Poster Hall: Abstracts & Authors

The following posters were selected for inclusion in this year’s poster hall and you may earn additional CE by reviewing the information presented and answering the questions that follow each poster. You may also ask additional questions of the poster authors by email, using the address provided.

EARN CE: Posters are presented as PDFs. You must complete at least 4 poster quizzes successfully in order to earn 1 hour of CE credit. A maximum of 5 hours of CE may be awarded by successfully completing all 20 poster quizzes. These hours count as self-study for PT or PTA license renewal.

To submit your quiz answers for CE, follow this link and transfer your poster quiz answers to the submission form, where it will be scored and the CE credit will be awarded in your personal profile. Please note that you will be asked to sign in to the IPTA website in order to complete the poster quiz and be awarded CE.
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The deadline for Poster hall quiz submissions has been extended to March 31st. After March 31st, no more quiz submissions will be accepted. Don’t miss out on this opportunity to learn about these awesome research projects and earn CE!


1. The Effect of Robotic Assisted Gait Training for Children with Neuromotor Disorders in a Clinical Setting: A Case Series 

Ann Flanagan, PT, PCS; Shubhra Mukherjee, MD, FRCPC; Michelle Urban, PT, MHS, WCC; Kathleen Sweeney, PT, DPT; Brittany Prero, PT, DPT; Nicole Viverito, PT, DPT 

Description: Children with neuromotor disorders such as cerebral palsy, spinal cord dysfunction, and developmental delay often demonstrate impairments in posture, strength, selective control and the ability to walk efficiently. Therapy management of children with neuromotor disorders typically focuses on improving functional abilities, gait, health-related quality of life (HRQOL), participation and enhancing independence. One of the newer tools available is robotic assisted gait training (RAGT). RAGT utilizes partial bodyweight support treadmill training and a robotic exoskeleton to help improve gait and endurance by allowing a large number of partially assisted steps during a given treatment session. Robotics can help deliver highly intense and repeatable training but is often used in research and less often as a clinical tool.

Objective: The primary objective of this case series was to describe how RAGT was integrated into the physical therapy management of children with neuromotor disorders. Additionally, this study evaluated individual changes in measures of body structure/function, activity, and HRQOL after a series of RAGT sessions.

Methods: Four patients, Gross Motor Function Classification Scale (GMFCS) II-III (1F/3M, average age 11.5±1.7 years) with a variety of neuromotor disorders participated in a minimum of nine RAGT sessions in outpatient PT (Table 1). The ReoAmbulator robotic system (Motorika, Ltd., Mount Laurel, NJ, USA) was used along with virtual games built into the system for maximum child engagement. Daily robotic ambulation logs were completed for each therapy session. The following typical clinical outcome measures were used prior to and immediately following RAGT: lower extremity range of motion (LE ROM), lower extremity manual muscle test using PowerTrackII™ Commander hand held dynamometer with the average of 3 trials using a “make test”, Gross Motor Function Measure (GMFM) dimensions D (stand) and E (walk/run/jump), 6 minute walk test (6MWT), Functional Mobility Scale (FMS), and Gait Outcomes Assessment List (GOAL) parent report.

Results: Primary objective results demonstrated 20-60 minutes training sessions with actual stepping time on the device of 15-33 minutes per session (Table 2). Speeds increased and required body weight support decreased throughout the trials. Total mileage over the encounter ranged from 1.7-20.5 miles while average miles per session ranged from 0.2-0.9 miles. Secondary objective results for body structure/function revealed mild improvements in LE ROM for hip and knee extension for one subject and mild to moderate improvements in popliteal angle for all subjects. With training we expected an improvement in lower extremity extensor muscle strength and found mild improvements in hip extensors for 75% and knee extensors for 50% of subjects. Activity level outcomes using the FMS showed that one patient decreased the need for an assistive device at the 50 meter level post-therapy. Improvement on the 6MWT in the range for or exceeding published minimum clinically important differences (MCID) was seen for 50% of the patients. Change scores for the GMFM dimension D and E exceeded were in the range for or exceeded MCIDs for 75% of the subjects. Results of parent-reported HRQOL outcomes revealed improvements in total scores for all subjects with variable increases in many of the individual dimensions.

Discussion: This study demonstrated that the primary objective of integrating RAGT into the clinical management of children with a variety of neuromotor disorders was possible. Daily RAGT sessions needed to fit into a typical 60-minute PT time slot utilizing a variety of training time frames that included weekly and intensives depending on the ability of the child/family to participate. Total minutes walking per session was lower than expected but additional time was needed for set up and take down as well as monitoring of fatigue, effort and engagement of the child. The mileage and speed recorded during RAGT was greater than what would be expected in a typical session gait training with a child on land. Reviewing secondary objectives, we were able to see mild improvements in body structure/function with larger improvements in activity and HRQOL. Parameters were shown to improve after a minimum of nine sessions of RAGT but standardized protocols were not able to be developed as each session needed to be individualized to the child’s fatigue, motivation and ability level. Anecdotally, children and caregivers reported positive findings of feeling looser with a reduction in LE tone after the sessions and the ability to walk with greater endurance, confidence and balance. Issues encountered during the series included mechanical problems with the device with difficulty getting help from overseas vendors due to travel restrictions, limited ability to recruit subjects for several months due to Covid, and difficulty getting children to return for 6 month follow up with only 50% returning for follow up at this point. Balance, tone and quality of ambulation were not assessed as part of this case series but should be expanded upon in larger future studies as well as the impact of dosage on the short- and long-term outcomes.

Conclusion: This study established that RAGT is feasible in a clinical setting and provides short term benefits for children with neuromotor disorders in body structure and function but more importantly in activity level and HRQOL. While there were technical and time management difficulties in a clinical setting, RAGT did provide a means of intensive gait training that was tolerated well by a variety of children who ambulated with or without assistive devices.

Table 1: Demographics of the participants
Table 2: Summary of treatment logs
Table 3. Summary of outcomes pre- and post-therapy and change scores 

Poster #1:  The Effect of Robotic Assisted Gait Training for Children with Neuromotor Disorders in a Clinical Setting: A Case Series 

  1. Which statement is true regarding robotic assisted gait training (RAGT)?
    1. RAGT uses a robot to lift and transfer the child into a walker
    2. RAGT is only used in research
    3. RAGT uses partial bodyweight support treadmill training and a robotic exoskeleton
    4. RAGT can only be used for adult patients
  2. Outcomes of robotic assisted gait training can demonstrate short-term positive results in body structure and function, activity, and health related quality of life
    1. True
    2. False
  3. Which statement is false related to this study?
    1. This study was able to provide a standardized protocol and dosage for all future patients
    2. This study demonstrated that it is feasible to provide RAGT in a clinical setting
    3. This study was able to quantify total average mileage and peak speed for each subject
    4. This study was able to demonstrate improvement in health related quality of life gait & mobility and total scores for all subjects.

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2. Impact of High Intensity Interval Training on Community Reentry in an Individual Post Stroke: A Single-Subject Design Study 

Savannah Beetcher, SPT; Sydney Lazzell, SPT; Austin Lieberman, SPT; Christian Evans, PT, PhD; Janet Helminski, PT, PhD 

Introduction: Stroke is a leading cause of long-term disability. Gait abnormalities occur in more than 80% of stroke survivors and are associated with falls. Improving gait speed and returning to community mobility and activities is often an important goal for stroke survivors. Walking endurance relates to community reintegration in individuals post stroke. Task specific training to improve walking ability has been recommended and may include treadmill training or intensive practice of a wide range of mobility tasks. The Academy of Neurologic Physical Therapy strongly recommends high intensity interval training (HIIT) to increase mobility, walking speed and endurance in individuals with chronic stroke. However, no studies have determined the effectiveness of HIIT walking on a treadmill on increasing community reentry and participation. The purpose of this single subject-design study was to examine the effectiveness of HIIT walking on a treadmill on improving community reentry and participation for an individual with chronic stroke.

Methods: This single subject A, B, A’ study design was approved by the Midwestern University Institutional Review Board and the subject provided written, informed consent. We identified one subject with the ability to ambulate within the community with no greater than minimal assistance. The design was 2 weeks of pre-training phase (A, collection of baseline data), followed by 12 sessions over 5 weeks of 30 minute HIIT sessions (B), followed by 5 weeks of post-training phase (A’, collection of follow up data). The participant performed HIIT walking on a treadmill with a mobile, overhead harness system (LiteGait®Mobility Research), and was monitored with mobile 2-lead ECG (Checkme™ Wellue) and Borg scale perceived rate of exertion for safety and intensity. The HIIT session included 8, 30-second intervals of walking at 70-80% of age-predicted maximum heart rate (adjusted for the use of beta blocker) at 8-11% grade with one minute of recovery walking between each interval. The Pacer (Pacer Health, Inc.) and Garmin apps tracked distance walked and steps taken with daily routine, and number and location of trips taken daily.

Results: A 62-year-old male 5 years status post left cerebral vascular accident completed the protocol. At baseline, he required minimal assistance with community ambulation with a cane. Based on heart rate (HR) response and perceived rate of exertion, he met the criteria for HIIT, performing work between 65-85% of maximum HR. Gait speed, endurance and balance were measured via 10M walk test, 6-minute walk test, and Berg Balance Scale. All measures improved following HIIT, exceeding the established minimally clinical important difference when baseline was compared to 5-weeks post HIIT. From baseline through the HIIT protocol, participant increased average steps per day by 634 steps. The number of trips taken in the last week of Phase A, B, and A’ were 25, 19 and 21 trips, respectively. The patient reported improvements in walking endurance, but no changes in stability or adaptability such as walking on uneven ground or curbs .

Conclusion: The HIIT protocol was well-tolerated and resulted in improvements in walking speed, endurance, and balance scores. Improvements from task specific HIIT walking on treadmill did not translate into significant improvements in community reentry and participation which require stability and adaptability. A combination of HIIT and task specific functional mobility practice may have resulted in better carry-over into community reentry for this patient. 

Poster #2:  Impact of High Intensity Interval Training on Community Reentry in an Individual Post Stroke: A Single-Subject Design Study 

  1. High intensity interval training (HIIT) has been found to be effective for improving which aspects of mobility, function, or health for people recovering from stroke?
    1. walking speed
    2. step length
    3. endurance
    4. all of the above
  2. What percentage of the heart rate max is typically required during the high intensity intervals for training to be considered HIIT for people recovering from a stroke (this was the target HR used in the current study)?
    1. 40-60%
    2. 50-70%
    3. 65-80%
    4. 95-100%
  3. Which statement is true regarding the results of this study?
    1. While the subject traveled to more target locations during and after HIIT compared to baseline, he reported no improvement in navigating curbs and uneven surfaces.
    2. HIIT resulted in significant improvement in target visits and trips into the community as well as subjective reports of improved abilities in walking on stairs, curbs and uneven surfaces.
    3. HIIT had no effect on any aspect of function or mobility other than improved endurance.   

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3. The iWalk 2.0 Hands Free Crutch: Comparison to Normal Gait Pattern and Functional Use for Individuals with Lower Extremity Injuries 

Alyssa Fijalkowski, SPT; Allison Freehill, SPT; Luke Gentile, SPT; Andrea Rossi, SPT; Stacie Bertram, PT, PhD

Background/Purpose: Limited research has been conducted on a new assistive device called the iWalk 2.0, a hands-free leg crutch, that allows a similar gait pattern as unassisted ambulation and reduced use of the upper extremities. Current research has shown the iWalk to provide the patient with decreased hospital stay, perform ambulation with greater energy efficiency, lower levels of dyspnea, fatigue scores, and pre and post activity heart rate.1,2,3,4 Subjects from other research studies also reported the iWalk as more comfortable and affordable than the axillary crutches.

The purpose of this feasibility study was to compare how the iWalk hands-free leg crutch alters an individual’s normal gait pattern in terms of energy expenditure, ambulation time, and balance compared to gait without an assistive device to direct future data collection and study methodology.

Design and Methods: Ten healthy adults without any current musculoskeletal impairment between the ages of 22-30 participated in this feasibility study. The subjects completed the following functional tests: the 10 Meter Walk test, the Functional Reach test and the Timed Up and Go test with and without the iWalk leg crutch. Results: On average participants walked 3.36 (43%) seconds slower on the 10 meter walk test while wearing the iWalk. A paired samples t-test showed this increase to be significant (t (9) = – 9.416, p<.001). Their functional reach was 3.22 (19%) inches less, (t (9) = 2.914, p=.017) and their Timed Up and Go was 4.5 (46%) seconds slower (t(9) = -10.93, p=<.001) while wearing the iWalk. Average rating by the participants on difficulty of use was 3.4/5, stability during gait was 2.5/5, and 3.3/5 for comfort of use while wearing the iWalk 2.0.

Limitations: Some individuals in our study may have had previous experience with assistive mobility devices. This feasibility study with 10 participants was conducted during COVID-19 restrictions. There are plans to conduct a fully realized version of this study in the future. Results can only be generalized to our sample, and serve to direct data collection in future studies.

Discussion/Conclusion: Preliminary results are consistent with previous research showing differences in functional ambulation between individuals wearing the iWalk and those walking unencumbered by a device. Additional research could include comparing an individual’s gait pattern when wearing an iWalk compared to another assistive device such as the axillary crutches or wheeled walker and include data such as step length, step width, and stride time in addition to our current parameters when comparing the two gait patterns with different assistive devices. 

Poster #3:  The iWalk 2.0 Hands Free Crutch: Comparison to Normal Gait Pattern and Functional Use for Individuals with Lower Extremity Injuries 

  1. What type of injuries are indicated for use of an iWalk?
    1. Acetabulum fracture
    2. Femur fracture
    3. Tibial head fracture
    4. Navicular fracture
  2.  How much slower (percentage) was gait with the iWalk than gait without an assistive device?
    1. 16%
    2. 25%
    3. 43%
    4. 58%
  3. From previous research, how does the iWalk compare in comfort to axillary crutches?
    1. iWalk is reported to be more comfortable than crutches
    2. iWalk is reported to be less comfortable than crutches
    3. iWalk is comparably the same to crutches
    4. There is no research on this

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4. Reliability of Tandem Gait as an Outcome Measure in Healthy Participants 

Andrew J Strubhar, PT, PhD; Casey Brunton, SPT; Megan Leguillon, SPT; Anna Wong, DPT; Andrew Knight, DPT; Bradley University Study

Purpose and Background: Tandem gait is often used as a variable in outcome tools to test an individual’s balance; however, it is rarely performed as a stand-alone test. Tandem gait is more challenging than normal gait, so this may expose more balance deficits rather than just testing speed, step/stride length, and distance of normal gait. Previous studies have found that gait speed in tandem gait to be a reliable measure. Most studies did not consider the amount of trunk movement that is a common characteristic during tandem walking. The purpose of this study was to explore whether variables of tandem gait (speed, lean, and sway) measured with VirtuSense® (VirtuSense Technologies, Peoria, IL) are reliable outcome measures based on data from healthy individuals. The VirtuSense has been shown to be a reliable and valid measure of gait and has the capacity to measure trunk lean and sway. We hypothesized that measures of normal gait and tandem gait would not change in a 10-week period with healthy unimpaired young adults.

Participants: Thirty healthy individuals, average age 23.5 years old from a Midwestern DPT program were recruited to participate.

Method: Before and after a 10-week period, participants were asked to walk 12 feet twice in their normal gait pattern, and twice in a tandem gait pattern. Participants were instructed to walk heel to toe on a 2″ (5.08 cm) wide piece of tape for tandem trials. The objective of the tandem gait pattern was to have the participant remain on the line. Data recorded through the VirtuSense in both tasks included gait speed, postural sway, and trunk lean. The Virtusense® defined lean as movement forward and backward from the base of support and sway as movement of the hips left and right.

Results: A paired sample t-test of pre and post normal gait speed (t = -1.07, p = 0.29), lean (t = 0.10, p = 0.92) and sway (t = 1.07, p = 0.29) showed no significant difference and low effect sizes between pre and post 10-week measures. (Means – pre gait speed [m/sec] 1.17 – post gait speed 1.20; pre lean [degrees] 2.30 – post lean 2.40; pre sway [cm] 2.32 – post sway 2.00). A paired sample t-test of pre and post tandem gait speed (t = -3.00, p = 0.005), lean (t = -2.88, p = 0.007) and sway (t = 4.60, p < 0.001) showed a significant difference and high effect sizes between pre and post measures. (Means – pre gait speed [m/sec] 0.39 – post gait speed 0.52; pre lean [degrees] 7.73 – post lean 6.81; pre sway [cm] 8.57 – post sway 5.78). The results suggest that tandem gait speed, lean, and sway are not reliable or stable measures over a 10 week period in this experiment. A post hoc analysis was done since the instability of tandem gait speed was somewhat surprising. A stepwise regression analysis was performed for normal and tandem walking speed with both step length and sway contributing to the regression. Lean did not contribute. The adjusted R2 for sway and step length were .59 and .77 respectively for normal and tandem gait speed. Since step length is an obvious contributor to speed the variance of the sway when in tandem could be a contributor to the unreliable speed.

Conclusion: Speed, sway, and lean did not prove to be reliable variables for the tandem gait. The directions to stay on the line may have impacted what the individual did to accomplish the task. When told to stay on the line, upper body sway may have been used to correct balance and is seen to be inconsistent over time. A more appropriate variable for the task given would be the number of errors (stepping off the line) rather than speed, sway, and lean. All the tandem measures indicated the participants were slightly more proficient on the post-test, so a slight learning effect could have been at play. Ways to improve tandem testing would be to state that the participant should go as fast as they can and stay on the line. Additionally, further research might consider low beam walking so that there is a greater challenge and is a more obvious error. Reliability for tandem walking as an outcome measure could also be done in the neurologically impaired population. 

Poster #4:  Reliability of Tandem Gait as an Outcome Measure in Healthy Participants 

  1. In this study all the following tandem and normal gait variables were measured with the VirtuSense EXCEPT:
    1. Speed
    2. Lean
    3. Sway
    4. Error
  2. What was the main finding of this study:
    1. Normal and Tandem gait can both be reliably measured with speed, lean and sway
    2. Normal gait cannot be reliably measured with the VirtuSense
    3. Tandem gait is not reliably measured by speed, lean, and sway
    4. Tandem gait is reliably measured by speed, lean and sway
  3. The inconsistency over time in Tandem gait speed was somewhat surprising, In the Post Hoc analysis, what variable might have had the greatest impact on Tandem speed?
    1. The amount of sway
    2. The amount of lean
    3. The width of the tape
    4. The number of steps taken

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5. The Effect of Overhead Support System on Reactive Stepping Behavior in Older Adults 

Jack Turk, SPT; Kristen Satala, SPT, LAT, ATC; Favio Nunez, SPT; Joe Krzak, PT, PhD; Janet Helminski, PT, PhD 

Problem/Background: Reactive stepping is an example of an automatic response to maintain balance and prevent a fall. When eliciting reactive stepping in a clinical environment, therapists often use equipment such as gait belts and/or overhead harness systems to ensure patient safety. However, it is unknown whether these safety mechanisms alter the characteristics of the stepping response. The purpose of this case series of 3 older adults was to describe the differences in stepping parameters during a clinical assessment of reactive stepping performed while individuals were either in a mobile overhead harness system or supported by a physical therapist using a gait belt.

Methods: Three healthy female community ambulators (age range: 59-64 years) were tested. Flexibility, strength, fall risk, community ambulation, and balance confidence were assessed. Protective steps were randomly evoked in the anterior, lateral, and posterior directions while supported by a physical therapist with a gait belt or in a mobile overhead harness system (LiteGait®, Mobility Research). Steps were evoked using the mini-BESTest (Balance Evaluation Systems Test© 2005-2012) compensatory stepping correction method. A total of twelve trials were performed (4 trials in each direction, 2 support conditions). The number of reactive steps; first step length, height, latency, and duration; as well as behavioral responses (e.g. reaching for upper extremity support) were determined. Footprint and video analysis (Dartfish™) were used. To describe differences in stepping parameters across support conditions, trials were averaged, and paired t-tests were calculated for each individual (α = 0.05).

Results: The AVE number of steps per trial and the percent of trials performed that required 1 step for participant 1, 2, and 3 was 1.2 (83%), 2.4 (33%) and 1.5 (67%). Participants 1 and 3 did not use an upper extremity protective response. When perturbed posteriorly, participant 2 grabbed for the examiner’s arms or harness system and pivoted towards the wall located on the right side. Participant 1 had no significant changes between use of the harness system and physical therapy/gait belt. Participant 2 had significant increase in anterior step length (p=0.027), increase in left step length (p=0.036), and reduced posterior step height (p=0.046) with use of overhead harness system. Participant 3 showed significant decrease in forward step length (p=0.033), decrease forward step height (p=0.006), decreased forward latency (p=0.023), and increased left step duration (p=0.019) with use of overhead harness system.

Conclusion/Implications: This preliminary study suggests that reactive balance reactions may be result in reduced step height and increase step length with assistance from a mobile overhead harness system versus physical therapist/gait belt. Individuals at risk for falls need to be tested to identify consistent differences between the two methods. 

Poster #5:  The Effect of Overhead Support System on Reactive Stepping Behavior in Older Adults 

  1. When evoking a protective stepping response, how are the first step parameters modified by an overhead harness system?
    1. Increase step height.
    2. Reduce step height.
    3. Increase latency of response.
    4. Reduce latency of response.
  2. In this study, which of the following environmental factors influenced the protective stepping response?
    1. Location of chair relative to harness system.
    2. Location of mirror relative to harness system.
    3. Location of wall relative to harness system.
  3. Which of the following statements is true?
    1. Individuals grabbed the harness straps for support.
    2. Individuals lowered themselves into the harness system for support.
    3. 30% of body weight was supported by the harness system.

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6. Vestibulotoxicity in Cancer Survivors: Identification and Treatment

Mary Jesse, PT, DHS, Board-Certified Specialist in Oncologic Physical Therapy, Board-Certified Specialist in Orthopedic Physical Therapy 

Description:  The number of cancer survivors in the United States has shown a steady increase in recent years. In 2019, there were an estimated 16.9 million cancer survivors in the United States; this number is expected to increase to 22.2 million by 2030 (31.3% increase).1 Approximately 39.5% of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2015-2017 data).1 This is related to two phenomena: 1) improvement in cancer survival rates due to early detection and improvement in cancer treatment, and, 2) the aging population.2 The impact of the disease and/or treatment along with an increased life expectancy may have an unwanted result of an increased fall risk.3,4,5
One factor that may affect balance in the oncology population is vestibulotoxicity.6,7,8,9 Vestibulotoxicity is imbalance caused by drug-induced damage to the vestibular system. Different drugs/medications have been identified as causes, including chemotherapy agents.6,7,9 Specifically, platinum-based chemotherapy agents, like cisplatin are noted to have long-term retention in the cochlea.6,7 Since the auditory and vestibular organs of the inner ear share blood, nerve, and fluid sources, both hearing and balance issues could present.6,7,9 In a scoping review performed by Prayuenyong6, the rate of occurrence of an abnormal vestibular function test after chemotherapy administration ranged from 0 to 50%.6 Results may vary by lack of recognition of signs and symptoms, either from underreporting or compensation by vision and proprioception, as well as attributing balance issues to other medications or to medical issues of dehydration, chronic fatigue, and/or anemia.6
This poster is designed to describe the patient population that might be affected by vestibulotoxicity related to chemotherapy as well as when this might occur in the course of their survivorship. As all physical therapists may be in a position to treat cancer survivors as lifespans continue to increase, awareness of this information may help better serve clients presenting with multiple diagnoses. Also presented will be diagnostic and treatment options for these patients. 

Poster #6:  Vestibulotoxicity in Cancer Survivors: Identification and Treatment

  1.  The clinical presentation of vestibulotoxicity may include:
    1. Positional vertigo
    2. Dizziness
    3. Unsteadiness
    4. All of the above
  2.  Vestibulotoxicity may be caused by drugs including:
    1. Cisplatin
    2. Carboplatin
    3. Gentamicin
    4. All of the above
  3. Vestibulotoxicity may be masked by other side effects of chemotherapy including:
    1. Deconditioned state
    2. Chronic fatigue
    3. Neuropathy
    4. All of the above

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7. Inter-device Reliability of Musculoskeletal Ultrasound Imaging: Hand-held versus Established Unit in Measuring Lumbar Multifidus Contraction 

Teresa Elliott-Burke, PT, DPT, MHS, WCS, PRPC; Thomas Dillon, PT, DPT, OCS; Jasmin Bailey, SPT; Rachel Joos, SPT; Shannon Miller, SPT 

Purpose/Hypothesis: The purpose of this study is to determine inter-device reliability of ultrasound imaging (USI) by comparing a handheld device (Butterfly IQ) to an established unit (Sonosite) when measuring the lumbar multifidus muscle (LMM) contraction. We hypothesized a difference in measurement accuracy between devices. USI can be utilized in the physical therapy setting to assess voluntary contraction of deep musculature like the LMM. Established units, such as the Sonosite, may not be utilized in physical therapy clinics due to high cost and space restrictions. There is limited research on the reliability of smaller, less expensive, handheld USI equipment in comparison to traditional units. This study investigated two types of USI devices measuring a voluntary LMM contraction to determine if there is a difference in muscle thickness.

Subjects: 42 subjects including healthy males and females with a mean age 38.5 years. Inclusion criteria included no current back pain or dysfunction and being capable of laying prone for at least 10 minutes.

Materials and Methods: This experimental study was approved by Midwestern University’s (MWU) IRB and data collection was conducted at the MWU Multispecialty Clinic in Downers Grove, IL. Participants were provided with brief instructions on how to contract the LMM. Participants laid prone on a plinth with a pillow underneath the abdomen. A LMM thickness measurement was recorded at rest with each device at the level of the L4 spinous process. Next, the participant was verbally cued to contract the LMM while an image was obtained with each device. The researcher operating the USI device was blinded to the thickness measurement value which was recorded by a second researcher. This process was completed for a total of three contractions for each participant. All measurements were obtained by a single novice user, student physical therapist, with limited training.

Results: Intraclass correlation coefficient (ICC) was calculated to determine statistical significance in inter-device and intra-rater reliability. Inter-device ICC was 0.778 (95% CI: 0.68- 0.84). ICC values between 0.75 – 0.9 indicate good reliability, suggesting that inter-device reliability between Butterfly IQ and Sonosite was good. For intra-rater reliability, the Butterfly IQ ICC was 0.755 (95% CI: 0.646 – 0.845) and the Sonosite ICC equaled 0.839 (95% CI: 0.759 – 0.901). These values indicate good intra-rater reliability for each device.

Conclusions/Clinical Relevance: Based on the results of this study, a handheld USI unit is comparable to a traditional USI unit. The Butterfly IQ is practical for use in a PT clinic for measuring muscle thickness changes considering there is a $33,000 difference between units. Additionally, a novice user, student physical therapist can reliably use USI. Incorporating USI into a Doctor of Physical Therapy program is feasible and beneficial. 

Poster #7:  Inter-device Reliability of Musculoskeletal Ultrasound Imaging: Hand-held versus Established Unit in Measuring Lumbar Multifidus Contraction 

  1.  In this study, at what level is the lumbar multifidus measured at?
    1. L5
    2. L4
    3. L3
    4. L2
  2. The inter-device reliability between the establish unit and the handheld unit when measuring the lumbar multifidus contraction with ultrasound imaging was:
    1. Poor-Fair
    2. Fair-Good
    3. Good-Excellent
  3. The intra-rater reliability of measuring the lumbar multifidus with the handheld ultrasound imaging unit was:
    1. Poor-Fair
    2. Fair-Good
    3. Good-Excellent

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8. Outpatient Physical Therapy for an Older Adult with Parkinson Disease and Potential Psychogenic Parkinsonism Characteristics 

Kevin Ruff, SPT; Kent E. Irwin, PT, DHS, GCS; Elizabeth Campione, PT, DPT, CLT-LANA 

Background and Significance: Parkinson disease (PD) is a common, complex progressive neurodegenerative condition with motor and non-motor symptoms that lead to an overall decline in function, safety, and independence. Biopsychosocial factors must be considered when implementing a plan of care for individuals with PD due to higher rates of depression and anxiety disorders compared to age-matched peers. The possibility of psychogenic symptoms must be investigated when objective measurement data do not coincide with patient reports. Psychogenic symptoms include features such as a sudden onset of symptoms, non-progressive manifestations of symptoms, and inconsistent movements that disappear when the patient is distracted. This case report describes outpatient physical therapy for an older adult diagnosed with PD, depression, and an anxiety disorder while considering biopsychosocial and psychogenic factors.

Case Description: The patient was a 66-year-old female diagnosed with PD, depression, and an anxiety disorder. The patient’s chief complaints were lateral leaning while in various sitting positions and midline low back pain during sitting to standing transitions. The examination indicated decreased rectus abdominis and bilateral hip extensor strength. The Four Step Square Test (FSST), Backwards Reach Test, Forward Reach Test, Activities Balance Confidence Scale (ABC scale), and 10-meter walk test revealed deficits in dynamic balance, balance confidence, and gait speed that categorized the patient as a high fall risk. Disparities between objective measurement data and patient reports suggestive of psychogenic symptoms included a non-progressive manifestation of symptoms; give-way weakness; controlled falls; intention tremors; inconsistent coordination patterns; and an immediate improvement in symptoms when distracted throughout physical therapy.

Intervention: Initial sessions focused on static and dynamic sitting balance as well as lower extremity and core strengthening activities. These exercises progressed to standing static and dynamic balance exercises and incorporated functional activities relevant to the patient’s daily requirements (e.g., folding laundry, washing dishes, opening cabinets). To address the patient’s biopsychosocial and potential psychogenic Parkinsonism symptoms, the PT utilized the biopsychosocial model of health via individualized treatment, strong verbal and non-verbal communication, and high-quality patient education.

Outcomes: After 4 physical therapy sessions, the patient demonstrated improvements in core strength, sitting balance, and standing dynamic balance. Improvements in the patient’s FSST score (17 seconds to 12.8 seconds [MCD = 4.6 seconds]), ABC scale (41.875% to 45% [MCD = 11-13%]), and gait speed (0.67 m/s to 0.78 m/s [MCD = 0.18 m/s]) indicated positive changes in function. Although these improvements in dynamic balance, ambulation confidence in the community, and gait speed were not large enough to be considered clinically significant, the patient expressed increased confidence in safely ambulating in the community with her trekking poles.

Discussion: This case report demonstrates how the consideration of biopsychosocial factors alongside individualized physical therapy may positively impact the function and social participation of individuals with PD, depression, an anxiety disorder, and potential psychogenic Parkinsonism characteristics. The PT made a strong commitment to listen to, acknowledge, and validate patient questions and concerns throughout physical therapy to solidify a trusting relationship with the patient. Combined with strong verbal and non-verbal communication and high-quality patient education, the PT appropriately addressed the biopsychosocial factors that ultimately resulted in a positive physical therapy experience for the patient. 

Poster #8:  Outpatient Physical Therapy for an Older Adult with Parkinson Disease and Potential Psychogenic Parkinsonism Characteristics 

  1. True or False. Individuals with Parkinson disease (PD) demonstrate higher rates of anxiety and depression than age-matched peers.
    1. True
    2. False
  2. Over the course of treatment, the physical therapist addressed the patient’s biopsychosocial and psychogenic factors by:
    1. Ignoring the patient’s subjective complaints and focusing on the patient’s impairments.
    2. Building trust with the patient, utilizing strong verbal and non-verbal communication, and ensuring high-quality patient education.
    3. Confronting the patient regarding her potential psychogenic symptoms
    4. Referring the patient to a clinical psychologist to confirm the patient’s potential psychogenic symptoms.
  3. Which of the following symptoms did the patient demonstrate that were suggestive of potential psychogenic origin?
    1. Impaired gait speed
    2. Improvement in symptoms with distraction
    3. Poor dynamic balance
    4. Bradykinesia with upper extremity coordination testing

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9. The Effect of Mindfulness on Musculoskeletal Pain and Function: A Case Report 

Paige Dougherty, SPT, ATC; Christine Conroy, PT, DPT, PhD, FNAP 

Background and Purpose: Mindfulness-Based Stress Reduction (MBSR) is a therapeutic tool that is an emerging topic in pain research. It has been used as a method to decrease patient’s pain levels and kinesiophobia in patients with chronic disease and pain. The purpose of this case study is to explore the effect of Mindfulness-Based Stress Reduction on a non-chronic pain patient post-proximal humerus fracture who showed slow progression with standard treatment.

Description: The patient was a 53-year-old woman status post closed fracture of the proximal right humerus resulting from a fall injury sustained at work. Clinical findings upon examination revealed glenohumeral range of motion loss, shoulder muscle strength loss, grip strength loss, and apprehension to movement. MBSR techniques were introduced as an adjunct therapy seven weeks into the plan of care. The intent was to decrease pain levels and apprehension to movement from trauma and improve progress.

Outcomes: By the end of 13 weeks of physical therapy, the patient’s outcomes had subjectively and objectively improved. This allowed her to have better participation in therapy and her home exercise program. The patient achieved all her long-term goals regarding return to work, active motion, and social participation. Functional outcome measures using the DASH and the SPADI showed a 50% improvement after introduction of MBSR.

Discussion: The patient demonstrated improvement through improved body awareness, decreased negative thoughts regarding body perception, decreased perceived pain, and an improvement in fear of movement. The techniques primarily used in this case were body scan, mindful breathing, and mindful movement. Evidence supports these improvements in chronic pain patients. This case showed that these techniques can also be applied to more acute injuries.

Conclusion: The use of MBSR showed to be beneficial to this patient with a proximal humerus fracture diagnosis. 

Poster #9:  The Effect of Mindfulness on Musculoskeletal Pain and Function: A Case Report 

  1. Based on the current available literature on MBSR techniques, what is the most researched population using this treatment technique?
    1. Acute pain patients
    2. Patients with lumbar degenerative diseases
    3. Chronic pain patients
  2. After the introduction of MBSR, the patient had a greater than 50% decrease in perceived pain during ADLs and other movements.
    1. True
    2. False
  3. Which MBSR techniques were utilized in this study?
    1. Body scan, mindful stretching, object meditation
    2. Body scan, mindful movement, mindful breathing
    3. Mindful movement, mindful stretching, body scan

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10. The Impact of a Pandemic: Influence of Wearing a Mask on Therapist Communication 

Sally Taylor, PT, DPT; Julia Carpenter MA, CCC-SLP; Kristen Collins, SPT; Brian Cua, SPT; Robert Staszak, SPT; David Brewington, PhD; Emily Becker PT, MSPT 

Purpose: Safety precautions established by the Centers for Disease Control and Prevention in response to the COVID -19 pandemic impacted organizational infection prevention policies.1 Subsequently the Shirley Ryan AbilityLab adopted a universal mask wearing policy for all employees. The impact of mask-wearing on provider-patient communication has gained attention, 2-7 yet to date has not been systematically studied. The intention of this study is to provide a better understanding of the impact of provider mask wearing on communication during wheelchair education.

Description: This survey aimed to identify the impact of provider mask wearing during wheelchair education sessions with patients and/or caregivers that occur during standard clinical practice. The survey contained questions regarding perceived impact of mask wearing on communication effectiveness, frequency and types of communication strategies used to repair communication breakdowns, and knowledge/confidence in communication strategies and perceived training needs to improve communication effectiveness.

Sixty-six physical and occupational therapists from inpatient, outpatient, and day rehabilitation participated in a voluntary survey. Experience ranged from less than two to six or more years, with 56.1% reporting six or more years of experience. Wheelchair education expertise ranged from beginner, advanced beginner, competent, proficient and expert, with most rating their expertise as advanced beginner (31.8%).

Results from the survey show that clinicians identified that mask wearing impacted communication at least some of the time as it relates to clarity (80.3%), efficiency (78%), and ability to establish rapport (60.6%). Clinicians reported a variety of strategies to limit communication breakdowns, at least some of the time repeating statements (84.8%), raising their voice (78.8%), increasing patient proximity (78.8%), using nonverbal cues (75.8%), conducting sessions in an alternative location (68.2%) using pictures or video supports (47.0%), and using written communication (40.9%). Clinicians agree that they would like further training in printed resources (68.2%), ways to integrate communication tools (51.5%), nonverbal communication techniques (31.8%), and vocal hygiene strategies (30.3%).

Summary of use: Results from this study indicate clinicians used a variety of communication strategies to reduce communication breakdowns while wearing a mask. Clinicians reported their communication remained effective for wheelchair education activities, though multiple strategies were utilized to minimize the impact. Staff identified additional training and resources necessary to support effective patient-provider communication while wearing a mask. Factors that may impact the results of this study include variations based on level of experience, patient diagnosis, and prior institutional training efforts in communication strategies.

Importance to Members: Leaders can use this information to ensure staff receive appropriate training and resources for effective communication to comply with mask wearing guidelines. 

Poster #10: The Impact of a Pandemic: Influence of Wearing a Mask on Therapist Communication 

  1. Mask wearing impacts which aspect of communication the most?
    1. Clarity
    2. Efficiency
    3. Ability to establish rapport
  2. Which of the following was NOT a communication strategy used by clinicians?
    1. Repeating statements
    2. Using non-verbal cues
    3. Decreasing proximity to patient
  3. Patient diagnosis was considered in the analysis of survey data.
    1. True
    2. False

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11. Perceptions of Physical Therapy Clinicians on the Impact of COVID-19 on a Physical Therapy Patient’s Mental Health 

Brandy Chase, DHSc., PTA; Amy Barnett, Ph.D., LPC, CSP 

Description: Purpose: The purpose of this study was to assess perceptions of physical therapy clinicians regarding the impact of the COVID-19 pandemic on a physical therapy patient’s mental health. Research shows the COVID-19 outbreak can negatively affect a person’s mental health, especially those at a higher risk with debilitating conditions (Javed, Sarwer, Soto & Mashwani, 2020). This study was focused on examining the impact specifically for physical therapy patients in a variety of clinical settings.

Methods: One hundred fifty physical therapy clinicians were sent a survey to complete. A 25-item survey was sent regarding the clinician’s perceptions of the impact of COVID-19 on their patients.

Results: Fifty participants completed the survey during the first round which is a 33.33% return rate. Results revealed that physical therapy clinicians perceived that there was a negative impact on mental health in physical therapy patients who resided in long-term care facilities. Results also revealed a statistically significant relationship between a patients age and mental health impacts during the pandemic according to physical therapy clinician’s perspectives.

Conclusions: The COVID-19 pandemic has had a significant impact on the overall mental health of physical therapy patients, particularly those in long-term care facilities. Clinicians should be educated on identifying the deteriorating mental health of their patients and understanding appropriate ways to intervene or refer for mental health services. 

Poster #11:  Perceptions of Physical Therapy Clinicians on the Impact of COVID-19 on a Physical Therapy Patient’s Mental Health 

  1. What % of clinicians indicated that they had not received any training related to mental health or self-care?
    1. 65.91%
    2. 59.7%
    3. 45.5%
    4. 32.4%
  1. What % of physical therapy clinicians perceived a negative impact on patient’s mental health, particularly those in long-term are facilities?
    1. 25.7%
    2. 63.2%
    3. 75.6%
    4. 44.1%
  1. Clinicians should be better educated on mental health and appropriate ways to intervene.
    1. True
    2. False

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12. Using a Rehab Explorer Program in High School Students to Spark Interest in Physical Therapy as a Career 

Jonathan E. Gallas, PT, PhD, DPT, CSCS; Heather S. Riley, PTA 

Description: A Rehab Explorer Program may be beneficial to high school students interested in the field of Physical Therapy. Holding an in-person, half day course, presented by experienced PTs and PTAs who work with students regularly as Clinical Instructors, as Site Coordinator for Clinical Education, and who are staff of these programs has shown to improve admittance to these programs. Our outpatient clinic, OrthoIllinois, hosts many PT/PTA students for clinical rotations, and we regularly serve as CIs. We have coordinated with local high schools, many of which have clubs or programs for those interested in Health Sciences. During the sessions, attended by approximately 15 students, both of us (PT and PTA) discussed the career, work settings, salary, job outlook, and nature of the profession. We used APTA data and information from several schools as references. At the end of the 45 minute presentation, attendees had ample time for questions. During the second part of the program, students were brought to the PT gym and exposed to exercise equipment, trialed exercises, Ultrasound machines, Estim units, Game Ready machines, traction table, and saw a demonstration of dry needling and IASTM (not performed on attendees.) By exposing these potential PT/PTA students to both sections in an intimate setting, most were fueled with excitement and determination to apply to PT or PTA programs. They also learned the best path to take regarding high school courses, or which areas to focus on, and how to be involved in the community, groups, and how to obtain clinical observation hours or work in a PT clinic for experience. When we reached back out to attendees several months later, most had already been accepted to PT/PTA schools, were planning on applying when the time approached (for the younger students,) or had applied for jobs as PT Aides/Techs for experience. All said they received valuable information regarding the field, and how to best prepare for the intensity of the programs while still in high school, and possibly prevent or decrease failure or dropout rate. We also received feedback from teachers and counselors at the local high schools, saying they were impressed with our program, and have asked us to present to larger groups at the schools when time and space allow. We, as clinicians also enjoy this program, as we feel we are giving back to the profession by encouraging future clinicians. As an organization, we hope to expand time we have with these students. We often have students observe for application guidelines and return for clinical rotations. We often hire our students (25 PT/PTA/OTs thus far.) We intend to continue this program twice yearly, and expand as time and space allow. 

Poster #12: Using a Rehab Explorer Program in High School Students to Spark Interest in Physical Therapy as a Career 

  1. What ages does the Rehab Explorer Program target?
    1. 18-22
    2. 15-20
    3. 13-18
    4. 16-25
  2. How many times does the Rehab Explorer Program take place each year?
    1. 2
    2. 4
    3. 3
    4. 1
  3. What is the goal of the Rehab Explorer Program?
    1. To “spark” interest in students aged 15-20 interested in physical therapy as a career.
    2. Prep students to have all of their prerequisites completed to apply to physical therapist and physical therapist assistant school. therapist assistant school. 
    3. Educate students in the areas in which physical therapists and physical therapist assistants work.
    4. All of the Above

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13. Intrarater Reliability of a Modified Still Photography Procedure for Measuring Habitual Head Deviation from Midline in Infants with Congenital Muscular Torticollis: A Pilot Study

Mary Rahlin, PT, DHS, Board-Certified Clinical Specialist in Pediatric Physical Therapy, Nancy B. Haney, PT, MS; Joyce Barnett, PT 

Background and Purpose: Infants with congenital muscular torticollis (CMT) present with asymmetrical posture that typically includes head lateral flexion to the side of the involved sternocleidomastoid muscle and rotation to the opposite side. Still photography for measuring habitual head deviation from midline is an examination method included in the American Physical Therapy Association Academy of Pediatric Physical Therapy evidence-based Clinical Practice Guideline (CPG) for infants with CMT. The original measurement procedure consisted of positioning an infant supine, taking and printing their photograph, drawing one line through the lateral corners of the eyes and the second line through the acromion processes, and measuring the angle between the lines with a protractor to the nearest degree. An examination of inrarater reliability of this examination method yielded an ICC(3,1) ranging from 0.79 to 0.84. The authors recommended modifications to the measurement procedure designed to improve its accuracy. The purpose of this pilot study was to examine the intrarater reliability of a modified still photography procedure that follows these recommendations prior to its use in a randomized controlled trial (RCT) of two interventions for infants with CMT.

Subjects: Ten infants with CMT, age range 3-6 months, 3 girls and 7 boys, were a sample of convenience recruited from an outpatient department of a large pediatric hospital. The CMT severity grades were 1-3, and 3 of 10 participants had right CMT. Parents signed an informed consent form allowing their infants to participate in this study.

Methods: A total of 60 photographs of 10 infants taken in a supine position were obtained by 2 physical therapists. Each therapist took 3 photos of 5 infants at 2 appointments scheduled 1 month apart (6 photos per child). An assessor measured the photos twice, with the second measurement scheduled at least 1 month after the first. The assessor was blind to the first set of measurements. A modified still photography procedure included the following: 1) The physical therapist attached small band aides to the infant’s acromion processes and used a marker to draw a dot on each band aid to mark the most prominent part of the acromion; 2) The therapist aligned the infant’s pelvis with the trunk manually prior to taking the pictures; 3) Three photos of the infant taken at each appointment were measured, and the average of 3 obtained angles was calculated; 4) The assessor used a mechanical pencil and a clear ruler to draw the lines. The line connecting the acromion processes was drawn through the center dots marked on the band aides. Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (Armonk, NY: IBM Corp.). Intraclass correlation coefficients, ICC(3,1), were calculated to estimate the intrarater reliability of still photography.

Results: Data analysis yielded the ICC(3,1) = 1.00, 95% CI: 0.99-1.00.
Discussion and Conclusion: The ICC(3,1) obtained in this pilot study was very high, and the corresponding confidence interval was very small, indicating good intrarater reliability. Although the sample size was small, it was representative of the infants with CMT typically treated in the outpatient department of a hospital where this examination method was to be used in a RCT. The study results indicated that a modified measurement procedure improved the intrarater reliability of still photography used to measure habitual head deviation from midline in infants with CMT. 

Poster #13: Intrarater Reliability of a Modified Still Photography Procedure for Measuring Habitual Head Deviation from Midline in Infants with Congenital Muscular Torticollis: A Pilot Study

  1. Still photography used with infants with congenital muscular torticollis in this study was a measure of the following:
    1. Active range of motion in the cervical spine
    2. Habitual head deviation from midline
    3. Lateral flexion passive range of motion in the cervical spine
    4. Cervical rotation passive range of motion
  2. The study participants were
    1. Ten infants with congenital muscular torticollis
    2. Seven boys and 3 girls
    3. A sample of convenience
    4. All of the above
  3. Results indicated the following:
    1. The intrarater reliability of still photography was poor
    2. The interrater reliability of still photography was good
    3. The modified still photography procedure improved the intrarater reliability of measurement
    4. The original still photography procedure was superior to the modified procedure used in this study

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14. The Impact of a Positive Therapeutic Alliance and Pain Education as adjuncts to A Moderate Intensity Strengthening Program for an Adult with Multiple Sclerosis and Chronic Pain

Randy Nava, SPT, Sarah Keller PT, DPT, NCS 

Introduction: Multiple Sclerosis (MS) is a chronic inflammatory disease that affects the Central Nervous System (CNS).1 Relapsing Remitting Multiple Sclerosis (RRMS) is the most common type, and typically presents more often in women with an onset between 20-40. It can present as pain, fatigue, burry vision, decreased strength, and/or balance deficits which can have varying levels of impact on a patient’s independence with function and community mobility.1

Case Description: The patient was a 44-year-old female with a 3-year history of chronic pain and RRMS presenting to physical therapy for right hip pain following a fall. Since her diagnosis of RRMS, she reported not being able to participate in IADLs and ADLs due to pain and fear of further progression of her RRMS. Since her diagnosis she did not ambulate in the community without a walker or family member present, she did not drive a car due to fear of fatigue levels, she was not participating in home care or cooking, and has primarily stayed in her apartment due to pain, fear of causing a flare-up, and fatigue. She has also had multiple ER visits and hospitalizations due to her pain levels.

Intervention: Given the patient’s significant history of decreased activity and pain, an emphasis was placed on a multi-modal approach to improve the patient’s understanding of her condition and improve her strength, pain, and mobility. There was a significant effort to understand the patient and the patient’s perception of both her health condition and how therapy could impact her pain, independence, and mobility. This was essential to develop a positive therapeutic alliance. Education on pain, pain neuroscience, and Multiple Sclerosis was provided as the patient had a significant fear that any activity would increase pain and increase her symptoms. In addition to the education component, the therapist focused on feedback within therapy to improve the patient’s belief she could make positive change in her health condition and pain. The physical therapy interventions included moderate intensity strengthening and endurance training to improve strength, endurance, pain, balance, and patient self-efficacy.

Results: Overall, her pain decreased from 9/10 pain in her R hip, R knee, and R foot to 0/10 at the hip and knee and 1/10 in her R foot. Her Timed up and Go decreased from 33 seconds to 6.9 seconds at discharge and she was no longer requiring an assistive device. Her Quad index increased from 70 pounds to 85 pounds on her right side. She reported being able to mop her kitchen floors, walk to the grocery store without her walker, and drive a car for the first time in 3 years.

Discussion: Due to lack of success with her previous therapy episodes, it was important to establish a good rapport with the patient to build a good therapeutic alliance. Ultimately, her goal was to become independent with ADLs and IADLs. In ten visits, she returned to participating in activities she had not done in years.

Conclusion: Multiple Sclerosis is a lifelong disease and can severely limit a person’s ability to be independent in ADLs and IADLs. Prior to this encounter, the patient had significantly decreased her participation in activities due to pain and fear of the impact on her MS. Through education, a good therapeutic alliance, and moderate exercise she began to return to activities she had not done in years. 

Poster #14:  The Impact of a Positive Therapeutic Alliance and Pain Education as adjuncts to A Moderate Intensity Strengthening Program for an Adult with Multiple Sclerosis and Chronic Pain

  1. True or False: RRMS primarily affects men more than women?
    1. True
    2. False
  2. What did the patient present to physical therapy for?
    1. Right hip pain
    2. MS flare up
    3. Weakness
    4. Deconditioning
  3. What was the primary goal of patient education?
    1. The physical complications of Multiple Sclerosis
    2. The progression of Multiple Sclerosis
    3. That movement will not increase symptoms

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15. The Role of Self Efficacy in Balance and Mobility Post-Stroke: A Rapid Evidence Assessment 

Shannon Ryan, SPT; Amanda Cox, SPT; Sarah Keller, PT, DPT, NCS 

 Introduction: Stroke is the largest contributor to adult acquired disability resulting in cognitive and/or physical impairments worldwide. The psychological concept of self-efficacy was developed by Bandura and can be described as an individual’s attitudes and confidence in their physical abilities to complete a task.6 Self-efficacy accounts for the intrinsic factors that influence an individual’s behavior and can impact one’s level of motivation, fear, and desire toward participation in therapeutic and community activities. Balance confidence is directly related to fear of falling, which is critical to note because the incidence of falls poststroke is approximately 73%.1 Overall, it appears that self-efficacy could have a significant impact on patient care thus, the goal of this review is to determine what role self-efficacy has in relation to balance, walking, and community ambulation in the post-stroke population.

Search Strategy: This review adhered to the general principles recommended by the PRIMSA guidelines. After several scoping searches, a full search was completed on June 16, 2021, on 5 databases(Ageline, CINAHL, MEDLINE, MEDLINE COMPLETE, and SportsDiscuss). Search terms were “self-efficacy” OR “self-confidence” OR attitudes OR “patient attitudes”, balance OR mobility, and stroke OR Cerebrovascular N2 (accident* OR stroke) OR CVA. Studies were included if they a) had been published full text b) in English c)published within the last 10 years d) were conducted on human subjects e) had an outcome measure that evaluated pre and post self-efficacy or efficacy f) had an outcome measure of balance or mobility included and g) population was specific to survivors of stroke. Studies were excluded if they a) were a case study or series b) not available in full text c) not available in English d) animal studies or e) researchers did not isolate data for the stroke population.

Quality Appraisal: The methodological quality of the included studies was evaluated independently by two authors and differences were resolved in group discussion with all authors. Cross-sectional studies were evaluated using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the one RCT was evaluated using PEDro scale.

Results: Electronic database search identified 226 articles, once duplicates were removed, 131 unique articles were available for screening. Titles and abstracts were assessed for relevance by the three authors, leaving 29 studies for full text review. Following full text review, 22 articles were determined to meet inclusion and exclusion criteria to be included in this review.

Discussion: This literature review examined the role that self-efficacy has in correlation to improvements in balance, walking, and community ambulation in the post-stroke population. The articles included in this review demonstrated a positive relationship between self-efficacy and variables such as perceived mobility, actual mobility, balance, and community ambulation. The stroke experience is different for each patient, therefore identifying personal factors that can influence motivation, confidence, and perseverance will personalize the rehabilitation process. This will allow the patient to see themself as a stakeholder in the process and help them to understand the impact that their beliefs about their abilities can have on their physical performance. Studies found that time since stroke, number of comorbidities, social support and personal beliefs contribute either positively or negatively to self-efficacy.16,17 Addressing confounding factors such as anxiety, depression and motivation may improve self-efficacy and facilitate the rehabilitation process.16,18 This systematic review had several limitations. First, the level of evidence in the current research is limited to small sample sizes and lack of quality methodological studies thus leading to increase bias and threats to external validity. Second, due to the design of studies included in this review, we could not make causal inferences from the data.

Conclusion: The findings of this review suggest that self-efficacy has a major role in improving balance, walking, activity and participation, and community ambulation in the post-stroke population. Therefore, rehabilitation programs, particularly physical therapy, should include interventions that target improving self-efficacy in the stroke population. 

Poster #15:  The Role of Self Efficacy in Balance and Mobility Post-Stroke: A Rapid Evidence Assessment 

  1. Self-Efficacy can be described as:
    1. The individual’s attitudes/confidence in their physical ability
    2. The individual’s hope towards potential improvement
    3. The individual’s actual ability to maintain balance with activities
  2. A measure of self-efficacy is:
    1. Berg Balance Scale (BBS)
    2. Timed Up and Go (TUG)
    3. Activities Balance Confidence Scale (ABC)
  3. (True/False)  Improving a patient’s confidence can directly impact perceived recovery and participation.
    1. True
    2. False

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16. Effectiveness of Low-Load Blood Flow Restriction Training in a Patient with an Achilles Tendon Rupture: A Case Report 

Jeremey Perales, SPT, CSCS; Christine Conroy, PT, DPT, PhD 

Description:  Introduction/Background: Achilles tendon ruptures are the most common type of tendon rupture, and requires extensive rehabilitation efforts port-injury to address physical impairments and disability. Blood flow restriction (BFR) training is a technique used to improve muscle performance and connective tissue strength under low loading conditions. The purpose of this case report was to evaluate the effectiveness of low-load BFR training in a patient with a non-operative, complete Achilles tendon rupture. Currently, there is not strong evidence for the clinical use after an Achilles tendon rupture.

Case Description: A 32-year-old male recreational soccer player presented to an outpatient physical therapy clinic with a diagnosis of a complete Achilles tendon rupture, with a goal of eventual returning to sport. The patient was treated with manual therapy, gait and balance training, progressive stretching and strengthening exercises, functional activities, and low-load blood flow restriction training. Most evidence supporting the use of BFR training occurs in healthy, non-injured individuals. BFR training was used to enhance muscle and tendon strength and size through metabolic stress mechanisms to enhance traditional physical therapy outcomes.

Outcomes: At the end of twelve weeks of physical therapy, the patient demonstrated improvements in muscle performance, range of motion, and functional activities. Patients goals were primarily measured through administration of FOTO questionnaire outcome measure, which improved from a score of 68 to 80.

Discussion: By the end of week twelve of physical therapy, the patient had objectively and subjectively demonstrated improvements in muscle performance, range of motion, and functional activities, indicating readiness for re-introduction of more intensive functional and sport-specific activities. The patient did experience a minor setback while in the community after week six of rehabilitation, which ultimately did not affect his ability to reach sport-specific activities set in the plan of care at week thirteen.

Conclusion: The use of BFR-training may be beneficial as an adjunct to traditional rehabilitation procedures.  factors such as anxiety, depression and motivation may improve self-efficacy and facilitate the rehabilitation process.16,18 This systematic review had several limitations. First, the level of evidence in the current research is limited to small sample sizes and lack of quality methodological studies thus leading to increase bias and threats to external validity. Second, due to the design of studies included in this review, we could not make causal inferences from the data.

Poster #16: Effectiveness of Low-Load Blood Flow Restriction Training in a Patient with an Achilles Tendon Rupture: A Case Report 

  1. What is one variable most correlated to AT re-injury after an ATR?
    1. Hip Abductor strength
    2. Hamstring flexibility
    3. AT and calf strength
  2. What type of stimulus does BFR provide?
    1. Metabolic stress
    2. Mechanical stress
    3. Eccentric stress
  3. What was the primary purpose of including BFR in this Case Report?
    1. To improve lower extremity endurance and agility to get back to soccer
    2. To increase the size and strength of the AT and calf musculature without significant load
    3. To increase the strength of the entire lower extremity without significant load

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17. Comparison of Patient Demographics and Outcomes Using Clinical Informatics: A Retrospective Study of Patients with a Diagnosis of Upper Quadrant Lymphedema 

Caitlyn Cayemberg, SPT; Haley Gould, SPT; Matthew Hesch, SPT; Kathleen J. Klein, SPT; Deborah K. Anderson, PT, EdD, MS; Elizabeth Campione, PT, DPT, CLT-LANA 

Background and Purpose: Patients with the diagnosis of upper extremity lymphedema are frequently seen in outpatient physical therapy clinics to address upper extremity pain, dysfunction, and/or lymphedema. The unpredictability of prognostic factors for this patient population can be challenging for physical therapists secondary to the variability in clinical research methods and the frequent presence of multiple underlying medical conditions. Clinical informatics is a subset of health informatics that focuses on the application of informatics and information technology to deliver healthcare services. It has the potential to guide clinical decision making, and track patient outcomes and other metrics that enhance the patient care experience. The purposes of this study were 1) to investigate if the clinical informatics on secondary upper quadrant lymphedema (SUQL) gathered from a large national outpatient orthopedic organization are consistent with those reported in the literature, and 2) to explore the relationship, if any, between SUQL and gender, age, body mass index (BMI), pain, psychological risk factors, function, and comorbidities.

Methods: A HIPAA-compliant data set of patients who received physical therapy from a large national outpatient physical therapy company for SUQL was used. Inclusion criteria included: subjects 18 years of age or older with an ICD-9 or ICD-10 code indicating the diagnosis of upper extremity lymphedema. The following variables were analyzed using SPSS 26 for descriptive (means and ranges) and correlation statistics (Pearson’s R): gender; age; BMI; comorbidities; pain: Numeric Pain Rating Scale (NPRS); upper extremity function: QuickDASH (qDASH); University of Pennsylvania Shoulder Score (PENN); and quality of life (QOL): Veterans Rand-12 Physical Component Score (PCS) and Mental Component Score (MCS)

Results: Four hundred and forty-nine (n=442 females; n=7 males) subjects were included in the analysis. Subjects experienced between 0 and 18 comorbidities with a mean of 4.23 + 3.04. Approximately 46% (n=206) had hypertension and 7.1% (n=32) reported smoking. The mean BMI was reported as 29.39 + 6.06, which is classified as overweight/borderline obese. Statistically significant and potentially meaningful clinical correlations (p<0.001) were found between the following variables of interest: initial scores of PCS and qDASH (r=-0.57); initial PCS and PENN(r=0.60); initial qDASH and at rest NPRS (r=0.53); initial qDASH and activity NPRS (r=0.59), initial PENN and at rest NPRS (r=-0.48); initial PENN and activity NPRS (r=-0.62) demonstrating a relationship between pain, function and QOL.

Discussion/Conclusion: Clinical informatics has the potential to provide clinicians with information to guide interventions and improve patient outcomes. The results from this study are consistent with the existing literature that identify overweight/obesity and hypertension as risk factors for the development of lymphedema. In addition, upper extremity lymphedema is associated with decreased upper extremity function and decreased QOL. However, lymphedema is often described as uncomfortable versus painful. The results of this study appear to suggest a medium to strong correlation between pain, upper extremity function, and quality of life in patients with upper extremity lymphedema. Given the complex nature of this patient population additional attention and research should focus on the management of pain and its relationship to function and QOL. 

Poster #17:  Comparison of Patient Demographics and Outcomes Using Clinical Informatics: A Retrospective Study of Patients with a Diagnosis of Upper Quadrant Lymphedema 

  1. Which of the following is a risk factor for developing secondary upper extremity lymphedema?
    1. Overweight/obesity
    2. Patient age
    3. Upper extremity pain
  2. Which patient reported outcome measure was utilized to measure quality of life? 
    1. Veterans Rand-12 Physical Component Score (PCS) and Mental Component Score (MCS)
    2. Short form survey 12 (SF-12)
    3. LYMPH-Q
  3. True or False. Clinical informatics has the potential to improve patient care and clinical decision making.
    1. True
    2. False

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18. The Microbiome of an Outpatient Sports Medicine Physical Therapy Clinic: Factors Contributing to Surface Contamination 

Rabia Alegoz, SPT, Midwestern University, College of Health Sciences, Physical Therapy Program
Kelley Hester, SPT, Midwestern University, College of Health Sciences, Physical Therapy Program
Kayla L. Sierzega, SPT, Midwestern University, College of Health Sciences, Physical Therapy Program
Greer Russell, MS, Midwestern University, Arizona College of Osteopathic Medicine, MS-1
Martin Szul, PhD, Midwestern University, College of Graduate Studies, Immunology and Microbiology
Nathan Hubert, MS, Bioinformatics Contractor
Mae Ciancio, PhD, Midwestern University, College of Graduate Studies, Biomedical Sciences Program
Kristina Martinez-Guryn, RD, PhD, Midwestern University, College of Graduate Studies, Biomedical Sciences Program
Timothy Rylander, PT, EdD, MPT, OCS, CSMT, CBIS, Impact Physical Therapy
Sarah Jensen, PT, MPT, COMT, Impact Physical Therapy
Christian Evans, PT, PhD, Midwestern University, College of Health Sciences, Physical Therapy Program 

Background: The microbiome of outpatient clinics plays an important role in healthcare associated infections. Sports medicine physical therapy clinics (SMPT) have a unique set of factors that likely contribute to contamination such as the need for patients to expose skin to mats and treatment surfaces and the use of manual therapeutic techniques.

Purpose: Examine the microbiome of an outpatient SMPT clinic and determine how contact by therapists and patients, and surface type contribute to contamination.

Methods: This study was approved by the Midwestern University IRB and all subjects agreed to participate. To measure degree of contact, patients and staff at the clinic used hand sanitizer altered by the addition of a fluorescent dye, GloGerm™ on separate days. At the end of each experiment day, surfaces were swiped and residual GloGerm was used as an indicator of contamination. Surfaces were also swiped for bacterial and viral material and DNA and RNA were isolated. Total bacterial DNA was determined using the Femto DNA Quantification™ kit (Zymo Research, Inc.) and sequenced using the MiSeq Illumina system (Argonne National Laboratory). RNA samples were assayed for SARS-CoV-2 using the 2019-nCoV RUO Kit™ (IDT). Bioinformatic analysis included LEfSe, ANOVA and ADONIS to examine differences in microbial make up based on clinic factors. Relationship between factors and contamination were examined by Person or Spearman correlations (p ≤ 0.05).

Results: Surfaces with the highest contact by staff were the balance board, gym ball, and foot board, whereas the highest contact by patients was on handles of the NuStep exercise machine, a resistance cord, and edges of a treatment plinth. The most contaminated surfaces by bacteria were the resistance cord handles (8.97fg), edges of a treatment plinth (12.6fg) and an exercise bench (12.4fg). The bacterial species R. pickettii predominated on surfaces (49.5% of total reads, 14 of 40 sites). Contact by patients significantly correlated with bacterial contamination (r = 0.3549, p = 0.0123) and contact by hand was associated with R. pickettii based on LEfSe analysis. No surfaces were positive for SARS-CoV-2.

Discussion: Findings suggest patient and hand contact play a large role in contamination. A limitation is that presence of bacterial DNA does not necessarily indicate infectivity. Results may help SMPT clinics design more effective cleaning strategies such as use of bleach-based cleaners to eliminate DNA and RNA. 

Poster #18:  The Microbiome of an Outpatient Sports Medicine Physical Therapy Clinic: Factors Contributing to Surface Contamination 

  1. Health-care associated infections (HAI) occur in all settings of care, but which setting is least studied in terms of understanding the microbiome and risk of HAIs?
    1. All inpatient facilities
    2. Hospitals
    3. Outpatient PT clinics
  2. Which surface was one of the most contacted by patients and also one of the most contaminated surfaces by bacteria in the current study?
    1. NuStep
    2. Balance board
    3. Gym ball
    4. Edges of a treatment plinth
  3. Based on the findings of this study, when cleaning an outpatient PT clinic such as this sports medicine facility, cleaning and sanitization efforts should pay particular attention to:
    1. Patient hand contact
    2. Staff/therapist contact
    3. The type of cleaner used
    4. Surfaces contacted by foot

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19. Sex differences in the Chicago Marathon: A Window into The Sampling Bias in Rehabilitation 

Rachel Nesburg, SPT; Azara Mason; Brynn Fitzsimmons; Sandra K. Hunter, Ph.D.

DESCRIPTION: Females participate in athletics, including most major marathons, at a lesser rate than males, particularly among older age groups. Males are ~11% faster than females in marathon running at the elite level, due to sex differences in physiology. This sex difference in performance, however, is often greater than 11% especially in older runners with a lower proportion of females. PURPOSE: To provide insight into the effects of sampling bias of males and females in studies of performance, we determined (1) the participation ratios (numbers of males to females) across a range of age groups in the Chicago Marathon from 1996-2018 and (2) whether the sex difference in performance was predicted by these participation ratios. We hypothesized that the sex difference in marathon running times would be strongly predicted by the ratio of male: female runners among lower placed and older runners.

METHODS: The number of male and female finishers within 10-year age groups (20-79 years) and the running times of the top 10 age group runners who competed in the Chicago marathon (1996-2018) were retrieved from a public database ( Univariate ANOVA and correlation analysis determined differences and associations between the ratios of male: female finishers and the sex difference in velocity.

RESULTS: The ratio of male-to-female runners, inclusive of all ages, decreased linearly from 2.19 in 1996 to 1.15 in 2018 due to a larger increase in female than male runners. In the 20–29-year age category, females outnumbered men from 1999 onward. The ratio of male: female runners increased with older age groups (p<0.001) and the place of the runner (p<0.001). Males were faster than females across all age groups (17.4% ± 0.2%). The sex difference, however, was smallest for 1st placed runners and largest for the 10th placed finishers (14.8 ± 0.5% to 18.5 ± 0.4%). The ratio of the number of male: female runners was correlated with the sex difference in velocity (%) (n=2325, r = 0.53, r2 = 0.28, p<0.001): lower female participation was associated with a larger sex difference in running velocity. The strength of the associations progressively increased between 1st and 10th place, and with older age up to but not including the 70-79-year-old group. The association for 20-29 year olds was r2 = 0.14 (p<0.001, n=440) and 60-69 year olds, r2 = 0.37 (p<0.001, n=406).

CONCLUSION: Males outnumber females in participation in the marathon, especially among the older age groups, and inflate the sex difference in performance above expectations based on physiological differences. This is a form of sampling bias (less female than male subjects) that can be similarly harmful and misleading when evaluating the results of human performance and rehabilitation studies. The prevalence of such sampling bias in rehabilitation studies may provide an inaccurate understanding of the sex differences in response to treatment and rehabilitation. 

Poster #19:  Sex differences in the Chicago Marathon: A Window into The Sampling Bias in Rehabilitation 

  1. What place, between 1-10, was the sex difference in performance the smallest?
    1. 1st
    2. 5th
    3. 10th
    4. None of the above
  2. Lower female participation was associated with a larger sex difference in ______
    1. Strength
    2. Velocity (speed)
    3. Age
    4. BMI
  3. Why is it important to have an even number of male and female participants in a study?
    1. To identify any differences in physiology or treatment between sexes
    2. To prevent sampling bias
    3. To ensure the sex difference is not inflated or misinterpreted
    4. All of the above

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20. Variable Physiological Responses to Acute Intermittent Hypoxia in Healthy Participants: Pilot Study 

Kendall Fosse, SPT, William Lindstrom, SPT, Alison Adaniya, SPT, Benjamin Carter, SPT, Christopher Swen Shaw, SPT, Mark Hoggarth, PT, DPT, PhD, Greg E.P. Pearcey, PhD, CSEP-CEP, Departments of Physical Medicine and Rehabilitation, and Neuroscience, Jennifer Marie Ryan, PT, DPT, MS, Board Certified Cardiovascular and Pulmonary Clinical Specialist, Molly Bright, D.Phil, Assistant Professor of Physical Therapy and Human Movement Sciences and McCormick School of Engineering 

Purpose/Hypothesis: In this work we propose a framework to better understand and observe the physiological effects of acute intermittent hypoxia (AIH), an emerging therapy in neurological rehabilitation. Individual responses to hypoxia interventions are varied and little is known about what physiologic and conscious factors should be considered when delivering hypoxia. We hypothesize that respiratory rate will be predictive of SpO2 response to AIH.

Number of Subjects: 3

Materials and Methods: Healthy participants were given a 30 minute AIH intervention, consisting of 15 alternating bouts of hypoxia (9.5%) and normoxia (20.9%) in 2 minute blocks. During each block, hypoxia was administered for approximately 30 seconds, with the remainder of the time being held at normoxia. During the intervention, SpO2, traces of the cardiac pressure wave, relative respiratory movement, and end- tidal partial pressures of oxygen (PETO2) was continuously monitored. Duration of hypoxia and normoxia bouts, maximum changes between baseline and minimum SpO2 and PETO2, and means and standard deviations of the heart and respiratory rates were calculated for each block. A linear model of the change in SpO2 was created, with participants as factors, and covariates: hypoxia duration, and mean and variability in heart and respiratory rate. Significance was tested using ANOVA with α = 0.05.

Results: A significant regression equation was found (F(7,37) = 2.45, p = 0.036), with an R2 of 0.317. Significant factors that contributed to SpO2 response were hypoxia duration (p=0.031) and mean respiratory rate (0.048). Heart rate variability was nearly significant as well (p=0.065).

Conclusions: While these are preliminary data from an ongoing study, the emerging pattern indicates respiratory rate and heart rate variability as physiological factors that may predict SpO2 response to AIH. Although heart rate variability is not modifiable via conscious effort, respiratory rate is and could be controlled to improve consistency in AIH duration response. Underscoring the need for further study, change in PETO2 was not significantly related to change in SpO2, potentially due to differences in alveolar recruitment between participants. Future work is needed to better characterize the relationship between these physiological measures, duration, and AIH response in a larger sample of healthy participants, and in those with neurological injuries or dysfunction.

Clinical Relevance: AIH is a technique shown to improve visceral and somatic motor function in those with spinal cord injury. This work suggests that paced breathing during AIH may help to improve consistency of SpO2 response between patients. Clinicians utilizing this intervention should be cautious and vigilant of patient physiological response to AIH, and tailor hypoxia duration accordingly until better protocols are developed. 

Poster #20:  Variable Physiological Responses to Acute Intermittent Hypoxia in Healthy Participants: Pilot Study 

  1. Respiratory rate does not appear to effect SpO2 changes during acute intermittent hypoxia.
    1. True
    2. False
  2. The Acute Intermittent Hypoxia in this experiment used which of the following protocols:
    1. 30 minutes of hypoxia then 30 minutes of normoxia for 15 days
    2. 15 2 minute bouts of 25-35 seconds of hypoxia then by 95-75 seconds of normoxia, over 30 minutes
    3. 30 1 minute bouts of 30 seconds hypoxia and 30 seconds of normoxia, over 30 minutes
  3. The level of hypoxia delivered in this intervention was which of the following:
    1. 9.5% O2
    2. 20.9% O2
    3. 35% O2

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