and gait outcome measures when compared to CPT alone.

Clinical Bottom Line: 

There is limited, moderate-level evidence that suggests that virtual reality in addition to physical therapy is more effective than physical therapy alone in improving gait and balance outcome measures.

Limitations of the Evidence:

• Small sample sizes were utilized in all of the studies.
• There was an inconsistence across the studies of the blinding of therapists, raters, and participants.
• All samples utilized a sample of convenience, limiting the ability to generalize these results to the general stroke population.
• All studies utilized strict inclusion and exclusion criteria limiting the generalizability to the general stroke population.
  • All studies only included participants that were ambulatory with high cognitive abilities which does not depict all stroke survivor abilities.
• There was an inconsistence in control group demographics across all 5 studies.
• Not all studies utilized the same methods to implement standard physical therapy or virtual reality limiting our ability as providers to determine the best way to implement virtual reality in addition to normal physical therapy in a plan of care.
• All studies were completed outside of the United States.
• There is an inconsistence across available literature about what the definition of virtual reality is.
• A lot of studies had to be eliminated from this critically appraised topic due to their use of video gaming systems as methods to implement virtual reality within their study.

Recommendations for Future Research:

Overall, there are many opportunities for future research to improve research on virtual reality in chronic stroke patients. In future research, there should be a clearer definition in what constitutes virtual reality. Currently, there is such an inconsistent interpretation of what constitutes virtual reality and the implementation of virtual reality. Many current studies utilize video game consoles and televisions as virtual reality treatment; however, all studies that utilized video games consoles were excluded from this CAT, significantly limiting the available research. Future research should also standardize what constitutes conventional physical therapy treatment, as it is difficult to implement and generalize vastly different conventional physical therapy programs into one physical therapy program. In addition, in future research, larger sample studies should be utilized to increase the statistical power and significance of future research, leading to the ability to generalize this research to the general chronic stroke population. Future research should also implement long-term follow-up periods to determine the long-term retention effects of the additive effects of virtual reality treatment.

Conclusion and Application to Case Scenario:

This evidence supports the notion that virtual reality in additional to conventional physical therapy will significantly improve these balance and gait outcome measures. Based on the current literature, integrating the use of virtual reality into a conventional physical therapy treatment program proves to be more superior than utilizing standard physical therapy alone for balance and gait deficits in chronic stroke patients with residual hemiparesis. Overall, throughout this literature, there have been no adverse events associated with the use of virtual reality; based on this information, the benefits by far outweigh the potential harm. Although there are proven benefits of implementing virtual reality in conjunction to a conventional physical therapy program, it is expensive to invest in virtual reality technology; therefore, its utility may vary depending on patient volume, finances in any given clinic environment, and space in any given setting. By showing that there are no negative consequences to utilizing virtual reality in addition to conventional physical therapy for chronic stroke patients with residual hemiparesis, may prompt more clinics to integrate virtual reality in their treatment program.

In this scenario, Mrs. Cooke presents to an outpatient clinic with balance and gait deficits following a stroke that resulted in residual hemiparesis. This condition and these deficits fall within the scope of current virtual reality research and within a physical therapist’s scope of practice. Since this is the case, the physical therapist may elect to include virtual reality into Mrs. Cooke’s conventional physical treatment program. By integrating virtual reality into Mrs. Cooke’s treatment program, she will have the opportunity to interact with an environment that is similar to the real-world while in a controlled and safe situation. In addition, by including virtual reality in addition to a conventional physical therapy program, Anita will have the ability to receive real time feedback to provide further improvements in her balance and gait outcome measures.

Although most of these research studies have proven the effectiveness of the use of virtual reality in addition to an individualized conventional physical therapy treatment program, there are several gaps in the evidence that lead to difficult application to this clinical question and scenario. The largest gap in the application to this case scenario is that within research that there was no common method of implementing virtual reality therapy or in the standardization of conventional physical therapy throughout these studies. In addition, all of these research studies were performed outside of the United States. Lastly, although the intervention and comparison groups were fairly similar across all studies, there was a large diversity in population as they were not standardized throughout the research.

After reviewing the literature, it will be beneficial to integrate the use of virtual reality technology into a conventional physical therapy treatment program for Mrs. Cooke. Anita’s treatment program should include both an individualized conventional therapy treatment program that is based on both the neurodevelopmental and motor learning theory. Anita should participate in physical therapy four times per week, for a total of 70-minute sessions with 40-minutes being dedicated to conventional physical therapy and 30-minutes of virtual reality treatment with the IREX VR system.

Obtained from: http://www.gesturetek.com/images/press/media-oct29-09-3.jpg

Virtual Reality Training should utilize various games on the IREX VR system in order to encourage active lower-limb movement, weight shifting, and single-limb stance. This will facilitate improvement in balance, mobility, stepping and ambulation skills, while simultaneously increasing her strength and range of motion.The difficulty of the games should be increased as Mrs. Cooke makes improvements in order to maximize her ability to progress. Weight and therabands can be added to provide external resistance and make the games harder and promote increased muscle strength and endurance.

Obtained from: https://acewebcontent.azureedge.net/certifiednews/BalanceExer2.jpg

The conventional physical therapy should be designed to be patient-specific and progress from static balance training to dynamic balance training. Since Anita is independent in quiet static standing balance, Anita would benefit most from progressing from static balance activities within the first few sessions as soon as she is able to shift her weight in the anteroposterior and mediolateral planes while performing functional reaching tasks. Her PT program should also include strengthening for the gluteus medius to improve controlled mobility of the pelvis during the stance phase of gait because she is having difficulty walking, particularly on uneven ground. Anita’s program should also include gait training and dynamic balance on unstable surfaces, because one of her main goals is to be able to walk around her neighborhood again.

References:

1. Stroke facts. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/stroke/facts.htm. Updated 20152016.
2. National Stroke Association Web site. http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/hemiparesis. Accessed October 16, 2016.
3. Cho K, Lee W. Effect of treadmill training based real-world video recording on balance and gait in chronic stroke patients: a randomized controlled trial. Gait & Posture [serial online]. 2014;39(1):523-528. Available from: MEDLINE, Ipswich, MA. Accessed September 11, 2016.
4. Chi-Ho L, Yumi K, Byoung-Hee L. Augmented reality-based postural control training improves gait function in patients with stroke: Randomized controlled trial. Hong Kong Physiotherapy Journal [serial online]. December 2014;32(2):51-57. Available from: CINAHL, Ipswich, MA. Accessed September 11, 2016.
5. Kang H, Kim Y, Chung Y, Hwang S. Effects of treadmill training with optic flow on balance and gait in individuals following stroke: randomized controlled trials. Clinical Rehabilitation [serial online]. March 2012;26(3):246-255. Available from: CINAHL, Ipswich, MA. Accessed September 11, 2016.
6. Lloréns R, Gil-Gómez J, Alcañiz M, Colomer C, Noé E. Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke. Clinical Rehabilitation [serial online]. March 2015;29(3):261-268. Available from: Psychology and Behavioral Sciences Collection, Ipswich, MA. Accessed September 11, 2016.
7. Kim J, Jang S, Kim C, Jung J, You J. Use of virtual reality to enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled study. American Journal Of Physical Medicine & Rehabilitation / Association Of Academic Physiatrists [serial online]. September 2009;88(9):693-701. Available from: MEDLINE, Ipswich, MA. Accessed September 11, 2016.

Please contact Cara Fowler at cara.fowler@temple.edu with any additional questions you may have regarding this topic.

Background:

Depression affects over 120 million people worldwide. Major depression disorder is one of the most common mental disorders in the United States and it is estimated that by the year 2020 it will be second only to coronary artery disease for disability-adjusted life years lost for both sexes.

Currently, the first option for the treatment of depression is antidepressant medications, which are shown to have significant side effects

Case Scenario:

My patient is a 45 y/o female who presents to physical therapy with a primary complaint of chronic low back pain (LBP). She is a single mother of 3 and currently works as a lawyer. She reports high levels of stress and decreased activity; she used to be an avid runner and tennis player. Patient has a PMH significant of depression. She participated in PT for 4 weeks with only marginally improvements in disability index score. Patient continues to complain of LBP. In addition, pt now complains of fatigue, weight loss and trouble sleeping. Therefore,  severity of depression outcome measures implemented.

Clinical Question:

In adults with depressive disorder is moderate intensity aerobic exercise a MORE effective treatment compared to traditional treatment in decreasing depressive symptoms and increasing QOL?

Two outcome measures were analyzed :

1. Severity of Depression Scale: Hamilton Depression Rating Scale (HAM-D); Beck Depression Inventory-II (BDI-II)
2. Quality of Life: WHO Quality of Life- BREF (WHOQOL-BREF)

Search Strategy:

Inclusion Criteria:

Articles within 10 years (2006-2016); diagnosed with a depressive disorder; Adults 18 and older; moderate intensity exercise; article had to compare either exercise and usual care to medication OR compare exercise to medication

Exclusion Criteria:

Presence of another primary psychiatric disorder (bipolar disorder, anxiety etc.); medical co-morbidities (diabetes, CHF etc.)

Levels of Evidence:

Results- Aerobic Exercise vs. Medication:

Graph 1:

The only article that looked at AE vs. Medication was by Blumenthal at al. The graph represents the mean difference in HAM-D scores between the two groups at 16 weeks. There was no statistical difference between groups, however there was statistically significant changes in severity of depression scores within all groups. This shows that Moderate intensity aerobic exercise (AE) could be as effective as medication only.

Results: Aerobic Exercise + Medication vs. Medication

Graph 2:

This graph on the left represents the mean difference in HAM-D scores between two groups at discharge (Avg. LOS=  3 weeks) The asterisks sign represents statistical significance. There was a larger reduction in depressive symptoms in the AE + medication group compared to the medication only group. In addition, the decrease in depressive symptoms for the exercise group were considered clinically meaningful.

The graph on the right represents the difference in QOL between the groups at discharge. There was a larger increase in the QOL score in the AE + medication group compared to the medication only group for only 2/4 domains (physical and psychological domains).

Graph 3:

These two articles by Legrand and Carneiro, looked specifically at the Becks Depression Inventory. The two graphs represent the mean difference in BDI-II scores between the two groups at 10 days for Legrand and 16 weeks for Carneiro. The asterisk sign represents statistical significance.  Meaning there was a larger reduction in depressive symptoms in the AE + medication group compared to the medication only group. In addition, the decrease in depressive symptoms for the exercise group were considered clinically meaningful.

Graph 4:

This graph represents the mean difference in HAM-D scores and BDI-II scores between the two groups at 12 weeks. There was a larger reduction in depressive symptoms in the AE + medication group compared to the medication only group for both the HAM-D and BDI-II. In addition, the decrease in depressive symptoms for the exercise group were considered clinically meaningful.

Clinical Bottom:

Severity of Depression:

• 1 out of 1 articles shows that AE is equally as effective as medication in reducing depressive symptoms.
• 4 out of 4 articles show AE + Medication is more effective than Medication alone in reducing depressive symptoms. In addition, the 4 out of 4 articles are considered clinically meaningful.

Quality of Life:

• 1 out of 1 articles AE + medication is more effective than medication alone in increasing QOL in 2/4 domains: Physical and Psychological domain.

Limitations:

• Small sample size
• Patient volunteers; more motivated to exercise? Therefore, harder to generalize to the population.
• Women only (Carneiro et al). Therefore, harder to generalize to the population.
• Severity of Depression as a secondary outcome measure (Blumenthal et al)
• In addition, further research is needed on Exercise vs. Medication and long-term effects of exercise on depression.

Clinical Application:

Based off of level 2 quality evidence, moderate intensity aerobic exercise is comparable to antidepressant medication in decreasing depressive symptoms and increasing QOL. Exercise has possible effective therapeutic advantages compared to medication as treatment for depression: inexpensive therapy, health benefits, improves general well-being, minimal side-effects.

Application to Case Scenario:

In addition to LBP management an exercise program can be implemented to decrease depressive symptoms.

For example: 3-4x/week for 6–12 weeks (both in clinic and a home-exercise program) for 30–45 minute duration of moderate intensity aerobic exercise (brisk walking, running, stationary cycling, swimming). In addition, treating co-morbidities such as depression may improve functional outcome measure for the primary complaint (LBP). Furthermore, it is important to encourage the patient to continue exercising after the exercise program is complete to continue to benefit from the benefits of aerobic exercise on depression.

References:

1. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and Pharmacotherapy in the Treatment of Major Depressive Disorder. Psychosomatic Medicine. 2007;69(7):587-596. doi:10.1097/psy.0b013e318148c19a.
2. Carneiro LS, Fonseca AM, Vieira-Coelho MA, Mota MP, Vasconcelos-Raposo J. Effects of structured exercise and pharmacotherapy vs. pharmacotherapy for adults with depressive symptoms: A randomized clinical trial. Journal of Psychiatric Research. 2015;71:48-55. doi:10.1016/j.jpsychires.2015.09.007.
3. Legrand FD, Neff EM. Efficacy of exercise as an adjunct treatment for clinically depressed inpatients during the initial stages of antidepressant pharmacotherapy: An open randomized controlled trial. Journal of Affective Disorders. 2016;191:139-144. doi:10.1016/j.jad.2015.11.047.
4. Mota-Pereira J, Silverio J, Carvalho S, Ribeiro JC, Fonte D, Ramos J. Moderate exercise improves depression parameters in treatment-resistant patients with major depressive disorder. Journal of Psychiatric Research. 2011;45(8):1005-1011. doi:10.1016/j.jpsychires.2011.02.005.
5. Schuch F, Vasconcelos-Moreno M, Borowsky C, Zimmermann A, Rocha N, Fleck M. Exercise and severe major depression: Effect on symptom severity and quality of life at discharge in an inpatient cohort. Journal of Psychiatric Research. 2015;61:25-32. doi:10.1016/j.jpsychires.2014.11.005

References
1. Rabago CA, Wilken JM. Application of a mild traumatic brain injury rehabilitation program in a virtual realty environment: A case study. J Neurol Phys Ther. 2011;35(4):185-193.
2. Fritz NE, Basso DM. Dual-task training for balance and mobility in a person with severe traumatic brain injury: A case study. J Neurol Phys Ther. 2013;37(1):37-43.
3. Howell DR, Osternig LR, Chou LS. Return to activity after concussion affects dual-task gait balance control recovery. Med Sci Sports Exerc. 2015;47(4):673-680.
4. Dorman JC, Valentine VD, Munce TA, Tjarks BJ, Thompson PA, Bergeron MF. Tracking postural stability of young concussion patients using dual-task interference. J Sci Med Sport. 2015;18(1):2-7.
5. Register-Mihalik JK, Littleton AC, Guskiewicz KM. Are divided attention tasks useful in the assessment and management of sport-related concussion? Neuropsychol Rev. 2013;23(4):300-313.

Picture credit: http://i.huffpost.com/gen/3861974/images/o-ORGAN-TRANSPLANT-facebook.jpg

Picture credit: http://c8.alamy.com/comp/ED5G9Y/box-in-a-hospital-saying-human-tissue-for-transplant-ED5G9Y.jpg

Picture Credit: http://www.nature.com/bdj/journal/v201/n12/images/4814370-i1.jpg

Picture credit: http://www.bayareapt.com/images/whatispt.jpg

Research performed by Samantha Benson

Contact: samantha.benson@temple.edu for more information