Background: An 87-year-old female with history of osteoporosis presented to the emergency department (ED) with complaints of low back pain and difficulty walking due to falling onto the deck of a cruise ship two weeks prior. She landed on her left hip and, although she noticed immediate unilateral hip/groin and bilateral low back pain, she chose to continue the vacation with pain rather than return early. The medical staff aboard ship recommended Ibuprofen and follow-up with her physician.
Upon returning home, she presented to the ED. Given significant delay in accessing care and persistent symptoms, a lumbar computed tomography (CT) scan was ordered. Lumbar CT results were initially negative so the ED staff planned for discharge home. A physical therapist (PT) was consulted for discharge disposition recommendations due to concerns regarding mobility safety and because she fulfilled fall risk criteria (presented due to a fall, older than 65 years, and scored higher than 13.5 seconds on the Timed Up And Go Test).
Results: Physical therapy examination revealed painful and limited range of motion and decreased strength of left hip flexion and internal rotation. Gait was antalgic and walker-assisted; prior level of function included two miles of independent walking daily. Based upon examination findings and imaging guidelines, the PT recommended she receive left hip radiographs. Hip CT was ordered due to its superior specificity in detecting subtle fractures and to assist interventional planning in the setting of geriatric trauma. Imaging revealed three pelvic ring fractures. The orthopedic service deemed the fractures stable. After gait training to off-load during stair navigation (right ascent, left descent, railing use) and on level surfaces (walker), staff discharged her home with a referral to orthopedics for follow-up.
Conclusion: PT examination within the ED reduced the likelihood of adverse events post-discharge by expediting selection of appropriate intervention pathways.
Purpose/Hypothesis: The purpose of this systematic review is to determine the relationship of being overweight/obese with the incidence and severity of chemotherapy-induced peripheral neuropathy (CIPN).
Number of Subjects: This systematic review identified 12 studies including 4089 subjects.
Materials and Methods: Electronic databases PubMED, PEDro (Physiotherapy Evidence Database), CENTRAL (Cochrane Central Register of Controlled Trials), Ovid, and EBSCO were systematically searched in March 2019 for articles dated within the last 10 years. Reference lists of relevant articles were also hand searched. The following search terms were used: chemotherapy, neuropathy, risk factors, BMI (body mass index), obesity. Inclusion criteria included studies, systematic reviews, or meta-analyses that included adult subjects who were diagnosed with CIPN and that presented qualitative or quantitative data regarding presence of neuropathy and documentation of BMI or weight. Articles were excluded if documentation of BMI or weight was not quantified or if CIPN was not identified.
Results: Twelve articles met the inclusion criteria. These studies included subjects who were receiving or had received taxane therapy, platinum compound therapy, or bortezomib for treatment of breast cancer, multiple myeloma, esophagogastric cancer, or colorectal cancer. In this review, 11 of the 12 studies showed increased incidence of CIPN in subjects with higher BMI or BSA (body surface area). Also, the two studies that looked at severity of CIPN symptoms showed that overweight/obesity was a risk factor for higher grades of neuropathy.
Conclusions: An association between overweight/obesity and CIPN is documented. The mechanisms influencing this relationship may be related to the necessary increased dosing of chemotherapy related to a higher BSA as well as the link of obesity with metabolic syndrome. The systemic inflammation often present with metabolic syndrome can lead to peripheral and central sensitization in the pain transmission system as well as axonal damage and demyelination of the nerves occurring as a result of proinflammatory cytokines. Also a consideration with obesity is the presence of diabetes and related microvascular changes that may occur. No studies were found on associations between CIPN and the effect of weight gain or loss.
Clinical Relevance: Overall, being overweight or obese may put one a higher risk for the development and severity of CIPN. As clinicians, encouragement in healthy lifestyles including weight management and physical activity are important so that patients can complete prescribed treatment at recommended doses. Delays or dosing reductions could impact the desired results on the disease process. Awareness of the increased risk of the development of CIPN in this patient group might warrant increased monitoring of the incidence and severity of symptoms. Further research on the effect of weight loss on the incidence and severity of symptoms would also be helpful in directing care of patients.
Background and Purpose: Waldenstrom’s Macroglobulinemia (WM) is a rare form of cancer that may go untreated unless symptomatic. The purpose of this report is to follow the rehabilitation progress of a patient receiving chemotherapy for WM on a spinal cord injury unit. The vast majority of literature focuses on the medical treatment and results without mention of the functional impairments and disabilities patients experience. This report shares the patient’s presentation, clinical course and a possible strategy for successful treatment.
Case Summary: A 70-year-old male patient presented to the ER with complaints of low back and leg pain but steady gait. Within days of admission, the patient’s functional mobility, independence and strength rapidly declined and IVIG treatments began for suspected Guillain Barre Syndrome. The patient eventually progressed to being nonambulatory, endorsing weakness and altered sensation in his bilateral upper extremities. The patient completed approximately 20 sessions of acute inpatient rehabilitation before being recommended and transferred to spinal cord injury rehabilitation (SCIR) for further management. The patient received a monthly infusion of Bendamustine and Rituximab from April-September 2018 and then Rituximab only beginning in October, while continuing to participate in physical therapy (PT). The patient’s initial PT goal was modified independence from a wheelchair level which was achieved and led to patient discharge in May 2018. The patient began outpatient PT in June with continued recovery of strength and function noted, particularly once the patient was transitioned off Bendamustine.
Outcomes: At SCIR discharge, the patient was modified independent with bed, bath, toilet and car transfers. The patient required a manual wheelchair for locomotion and was still receiving monthly infusions of the 2 medications. After approximately 5 months of biweekly outpatient PT, the patient was a modified independent community ambulator using a Rollator and progressed to a single point cane by the sixth month. Also, by this time, the patient could safely ascend and descend a full flight of steps using handrails only. Ultimately with continued PT, the patient progressed to ambulating over ground without an assistive device for at least 150 feet with modified independence due to safety concerns because of continued gait and balance impairments.
Conclusion: Rehabilitation in patients with similar presentations or receiving infusions of the same medications may be more successful with graded goal setting that considers medication management and the natural course of disease recovery. Therefore, goal reassessment is paramount to ensure effective treatment. This patient experienced continual weight loss and missed therapy sessions while receiving the 2 drug infusions secondary to nausea and general malaise, however once he was transitioned to the 1 drug treatment, his weight recovered, his attendance improved and he progressed to ambulatory status. A paucity of PT related research in this area shows a need for more investigation into the role of PT in patients with this presentation of WM.
Background and Purpose: The incidence of degenerative disease at both the lumbar spine (LS) and hip joint increase with age and frequently occur concurrently. Symptoms present in the LS and hip may complicate the clinical presentation and require additional investigations to identify primary and secondary impairments contributing to the individual’s symptoms and activity limitations. Failure to recognize concurrent disease at both the LS and hip may lead to misdiagnosis and possibly ineffective physical therapy treatment. The purpose of this case report is to describe clinical decision making in the examination and treatment of an individual presenting with chronic low back pain (CLBP) and previously undiagnosed hip osteoarthritis (OA).
Case Description: The patient was a 59-year-old male with CLBP and right hip pain. His Oswestry Disability Index (ODI) was 54% indicating severe disability, low back and right hip numeric pain rating scale (NPRS) were both 5/10. Impairment-based exam findings included: positive bilateral lumbar quadrant testing, right hip joint restrictions limiting hip motion in all planes, anterior hip soft tissue restrictions, and a positive Flexion Abduction External Rotation test on the right. Magnetic resonance imaging available at the time of examination confirmed the presence of L4/L5 facet arthropathy. Primary impairments were determined to be right hip mobility and anterior soft tissue restrictions with secondary impairments consisting of lumbar spine extension limitation as well as gluteal muscular strength deficits in newly acquired range of motion. Physical examination revealed findings consistent with chronic lumbar facet arthropathy and right hip OA. The primary physical therapy interventions consisted of low and high velocity joint manipulation, stretching, and strengthening exercises to address right hip impairments contributing to altered movement patterns during functional mobility tasks (such as sit to stand transfers and gait).
Outcomes: At discharge, following 8 physical therapy treatment sessions, the patient demonstrated improvements in lower back and right hip NPRS from 5/10 to 0/10 (MCID = 2 points), lifting and gait tolerances, and ODI scores from 27/50 (54%), severe disability to 8/50 (16%), minimal disability (MCID = 12.8 points). Right hip mobility restrictions were significantly improved in the sagittal and transverse planes. At session 6, a Global Rating of Change Score of +7 was obtained, indicating the patient’s perception of feeling “a very great deal better.” Towards the final physical therapy session, the patient followed up with his primary care physician, received bilateral hip x-rays, and was diagnosed with severe right hip OA.
Discussion: Clinical decision making in the presence of concurrent LS and hip symptoms is often difficult due to the overlapping referral patterns and intricate interaction between the lumbopelvic region and the hip. This case report demonstrates how a physical therapist’s recognition of coexisting disorders can improve physical therapy management. Accurate identification of primary and secondary impairments contributing to altered movement patterns resulted in positive patient-centered outcomes. This case report supports how an impairment-based treatment approach directed at the hip joint can lead to favorable outcomes in a patient with a primary complaint of CLBP.
Purpose/Hypothesis: The purpose of this study is to determine if a predominately visual cue or a predominately auditory cue is more effective in producing a voluntary contraction of the lumbar multifidus muscle. The hypothesis is there will be a difference in the voluntary contraction of the lumbar multifidus when utilizing an auditory or verbal cue.
The lumbar multifidus is a postural muscle and segmental stabilizer. It is a vital muscle for maintaining posture during dynamic functional movements. The lumbar multifidus has been identified to be deficient in people with low back pain, and therefore can be commonly addressed in physical therapy. There is limited research on the effectiveness of cuing methods used when instructing patients how to voluntarily and consistently activate the multifidus muscle. This study investigated two types of cueing (predominately auditory and predominately visual) to determine which produced a larger muscle contraction using real time ultrasound imaging to measure change in muscle thickness.
Number of Subjects: 41 subjects (28 females and 13 males) ages 23 to 72 years old, mean age 36.8 years old.
Materials and Methods: This quasi-experimental study was approved by Midwestern University’s Institutional Review Board, and data collection was conducted at the Midwestern University Multispecialty Clinic in Downers Grove, IL. Participants were assigned to one of the two groups in alternating pattern and corresponding to the two types of cues: predominately auditory cue group (verbal description of the muscle) and predominately visual cue group (use of an anatomic three dimensional model). The size of the multifidus was measured using real time musculoskeletal ultrasound at rest and during contraction in response to the cue. The difference between these measurements was calculated as a percent change and used to determine which cueing method was most effective for teaching subjects how to voluntarily activate the multifidus.
Results: No significant difference was found between cue groups (n = 41, p = 0.22). Subjects less than or equal to 30 years old (n = 21) performed a better multifidus contraction compared to those older than 30 years (n = 20) regardless of cue provided (p = 0.003). Those with previous knowledge of the multifidus muscle (n = 21) did perform a contraction better than those without previous knowledge (n = 20), regardless of the cue provided (p = 0.049). Subjects without self-reported previous knowledge of the multifidus muscle produced a better muscle contraction when provided a predominately visual cue (n = 18, p = 0.014).
Conclusions: There was no difference between cue groups, however the results indicate a significant difference when considering age and previous knowledge of the lumbar multifidus muscle. Subjects less than or equal to 30 years old performed significantly better regardless of the cue provided. Subjects who have no previous knowledge of this muscle responded significant better to the predominately visual cue. Therefore, clinicians may consider investing in an anatomical model that includes the multifidus to educate patients and provide visual feedback regarding the contraction. Patients older than 30 years old may require more education, training time, or additional cues to produce an effective contraction.
Background and Significance: Eighteen percent of scheduled acute care physical therapy appointments do not occur secondary to patient refusal mainly due to decreased patient motivation and a negative rapport with the physical therapist (PT). A strong patient – PT therapeutic alliance significantly increases patient participation and provides opportunities for improved patient outcomes. Empathy, friendliness, confidence, non-verbal communication, active listening, and encouragement are essential components in establishing a therapeutic alliance. The purpose of this case report is to describe how a positive therapeutic alliance created resilience to overcoming internal and external barriers in treating a patient with complex neurological dysfunction in the acute care setting.
Case Description: The patient was a 27-year-old female who underwent a sleeve gastrectomy procedure due to morbid obesity with subsequent progressive sensorimotor polyneuropathy within one month of surgery, which significantly decreased her functional mobility and societal participation. Although a differential diagnosis of micronutrient deficiency versus Guillain-Barre syndrome (GBS) was considered, the specific etiology of the sensorimotor polyneuropathy was unknown for the majority of her acute care hospitalization. Prior to surgery, the patient was independent with all ADLs and IADLs. She lived alone in a fifth floor apartment and worked as a technician at a plasma clinic, which required prolonged sitting and standing, fine motor coordination, and repetitive upper extremity movement. The patient initially displayed a depressed mood, a high external locus of control, decreased motivation, and lack of trust in the PT as the patient experienced a fall at an outside hospital while in physical therapy.
Examination revealed suboptimal cardiovascular endurance, severe bilateral distal extremity weakness, bilateral sensory deficits in the distribution of the medial and lateral plantar nerves, 7/10 lower extremity pain on the Numeric Pain Rating Scale (NPRS) with weight bearing activities, and decreased lower extremity ROM. The patient required maximum assistance of two PTs for supine to sit transfers and needed a Hoyer lift for bed to chair transitions. The PT recognized that establishing a strong therapeutic alliance would be crucial to increase patient trust, motivation, and participation.
Intervention: A variety of therapeutic interventions were used to decrease pain, increase strength, and improve function for this patient including pressure relief, positioning techniques, ROM activities, bed mobility, and transfers. A sit-to-stand battery-powered mobility device assisted the PTs in safely attempting sit-to-stand transfers with this patient. However, the absence of proper bariatric accessories for this device made it difficult to properly utilize in the treatment sessions. A therapeutic alliance was intentionally developed on the basis of active listening, patience, communication, encouragement, education, integrity, compassion, and caring which are key attributes of the APTA Core Values. These strategies decreased the patient’s anxiety and distrust in the healthcare system by improving communication between the patient and healthcare providers.
Outcomes: After 11 visits of physical therapy, the patient demonstrated improvements in supine-to-sit transfers and increased upper and lower extremity strength. Pain continued to be a limiting factor as her NPRS score reduced from 7/10 to 6/10 (MCID = 1.7). Her Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks score decreased from 10/24 to 8/24 (MCID = 3.3-5.1). Although the patient demonstrated slight improvements in functional mobility, a strong therapeutic alliance developed as evidenced by the patient’s willingness to ultimately undergo appropriate medical tests that led to the diagnosis of acute inflammatory demyelinating polyneuropathy, a form of GBS. Because of the patient’s increased motivation in therapy participation and a stronger internal locus of control, she agreed to be discharged to the acute rehabilitation setting for further therapies.
Discussion: Several modifiable and non-modifiable barriers were present during this episode of care including the patient’s morbid obesity, high external locus of control, decreased motivation, learned helplessness, initial patient distrust of the PT, absence of appropriate bariatric equipment, lack of communication between healthcare providers, and an unknown medical diagnosis. The PT developed a strong therapeutic alliance with the patient through management of patient expectations, individualized therapeutic interventions, patient-provider partnership, identifying the roles and responsibilities of the PT, congruence, and strong verbal and non-verbal communication. The present case demonstrates the power that a therapeutic alliance has on a patient’s willingness to participate in treatment and mediate obstacles in physical therapy.
Background and Purpose: Little is known about pediatric physical therapists’ (PPTs) clinical reasoning associated with managing therapy-related behaviors. The purposes of this study were: 1) to explore PPTs’ opinions and beliefs on potentially difficult behaviors observed in infants and young children, their effects on the child’s progress, behavior management techniques, and caregiver and therapist roles in applying those techniques; and 2) to identify the main factors that guide PPTs’ decision making regarding the management of therapy-related behaviors in the children they serve.
Hypotheses: We hypothesized that 1) The majority of respondents would incorporate a family-centered approach to care in their decision making related to behavior management in infants and young children; 2) Respondents with greater clinical experience would consider collaboration with the child’s family in behavior management as a relationship building opportunity compared to those with less clinical experience; and 3) Respondents who learned about behavior management in the didactic portion of their entry-level physical therapy curriculum would report feeling more comfortable with applying behavior management strategies in their clinical practice compared to those who did not.
Methods: A 57-question Qualtrics survey was piloted to three therapists who assessed its content. Questions were multiple choice, multiple selection, ranking, yes/no, and open-ended. The survey link was received by 105 PPTs listed in the Rosalind Franklin University Department of Physical Therapy (PT) database. The survey was open for 6 weeks with reminder emails sent in weeks 3 and 5. Data were analyzed using descriptive statistics. Thematic analysis was performed for answers to open-ended questions.
Results: Survey response rate was 33%. Majority of respondents adhered to the family-centered philosophy when making behavior management decisions. PPTs with greater amount of experience reported using collaboration with the caregiver as a relationship building opportunity. There was no difference in respondents’ comfort with behavior management based on the content of their entry-level PT curriculum. Factors that affected clinical reasoning included the type of behavior, collaboration with the caregiver, personal clinical experience, and years of experience.
Discussion and Conclusions: This is the first study that provided insight into PPTs’ clinical reasoning associated with behavior management and identified the main factors that guide their decision making. The impact of related entry-level curricular content on clinical reasoning could not be fully determined based on obtained results and should be examined by future research. Results can be cautiously generalized to PPTs with demographic characteristics similar to the study sample.
Description: Traditional physical therapy clinical education has included a 1:1 student to clinical instructor model3,5,6,10. However, changes in healthcare delivery, billing, supervision, and the advent of the PTA profession and licensure in all 50 states warrants a sustainable model for clinical education supervision and delivery10. A 2:1 model is one solution that has been implemented to adapt to the changing healthcare environment 2,3,5,8,10. Traditionally a 2:1 model pairs either two physical therapist students (SPT) or two physical therapist assistant students (SPTA) with one clinical instructor (CI). More recently, a 2:1 model that includes a SPT and a SPTA to one CI has been used 1,10.
Malcolm X College Physical Therapist Assistant Program and John H. Stroger Hospital of Cook County are located in the heart of the Illinois Medical District of Chicago, Illinois. This proximity and dedication to the community has allowed a partnership and collaboration to develop a 2:1 clinical education model in the acute care setting that includes an SPT and SPTA with one PT CI. Each student was participating in a terminal clinical experience and the PT CI is a veteran clinical instructor and clinician within the acute care setting. Preparation prior to the initiation of this clinical experience included meetings between the academic program and clinical site teams to discuss and organize logistics, billing, documentation, supervision of the SPT and SPTA, and scope of practice of the PT and PTA. Ongoing communication throughout the preparation process and formal meetings at midterm of the clinical experience with all parties assisted in addressing positive outcomes and areas for further development.
Current literature shows that the primary positive outcomes regarding the PT-PTA relationship and the 2:1 model show improvement in communication, consultation, and delegation of tasks between the PT and the PTA 1,7,9,10. A 2:1 clinical education model that includes a student physical therapist (SPT) and a student physical therapist assistant (SPTA) to one physical therapist clinical instructor (PT CI) allows for benefits that include the following stakeholders: clinic/facility, academic program, students/future clinicians, and profession/community. Our current 2:1 PT-PTA collaboration clinical education model had demonstrated benefits for each stakeholder and has remained consistent with the current body of literature.
Challenges to the effective use of this 2:1 model include rehabilitation team buy-in and support, SPT and SPTA teamwork and collaboration ability and effort, coordination by the clinical site, baseline knowledge of the students and CI regarding scope of practice and application to current clinical setting.
To more formally investigate the benefits of this model of clinical education, our future plans include implementation of a confidence survey pre/post clinical rotation for the SPT, SPTA, and CI, qualitative exit interviews, survey of graduates following experience as licensed clinicians, and survey of rehabilitation team.
Background: Research regarding the difference between acute and chronic pain has grown substantially over the past two decades. With that, the evidence promoting patient education regarding pain science has become more prevalent. Although it has been recommended that this is a crucial aspect of patient functional recovery, standardized means of its’ implementation into patient care remains limited. The purpose of this case study is to explore the utilization of cognitive-behavioral therapy (CBT) in adjunct to standard physical therapy interventions to address functional limitations in a patient with knee pain. Additionally, it will highlight the importance of identifying and addressing fear avoidance behaviors through pain neuroscience education (PNE) and CBT.
Case Description: The patient is a 38-year-old male who presented to outpatient physical therapy with chief complaints of right lower extremity weakness and knee pain, which began 3 months prior to initial evaluation. Previous attempts to manage symptoms, which included Cortisone injection and knee aspiration, were unsuccessful. He reported severe limitations in functional mobility, required use of his arms to lift his right leg for transfers, and was dependent on a soft, counterforce brace for all weight bearing tasks. Past medical history included right sided low back pain (onset 6 months prior), asthma, and headaches. An MRI was performed on his right knee with pertinent findings including osteoarthritis, small radial tear of lateral meniscal body, and small joint effusion. On initial assessment, right lower extremity strength testing utilizing manual muscle testing revealed “trace” (grade 1/5) strength in hip flexion and knee extension, and poor (grade 2/5) strength in remaining hip and knee joint motions. Seated active lumbar spine mobility assessment revealed aberrant movement lack of full flexion or extension. Observational gait assessment displayed knee buckling during midstance phase and decreased stance time on right lower extremity. Fear avoidance beliefs were evident by positive findings for Waddell’s signs including, distraction, over-reaction, and superficial tenderness. Additionally, patient verbalized conscious activity modification and nonparticipation in activities of daily living due to anxiety of increasing pain and worsening his symptoms. Fear Avoidance Beliefs Questionnaire – Physical Activity (FABQ-PA) was given to patient on evaluation in which he scored 21/24.
Initial treatments focused on educating the patient on the difference between acute and chronic pain. A key component of this was emphasizing that the level of pain does not correlate with the level, or presence, of actual tissue damage. This was also done by assisting the patient in reflection on his thoughts and feelings regarding functional limitations; determining if they were being limited more by fear of experiencing pain or due to the presence of muscular weakness or joint instability. Self-reflection was also emphasized to be important during functional activities outside of the clinic. Patient-centered goal setting was implemented in order to provide meaningful physical therapy care as well as allow for autonomy. Reasonable, objective, and function-based goals were set between patient and therapist, irrespective of the absence or presence of pain. Finally, gradual exposure to lower extremity progressive exercise was implemented. Initial exercise focused on low level, open kinetic chain quadriceps and gluteal strengthening and was progressed to loaded, multi-joint, closed kinetic chain exercises. This systematic progression was utilized for both skilled physical therapy interventions as well as home exercise program. Additional therapies included lumbar spine manipulation and dry needling, both of which were utilized as adjunct treatment and after fear avoidance was significantly reduced.
Results: The patient completed 15 treatment sessions over 10 weeks, after which most limiting motions of hip flexion and knee extension strength testing were improved to fair + (grade 3+/5) and remaining hip and knee strength improved to good + (4+/5). Additionally, the patient no longer required
upper extremity assist for completion of car transfers, bed mobility, and squatting. Observational gait analysis revealed normalized mechanics without knee buckling during stance phase and symmetrical step length bilaterally. Lumbar spine mobility was restored to normal with good motor control and movement patterns. Improvements allowed the patient to return to recreational weightlifting with minimal restrictions. FABQ-PA score improved by 15 points, reducing to a score of 6/24. (Minimal Clinically Important Difference is 8 points).
Discussion: Restoring lower extremity strength and mobility are primary goals for many people seeking physical therapy. However, for patients who present with limited function in the absence of medically sinister pathology, it is critical to include some level PNE, as misunderstandings may inhibit or lessen improvements. Specific to cases involving high levels of fear-avoidant behavior, PNE and CBT in conjunction with exercise can prove to be the missing link to achieving optimal outcomes. %MCEPASTEBIN%
Background/Rationale: Participation in boxing fitness programs has shown to improve overall mobility, balance, and quality of life in people with Parkinson’s Disease. Participation in Pilates has shown to improve balance and quality of life in older adults. However, there is no evidence regarding the effects of a combination of Pilates with boxing in older adults.
Purpose/Research Objectives: To determine the effectiveness of a Pilates and boxing exercise program on older adults’ fall risk and quality of life.
Relevance: It is critical to find feasible options for older adults to improve their risk of falls and quality of life.
Methods: Twenty eight older adults participated in a pretest/posttest intervention program of Pilates and boxing exercise. Intervention was twice a week for four weeks. Statistical analysis was performed using SPSS version 25.0 to run dependent t-tests for the outcome variables of cardiovascular endurance (2-Minute Walk Test), gait speed (10-Meter Walk Test), functional strength (5 Times Sit to Stand), and balance (Multidirectional Reach Test and ABC-6). Wilcoxon signed rank was used to analyze the quality of life, as measured by the SF-36.
Results: Significant differences were observed between pre- and post-intervention measurements of balance in backwards reach (p=0.04) and left lateral reach (p=0.005), functional strength (p=0.029), and functional cardiovascular endurance (p=0.038).
Conclusions: A biweekly four-week Pilates and boxing class may decrease fall risk in older adults. Although not statistically significant, there was a positive trend in the data from SF-36 suggesting improvements in quality of life.
Background/Purpose: The Y-Balance Test (YBT) is a reliable and valid tool for assessing dynamic balance in healthy and patient populations. However, YBT performance does not take into account the movement strategy an individual uses. For example, to reach further an individual might sacrifice knee position for reach distance. Controlling knee position through external visual cueing may alter the lower extremity kinematic or kinetic strategy used and YBT performance, and the movement strategy may change with practice. Therefore, the purpose of this study was 1) to examine the effect of external visual cueing on YBT performance and lower extremity kinematics and kinetics during the YBT, and 2) to determine how practice affects lower extremity kinematics and performance on the YBT.
Methods: 11 participants without lower extremity dysfunction completed 8 YBT trials: 2 practice trials, 3 trials without and 3 trials with external visual cueing via a laser tracker on the knee. YBT performance was measured as normalized reach distance, kinematics were measured via angular change of 5 lower extremity angles using Dartfish analysis of video recordings, and kinetic changes at the foot were assessed using an F-Scan sensor.
Results: External visual cueing was associated with a proportional decrease in normalized reach distance compared to no cueing. Kinematically, cueing affected knee flexion (p<.05), but not knee varus/valgus (p>.05). Kinetically, cueing led to increased contact time of the heel and midfoot, and greater change in pressure at the first metatarsal. Regardless of cueing condition, the direction effect on the YBT was preserved across all trials with posteromedial normalized reach distance being the greatest (p<.05) and anterior normalized reach distance being the shortest (p<.05). Across practice trials, there was an interaction between trial and direction for hip flexion and adduction only such that adduction changed more for posteromedial and posterolateral directions in later trials, while flexion changed more in the anterior direction for later trials. However, there was no effect on YBT performance across practice trials.
Discussion: External visual cueing is not necessary to improve control of the knee position during YBT performance in a healthy population. However external visual cueing can be used to reduce the normalized reach distance during YBT and to prolong foot contact time. One practice trial is generally sufficient to stabilize kinematics and performance during the lower extremity YBT with some exceptions for hip adduction and flexion.
Purpose: Historically, aquatic intervention garners minimal respect in addressing functional impairments prevalent in the older adult population. Yet, if one considers the unique properties of water—buoyancy, hydrostatic pressure and viscosity–a safe atmosphere exists to promote dynamic balance, functional strength, and gait. These are areas of utmost concern in promoting independent function for older adults. This study examines the value of a specific aquatic exercise regiment to improve gait speed, dynamic balance, and functional strength for the community dwelling older adult.
Methods: This is a Pilot Study, with a single blind in that the instructor was unaware of which students chose to participate in a 10-wk, 2x/wk, 45 minute program. Data was collected prior to and post-class using: 2-Minute Git Speed, Timed Up & Go, Functional Reach, 4-Square Dynamic Balance Test, Functional Reach, 30-second Sit to Stand, and 30-Second Arm Curl.
RESULTS: Significant improvements were noted for dynamic balance, sit to stand and gait speed for all participants, and less so for upper extremity strength.
Conclusion: Appropriate water exercises can facilitate functional balance, gait speed and strength upgrades for the community dwelling older adult. Additionally, a long-term study should follow to determine specific dosage/exercise and to further substantiate the benefits of aquatic exercise to promote functional independence for this population.
Description: There are currently 25.1 million people with limited English proficiency in the United States. This language barrier has been linked to a direct negative impact on patient care. In an attempt to reduce this barrier, health care systems across the country have installed policies that require medical interpreters to be present for patients with limited English proficiency. In the Early Intervention setting, Illinois Amendment 500.80 part D number 2 and 500.115 part N stated that that session must be conducted in the patient’s primary language and use of the interpreter is required if the primary language is not English. Medical in-person interpreters are effective in improving patient to provider communication and decreasing the negative effects of the language barriers. Scheduling issues arise due to the limited amount of medical interpreters present, depending on the geographical locations. This creates an issue with providing physical therapy services to children and families in areas with limited medical interpreters. There are other methods of interpretation such as video conferencing, telephonic, and mobile applications that can be used in the event that an in-person interpreter is not available.The purpose of this scoping review is to analyze the effectiveness of different methods of interpretation other than in-person interpretation such as videoconferencing, telephonic interpretation, as well as mobile applications. A secondary purpose is to propose a change in policy allowing the use of alternative technology when an in-person interpreter is not available to accompany an EI service provider.
Background and Purpose: While there is emerging evidence supporting the use of mirror therapy for reducing pain, improving functional mobility, and increasing cortical activity in patients with neurologic conditions, there is limited research identifying the effects of mirror therapy in rehabilitation of orthopedic conditions. The purpose of this case report is to describe the use of mirror therapy in the early rehabilitation of a patient recovering from orthopedic surgery to preserve cortical representation of the immobilized upper extremity.
Case Descriptions: The subject was a 19-year-old female with a two-and-a-half-year history of bilateral (B) shoulder pain who underwent extensive right shoulder labrum repair after multiple traumatic shoulder dislocations. Post-operative outpatient physical therapy consisting of mirror therapy was initiated four weeks following surgery and continued through the 8-week post-operative shoulder immobilization period. The patient was prescribed a minimum of ten minutes of mirror therapy activities per day seven days per week for 4 weeks.
Outcomes: Pre-mirror training pain was assessed via Numeric Pain Scale, range of motion measurements were recorded by goniometry and function was assessed by the QuickDASH. Post-mirror training measurements were taken following the 4-week training period and demonstrated improvements in pain, range of motion and function. Pain was reduced from 7/10 to 0/10 on the Numeric Pain Scale. Right shoulder range of motion progressed from 80 degrees of passive shoulder elevation to 100 degrees of active shoulder elevation with no patient reported increase in pain. The QuickDASH score improved from 79.2 to 43.2 with functional improvements noted in overhead reaching.
Discussion: The patient described in this case report demonstrated advanced progression of upper extremity range of motion, pain reduction and function after mirror therapy. Mirror therapy may be an effective treatment for patients recovering from orthopedic surgery through increased cortical input to the CNS, thus preserving motor and sensory awareness to the immobilized limb.
Introduction: As the experience and knowledge of the pelvic floor physical therapist evolves, the complexity of cases ensues. This case study involved a female patient that experienced pelvic floor trauma due to forceps vaginal delivery and the role of physical therapy in her care.
Case Presentation: This case was unique as this patient had multiple barriers to treatment; pelvic floor trauma, pelvic pain, persistent granulation tissue, illness, difficulty coordinating pelvic floor muscles (PFM), PFM weakness and lifestyle challenges to overcome. This patient, exhibited significant sequelae from forceps vaginal delivery and barriers to rehabilitation of the pelvic floor. This new mom had to return to work early while trying to heal and help care for her baby. Some of the barriers not often realized with other investigations include sleep deprivation, equipment costs and time constraints for a proper rehabilitation routine.
Management and Outcomes: The patient received therapeutic exercise, neuromuscular re-education, manual therapy, instruction in self-treatment techniques for 7 sessions over a 6-month period. Often exercises or instruction in her home program had to be repeated simply because the patient did not complete her home program due to illness or time constraints in her day.
Using a numerical pain rating scale, the patient’s initial constant daily pelvic pain was reported as 3/10 (10 being the worst pain). She imagined the worst possible pain level with intercourse as she had yet to attempt intercourse. The patient specific functional scale (PSFS) was utilized as a functional outcome tool. The patient listed only 2 items, intercourse and increased physical activity. A rating of 0/10 provided for intercourse and a rating of 8/10 for increased physical activity such as walking. The overall PSFS was 60% (with 100% meaning full function). At the final session, the PSFS score for walking was 10/10 (100%) and 9/10 (90%) for intercourse. Therefore, the overall PSFS score was 9.5 or 95% for the two items provided at the initial session. The final numerical pain rating scale was 0/10 for every day activities and 1/10 intermittently with intercourse.
Discussion: This case study discusses a patient with significant trauma to the pelvic floor due to forceps delivery and her journey through pelvic floor physical therapy. The patient made progress with her physical therapy program over an extended duration despite many treatment barriers. Research varies on the diagnosis, duration, treatment type, and frequency of physical therapy sessions for pelvic floor disorders, so it is difficult to compare this particular patient’s situation to a standard treatment or time frame. Physical therapy is an effective avenue to assist with tissue healing, improving function and navigating barriers in conservative care after forceps assisted child birth. Physical therapists need to be aware of the challenges to successful outcomes.
Intro/Purpose: It is well-established that children with autism spectrum disorder (ASD) show motor deficits, in addition to the social communication and repetitive behaviors characteristic of the disorder. Although motor and communication weaknesses are common in children with ASD, these deficits have traditionally been targeted independently of one-another in intervention. New research suggests that motor and language skills may be interdependent and draw from the same neural systems. Given the proposed neural overlap, it is possible that targeting motor behaviors in children with ASD will have secondary benefits on their speech and language skills. The primary goal of this systematic review was to determine whether interventions with motor targets improved language outcomes in individuals with autism.
Methods: Five databases were searched using the following terms: autis*, asper*, motor*, therap*, interven*, and treat*. To be included in this systematic review, the article must have included an intervention study with participants who had a diagnosis of autism, were not labeled as bilingual, and did not have a concomitant diagnosis of genetic, cognitive, or hearing impairment. Furthermore, the article must have implemented a motor-based intervention, reported outcomes for at least one language-based measurement, employed an experimental design, and was published between 1989 and November 9th, 2018. The initial search resulted in 5,391 hits. After eliminating irrelevant and duplicate articles, 37 articles underwent full text review to determine whether they met the inclusionary/exclusionary criteria. Of these, 14 articles met all inclusionary/exclusionary criteria and underwent inter-rater reliability checks to confirm inclusionary status. To ensure that only high-quality evidence was considered for interpretation, all 14 articles were appraised for the quality of their research design, treatment fidelity, and interobserver agreement. Following the quality appraisal process, only 12 articles were included for data extraction.
Results: Of the 12 included motor-based intervention studies, nine showed increased language outcomes and four demonstrated increased motor skills in the children with ASD. Four studies presented mixed results, in that some participants showed improved language or motor outcomes, but not all participants. Two intervention studies revealed no change in the participants’ motor skills. In three studies, no conclusions on the effectiveness of the intervention could be drawn due to either equal gains made in the control group as the experimental group, or because the groups were unequally-matched at the initiation of the intervention.
Conclusions: Consistent with previous research, many of the children with ASD in these studies presented with weaknesses in both motor and language skills. In most of these studies, the motor-based interventions led to an increase in language skills, which aligns with current research trends indicating language and motor system interdependence. These findings also indicate that co-treatment between physical therapists and occupational therapists alongside speech-language pathologists may be warranted when working with children with ASD.
Purpose: To investigate the effects of Rhythmic Auditory Stimulation (RAS) training with and without exercise compared to a control without intervention on gait velocity, step length, turn time, and TUG scores for individuals with Parkinson’s disease.
Methods: A total of seven subjects, four males and three females with early to mid-stage Parkinson’s disease were tested before and after a 4-week control period of no intervention. They were then randomly assigned to one of two 4-week treatment groups of individual RAS sessions and RAS with subsequent 30-minute group exercise in a blocked-practice format. Group 1 (n=4) completed individual RAS sessions first. Group 2 (n=3) underwent individual RAS sessions plus a group exercise program first. After two weeks the groups switched interventions. RAS music was selected based on patient preference and was adjusted during RAS sessions to match each participant’s baseline cadence (0%), as well as their +5%, +10%, and +15% cadences.
Outcome Measures: Primary outcome measures were step length, gait speed, cadence, step width, and 6-minute walk test (6MWT) distance measured with a Zeno Walkway Gait Analysis System. A secondary outcome measure was fall risk, which was determined based on Timed Up and Go (TUG), TUG Cognitive (TUG-C), TUG Manual (TUG-M), and right/left 180-degree Turn Test (180-TT).
Results: There was a significant decline in function after the 4-week control session in TUG, dual-task TUG Cognitive and 180-degree Turn Test. After RAS sessions with exercise, participants demonstrated improvements in 6MWT distance, all three conditions of the TUG, 180-TT, and Cadence. After RAS sessions without exercise, participants demonstrated improvements in all three conditions of the TUG, 180-TT, and step length. There was no significant difference in performance comparing Group 1 and Group 2 to each other after 4 weeks of intervention.
Conclusion: The use of RAS training with or without exercise for individuals with Parkinson’s disease may be beneficial in reducing risk of falls and improving gait.
Background: Medial tibial stress syndrome (MTSS) is a common sports injury with an incidence rate of 14% to 20% of runners.1 The underlying cause of MTSS is still debated in the literature, with a proposed mechanism of bony overload to the medial tibia,2 as well as possible periostitis secondary to traction of the tibialis posterior, flexor digitorum longus, or soleus muscles.3 To date, there is limited evidence supporting treatment and interventions for MTSS, in both the short and long term time frames4. The purpose of this case is to describe the physical therapy management of a female runner with acute onset of MTSS during her marathon training.
Case Description: A 28-year-old female training for a marathon race less than 3 weeks away presented to physical therapy with acute onset of left (L) lower extremity shin pain. Her pain began 2 weeks prior to consultation, and was unchanging in status. Pain was worse with running and alleviated with rest, ice, and prednisone. She reported 8/10 worst pain on the Visual Analog Scale (VAS) and scored a 61/80 on the Lower Extremity Functional Scale (LEFS). Relevant examination findings revealed pain during running, pain with a L single leg squat, pain with palpation of the L posterior tibialis muscle along the medial border of the tibia, limited weight bearing lunge test (6.5 cm L compared to 8 cm R), and hypomobility of the L talocrural joint. Initial manual therapy interventions included soft tissue mobilization to posterior tibialis, and functional dry needling to posterior tibialis, soleus, and gastrocnemius with improvements in ankle mobility, but minimal change in pain levels. Talocrural joint mobilization and thrust manipulation further increased ankle mobility and immediately abolished pain with running and squatting. Additional interventions included therapeutic exercise, patient education, and training advice leading up to race day. After just 3 visits, she was able to successfully complete her marathon run.
Outcomes: The patient was seen for 4 total visits over 22 days. She completed her marathon with 0/10 shin pain for the duration of the race. She demonstrated talocrural joint mobility within normal limits and significant improvement in the weight bearing lunge test (6.5cm to 9.5cm). VAS improved from 8/10 worst to 0/10 worst. She scored 80/80 on the LEFS and reported a Global Rating of Change (GROC) score of +7.
Discussion: This case demonstrates the use of orthopedic manual physical therapy (OMPT) to successfully manage a female runner and allowed her to complete her marathon without pain. Further research is warranted in the use of manual therapy techniques, particularly directed to the talocrural joint, as a mechanism of pain relief for long-distance runners.
Background: In 2017, UnityPoint Health Meriter began an Emergency Department Physical Therapy Program. Various information will be presented. Hours available with number of referrals will be shown. Data will also show cost savings to the hospital. Counts of diagnosis as well as referrals to Outpatient physical therapy will also be explored.
Purpose: Parkinson’s Disease involves the destruction of neurons in the substantia nigra, leading to a decreased production of dopamine. This loss directly affects motor loops in the basal ganglia, hindering function. As a result, common symptoms of PD include bradykinesia, unsteady gait, and discoordination. Chewing gum and jaw movement has been shown in fMRI studies to increase blood flow to areas directly related to the basal ganglia and increase neuronal activity to areas affected by balance and coordination. The purpose of our study is to determine if chewing gum is beneficial in improving balance and functional characteristics of gait, such as deviation, speed, and cadence in patients with Parkinson’s Disease.
Subjects: Participants were recruited from Rock Steady Boxing Parkinson’s classes in a Midwestern region. Twenty-three participants completed the pilot study.
Materials and Methods: Outcome measures included Timed Up & Go (TUG), Modified Clinical Test of Sensory Interaction on Balance (mCTSIB), gait speed, functional reach, and 360 degree turn. Data were collected from TUG, mCTSIB, and gait speed using the VirtuSense™. Each measure was collected with and without chewing gum in a randomized fashion. Three trials of each test were performed, except mCTSIB, where only one trial was completed. Paired t-tests were used to determine any potential differences in performance of the gait and balance measures with and without gum.
Results: Participants walked with a wider base of support when chewing gum (M=13.5cm, SD=3.1) than without gum (M=12.8 cm, SD=3.0); t(20)=2.17, p=0.04. Participants had a significantly increased functional reach when chewing gum (M=33.07cm, SD=8.21) than without gum (M=30.87, SD=8.00); t(22)=2.46, p=0.02.
Conclusion: This study suggests that chewing gum may lead to positive effects during gait and functional tasks, including a larger base of support and increased limits of stability. Not only was chewing gum correlated with a wider BOS while ambulating, which can help reduce falls, participants had significantly improved functional reach measures.
Clinical Relevance: These findings are important as the high rate of falls for those with PD may be impacted by these improved measures and chewing gum. Falls often take place during walking or when a change in the center of mass occurs that pushes someone outside of the limits of stability. By improving both of these measures, chewing gum may be able to have an impact on the reduction of falls experienced by those with PD. Outside of falls, this may help to improve the everyday lives of those with PD during functional tasks such as getting dressed, cooking, shopping, and recreational activities that requiring reaching. The potential improvements shown by simply chewing gum, could have real life application and improve the quality of life for those with PD.
Purpose: The overall purpose is to describe an interdisciplinary fall prevention protocol to effectively screen, assess and prescribe appropriate interventions according to risk stratification for older adults in the emergency department after a fall.
Description: Adults over the age of 65 years represent the fastest growing population in the United States, accounting for 23.1 million visits to the emergency departments annually1. In 2006, two million of these visits were a result of injurious falls, representing 10% of ED visits amongst this group2. This places a tremendous burden on the resources of emergency departments and results in increased hospital admissions and return visits to the emergency department.
As the number of emergency department visits increase for older adults, focus has been placed on the development of geriatric-friendly protocols, including the prevention of both first and recurrent falls. A systematic review found that no single risk factor significantly increases or decreases the risk of 6-month falls in geriatric emergency departments and that there is no fall risk screening currently validated for this population3.
The limited time that an older adult spends in the emergency department presents a challenge to implementing best practices for fall risk assessment and appropriate interventions based on risk stratification. The American Geriatrics Society and British Geriatrics Society clinical practice guidelines recommend a multifactorial fall assessment, which is impractical for an emergency department physician to complete due to time constraints. The Center for Disease Control developed the Stopping Elderly Accidents, Deaths, and Injury (STEADI) toolkit, which includes a 12-question questionnaire developed to screen for fall risk. While the cutoff score for fall risk alone does not accurately predict adverse outcomes, individual questions may be more sensitive to future risk. A unique fall protocol was developed by synthesizing evidence-based practices in order to meet the unique time and resource constraints of the emergency department.
Summary of Use: This poster will display how the CDC STEADI toolkit and 4 components of a multifactorial fall risk assessment were interwoven into a unique protocol to screen, assess, and intervene when older adults present to the emergency department after a fall. The platform will review how the protocol allows for timely care in the emergency department by engaging an interdisciplinary team, particularly the physical therapist. The poster will then discuss outcomes for 36 patients as it relates to hospital admission, return visits to the emergency department, and timely referral to targeted interventions for fall prevention.
Importance to Members: This poster is designed to share how a streamlined fall risk assessment and early evaluation and intervention by a physical therapist can achieve outcomes of reduced hospital admission and return visits to the emergency department.
Purpose: Foot strength is important in dynamically supporting the foot and controlling forces during functional activities. Foot strength deficits may negatively affect foot function, rehabilitation, and return to activity. Exercises which isolate intrinsic foot muscles may impact the negative effects of impaired foot strength. The Short Foot Exercise (SFE) is a common exercise which may best isolate strengthening the intrinsic foot muscles; however, it is difficult to learn. Practice and verbal cueing may facilitate learning when patients attempt a new exercise. The purpose of this study, therefore, was to determine whether cueing could facilitate learning to perform the SFE. We hypothesized that subjects given one week to practice without cues will yield the most significant improvement in performance of the SFE, followed by subjects who were given cues with less practice
Methods: Thirty-six subjects consented to participate and completed a demographic questionnaire. After receiving instruction about how to perform the SFE, subjects’ ability to perform the SFE successfully was evaluated by a single examiner on the following five criteria: 1)Toes remain extended; 2)No visible activation of tibialis anterior; 3)Elevation of the arch; 4)1st metatarsal head maintains contact with the ground; 5)Heel maintains contact with the ground. Then, subjects were randomly assigned to one of three groups: Group 1 practiced the SFE for 15 minutes without feedback, and then was re-tested; Group 2 practiced for 15 minutes with cueing provided by a research team member, and then was re-tested; Group 3 was given home exercise instruction and asked to practice for one week, then returned for re-testing. Performance of all 5 criteria determined a successful SFE. Pre-test, post-test within and between group comparisons for successful performance of the SFE and each of the five criteria were analyzed.
Results: All groups demonstrated an increase in successful performance of the SFE at post-testing. A Kruskall-Wallis test determined the difference in number of criteria met within each group from pre- to post-test, and found Group 2 had the highest mean rank. A McNemar test (p<0.05) found only Group 1 demonstrated significant changes in the numbers of participants who were able to successfully perform the SFE from pre-test to post-test. Criteria 2 and 3 were observed to be the most difficult to complete between the groups. Group 2 demonstrated the greatest ability to complete criteria 2.
Discussion/Conclusion: Practice appeared to be important in mastering the 5 criteria for successful performance of the SFE. Cueing may have potential to impact performance of the SFE because Group 2 was the most successful group at post-test, and also demonstrated the greatest ability to complete criteria 2. Because limiting tibialis anterior activation was observed to be the most difficult to complete between all groups, future cueing efforts may focus on methods to reduce tibialis activity during the performance of the SFE.
Clinical Relevance: Cueing may aid in learning of specific criteria in completion of the SFE. Clinicians may utilize the SFE in tandem with cues effectively in a young, healthy population.