Poster Hall: Abstracts & Authors


Aerobic Exercise for Cancer Survivors Receiving Radiation Therapy: A Systematic Review

Mary Jesse, PT, DHS, OCS

Purpose/Hypothesis: The purpose of this systematic review is to determine the appropriate intensity of an aerobic exercise program for cancer survivors receiving radiation therapy.

Number of Subjects: This is a systematic review of studies that identified 19 studies including 927 subjects.

Materials/Methods: The following databases were searched in May 2018 for articles dated within the last 10 years: PubMed, Ovid, PEDro, CENTRAL. Reference lists of relevant articles were also hand searched. The following search terms were used: cardiotoxicity, radiation therapy, and exercise. Inclusion criteria included studies describing aerobic exercise programs for patients receiving radiation therapy, studies describing both the intensity and duration of the exercise, and studies with outcome measures of aerobic performance.. Articles were excluded if the exercise intervention was not described in terms of intensity and duration, if aerobic performance outcomes were not recorded, or if subjects were not currently receiving radiation therapy. Studies were reviewed for outcomes achieved with
various exercise programs. Quality of studies were assessed using the PEDro scale.

Results: Nineteen articles met the inclusion criteria. In these studies, the aerobic intensity of exercise was measured by heart rate, perceived exertion, or VO2max. Seventeen of the studies used a moderate level intensity for individualized exercise with positive aerobic outcomes. The two studies that used a low to moderate level of individualized exercise listed no exclusions of cardiac conditions in their subjects and reported improved aerobic capacity.

Conclusions: These studies showed exercise as a beneficial way to increase, or limit decline, in aerobic capacity of cancer survivors receiving radiation therapy. Even in patients who warrant a program of low intensity, improvement is possible. Future research on exercise during radiation therapy among patients may be helpful in this population to give clinical guidelines for safe and effective programs in this growing population.

Clinical Relevance: Although radiation is very beneficial in the treatment of cancer, cardiac injury is a risk of treatment. Specifically, groups at high risk for left ventricular dysfunction are those who receive high-dose
radiotherapy and those who receive a combination of low-dose anthracycline and low-dose radiotherapy. The cumulative oxidative stress from chemotherapy and/or radiation treatments and exercise may result in damage to cardiac tissue and affect the intensity of exercise that can be safely tolerated. Exercise is supported early in survivorship, however, due to a quicker increase in antioxidant capacity and decrease in protein oxidative stress than would normally occur over time. Exercise participation at a monitored level in the radiation treatment period has been shown to improve aerobic capacity in this population as well as limit declines related to cancer-related fatigue and other cardiac comorbidities and should therefore be prescribed. Clinicians should be aware of current cardiac status when prescribing exercise programs.

The Effect of Sacroiliac Joint Dysfunction on Dynamic Balance

Thomas Dillon, PT, DPT, OCSTeresa Elliott-Burke, PT, MHS, WCS; Allison Conger, SPT; Morgan Lukert, SPT; Kenarr Matoesian, SPT

Purpose: This study explored the effect of sacroiliac joint (SIJ) dysfunction on dynamic balance by comparing Y-balance test (YBT) performance between individuals with SIJ dysfunction and an age matched healthy control group to determine if SIJ dysfunction is associated with impaired dynamic balance.

Background/Significance: Prevalence of SIJ dysfunction has been reported as 15%-30% of patients with low back pain. It has been suggested that SIJ stability is necessary to maintain balance in all closed chain activities and a previous study suggested that treatment of SIJ dysfunction can improve static balance in athletes. However, there is no previous investigation of the relationship between SIJ dysfunction and dynamic balance. Dynamic balance is required during activities where the body is in motion or changing positions, and many injuries involving the SIJ are during dynamic activities rather than static ones. The YBT has been shown to be an effective measure of functional dynamic balance for a variety of populations. It is a valid and reliable test to determine dynamic balance when ROM and strength of the lower extremities are within functional limits.
Subjects: Twenty-six participants with a mean age of 25.7 years old (range 23 to 42 years) were recruited for this study. Exclusion criteria for both groups were: over 65 years old, younger than 18 years old, lower extremity surgeries within the last 2 years, neurological conditions, arthritic or rheumatologic disorders in the low back or lower extremity, a concussion within the past 3 months, a history of dizziness or vertigo, a body mass index over 30, pregnancy within last year, loss of sensation in feet, taking medications that cause dizziness, vision problems outside of typical glasses/contact wear, and physical therapy treatment in the past 3 months that address low back or lower extremity conditions. Evaluative tests were conducted to determine if a subject was positive or negative for SIJ function, outlined in material and methods sections. Ultimately, there were 15 participants in the control group and 11 participants in the SIJ dysfunction group.

Methods and Materials: 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. The following SIJ evaluative tests were conducted to determine if SIJ dysfunction was present: Fortin fingers test, stork test, active straight leg raise test, and standing flexion test. Participants were included in the SIJ dysfunction group if they were positive on 2 or more of these SIJ special tests. Assessment of pain (via visual analogue scale), strength of knee extensors and hip extensors (via handheld dynamometry), range of motion of ankle dorsiflexion and hip flexion (via goniometry) were performed to rule out confounding variables. Finally, performance on the YBT was measured.

Analyses: The YBT composite scores for both right and left lower extremities were compared between the groups using independent t-tests. Individual composite scores for each direction tested during the YBT (anterior, posteromedial, and posterolateral) for each lower extremity were also compared between groups. Analyses determined if there were statistically significant differences in both individual and total composite scores between groups (p < 0.05). Effect size was calculated using Cohen’s d (small effect = 0.2, medium effect =0.5, large effect = 0.8). Between group t-tests were used to compare pain, strength, and ROM measurements to identify possible confounding variables.

Results: Results showed no statistically significant differences in total composite scores between groups (p > 0.05). Effect sizes however were medium (0.52 and 0.67 for the right and left composite scores respectively). There was a statistically significant difference between individual directional composite scores. Specifically, the left posterolateral direction was worse in the SIJ dysfunction group (p = 0.034) with a large effect size of 0.90. Significant differences were also found for R knee extension strength (p = 0.014) and L hip extension strength (p = 0.016) suggesting that the SIJ dysfunction group was weaker in these directions than the control group.
Conclusions: Results of this study suggest there may be a decrease in dynamic balance performance in individuals with SIJ dysfunction, and the effect sizes indicate that these may be clinical meaningful differences. The difference in right knee extension and left hip extension strength may suggest the SIJ group was weaker compared to the healthy individuals. Further investigation is recommended to determine clinical significance of the influence of SIJ dysfunction on dynamic balance.

Case Study: Short and long-term functional outcomes of scoliosis specific exercises in a patient with adolescent idiopathic scoliosis

Liz Hampton, PT, DPT; Nicole Viverito, PT, DPT; Ann Flanagan, PT, PCS; Kim Hammerberg, MD; Purnendu Gupta, MD; Sahar Hassani, MS

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity that occurs during periods of rapid growth. AIS may result in significant muscle imbalance, postural impairment, pain, breathing limitations, poor body mechanics, and functional limitations. These factors can limit an individual’s community involvement, participation in activities of daily living and negatively impact their mental health and quality of life (QOL). Conservative treatment of AIS includes observation, bracing and exercises. The purpose of scoliosis specific exercises (SSE), based on the works of Katharina Schroth, is to provide an individualized exercise program based upon the classification and presentation of the person’s curvature. The primary objective of this case study was to assess the short and long-term effects on functional outcomes as a result of weekly outpatient physical therapy (PT) utilizing SSE.

Hypothesis: Our hypothesis was that this patient would display improvements in trunk alignment, pain, overall diaphragmatic breathing patterns, and reported QOL at time of outpatient therapy discharge and maintain these improvements one year post outpatient PT.

Subject: A 14 year old female with a history of AIS with a 35 degree right thoracic and 32 degree left thoracolumbar spinal curvature. She wore a TLSO 23 hours per day.

Methods: The patient was evaluated prior to PT, at discharge from PT and one year later. Observational and objective measures included full body strength assessment, range of motion of hamstrings and trunk, standing posture, inclinometer in standing, angle of trunk rotation in sitting, and anthropometrics. Special tests included spiropet for lung capacity, rib cage circumference expansion in standing to assess diaphragmatic breathing, Numeric Pain Rating Scale (NPRS), and Beighton assessment for ligament laxity and joint hypermobility. Functional outcome measures included Scoliosis Research Society 22r (SRS-22r), Spinal Appearance Questionnaire (SAQ), and Revised Oswestry Disability Index. Patient participated in 12 weekly outpatient PT sessions with focus on SSE using verbal, visual, and tactile cues for postural alignment and proper body mechanics during functional mobility skills. A comprehensive home exercise program which was completed 5-7 days a week.

Results: The patient demonstrated improvement on all measured outcomes (Table 1 and 2) Using the NPRS (0-10), the patient initially reported pain ranging from 4-6 out of 10 on a daily basis. At time of discharge, her pain had decreased to 2-3 out of 10 and 1 out of 10 at time of one year follow-up. Using the scoliometer in sitting, the patient’s angle of trunk rotation improved at lumbar level by 2 degrees at time of discharge and by 5 degrees at thoracic level one year post therapy services. Rib cage circumference expansion in standing improved at the xyphoid level by 3 cm and she was able to maintain at time of one year post therapy in regards to diaphragmatic breathing. With use of Spiropet to measure overall lung capacity, patient was able to demonstrate a 367cc improvement at discharge compared to initial evaluation, and a further increase by 150cc at one year follow-up. She demonstrated a 1.0 improvement in the function and pain categories of the SRS-22r, 0.4 improvement in self-image and mental health categories, and 0.71 improvement overall at time of discharge. At time of one year follow-up, patient further improved each category of the SRS-22r increasing the total to 3.86/5.0. She originally reported 44% disability with use of the Revised Oswestry Disability Index and decreased to 18% at time of discharge and was able to maintain one year later. Posturally, she was able to demonstrate decreased bilateral shoulder protraction and internal rotation, achieve neutral head position, decrease right thoracic and left lumbar prominences, decrease anterior pelvic tilt to a more neutral pelvic position, decrease right pelvic elevation and posterior rotation without requiring verbal cues at time of discharge and maintained at one year follow-up (see photos). As noted on routine x-rays, she demonstrated a decreased right thoracic curvature by 1 degree and left lumbar curvature by 8 degrees at time of PT discharge. She was able to maintain the improvements in her curvature at time of her one year follow-up.

Decreased Serum Vitamin D Potential Risk Factor for BPPV: A Systematic Review

Maggie Rehm, SPTJanet O. Helminski, PT, PhD

Purpose: The purpose of this systematic review was to determine if 1) there is an association between serum 25-hydroxyvitamin D (25(0H)D) levels and the diagnosis of benign paroxysmal positional vertigo (BPPV) 2) there is an association between insufficient vitamin D levels and rate of recurrence of BPPV 3) treatment of insufficient vitamin D levels reduces the rate of recurrence of BPPV.

Background/Significance: Fifty percent of patients diagnosed with BPPV will have a recurrence of BPPV within 2 years. Decreased serum vitamin D levels may disrupt resorption of calcium carbonate in otoconia leading to the development of idiopathic BPPV. Evidence suggests low levels of serum 25(0H)D are associated with BPPV and its recurrence and that elevating serum 25(OH)D levels may prevent recurrence of BPPV. The aim of this study is to determine if decreased serum vitamin D is a potential risk factor for BPPV and its recurrence.

Subjects: Four articles met our inclusion criteria.

Methods and Materials: A systematic review was conducted to synthesize the available literature on the association of serum levels of 25(0H)D and BPPV. Data were obtained from an electronic search of the PubMed, CINAHL, and EMBASE from 1966 through July 2018 and the Cochrane Database of Systematic Reviews. The study topics were experimental and non-experimental design; the diagnosis of BPPV based on findings on the DHT; serum levels of 25(0H)D; and recurrence of BPPV (phone interview). Serum levels of 25(0H)D were defined as deficient (<10 ng/mL), insufficient(>10 ng/mL and <20ng/mL), and sufficient (>20ng/mL). Study descriptors, proportions and odd ratios were extracted from each study.

Analysis: Four studies met the inclusion criteria, one quasi-randomized controlled trial and three non-experimental.

Results: Two non-experimental studies reported on the prevalence of deficient and/or insufficient serum levels of 25(OH)D and BPPV. Independent of age, gender, BMI and decreased BMD, the odds in favor of having 25(OH)D deficiency and BPPV compared to community controls was 23(95% CI=6.88-77.05) and 25(OH)D insufficiency was 3.8(1.51-9.38). However, in another study, the odds in favor of having 25(OH)D insufficiency and BPPV compared to hospital controls was 0.6(0.3-1.16). In a non-experimental study, the odds in favor of having recurrent BPPV with vitamin D deficiency (< 10 ng/ml) when compared to vitamin D insufficiency (> 10 ng/ml) was 4.54 (95% CI= 1.41-14.58). The odds of reducing the rate of recurrence of BPPV with elevation of serum 25(OH)D was 0.18(95% CI not reported).

Conclusion: Limited evidence supports an association between the serum level of vitamin D and prevalence of BPPV. Vitamin D deficiency is associated with recurrent BPPV. The effectiveness of Vitamin D supplementation to treat deficiency and reduce recurrent BPPV is preliminary. A randomized control trial to determine if vitamin D supplementation increases the time to and decreases the rate of recurrence of BPPV using survival analysis.

Short-term Outcomes of Scoliosis-Specific Exercise Program: A Combined Clinical and Research Study

Nicole Viverito, PT, DPT; Elizabeth Hamptom, PT, DPT; Ann Flanagan, PT, PCS; Pumendu Gupta, MD; Kim Hammerberg, MD; Sahar Hassani, MS

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine that occurs during periods of rapid growth. Scoliosis can result in significant postural impairment, muscle imbalance, pain, breathing impairment, and functional limitations that can limit a person’s participation in daily activities and negatively impact quality of life. The purpose of scoliosis-specific exercises (SSE) based on the works of C.L. Schroth is to provide individualized exercises to patients with idiopathic scoliosis in order to address the three-dimensional component of the scoliosis to improve postural alignment. Exercises are determined based on the shape of the patient’s curvature as seen on x-ray, the observed trunk deviations and asymmetries, and the patient’s level of strength.

Objective: The primary objective of this pilot study was to assess the physical and functional outcomes as a result of treatment with SSE and to determine an optimal protocol for a future multi-center study.

Methods: Fourteen patients (13F, 1M) with AIS, ages 11-17 years old, with curves ranging from 10-47 degrees, 9 of whom wore a TLSO, and an average Risser score of 2.8±2.2, were treated in outpatient physical therapy with SSE. The following outcome measures were used at the initiation and end of the therapy encounter: Scoliosis Research Society-22r (SRS-22r), Spinal Appearance Questionnaire (SAQ), Revised Oswestry Disability Index, Numeric Pain Rating Scale (NPRS), posture analysis quantified with medical photography, range of motion (ROM), strength, flexibility, anthropometrics, angle of trunk rotation, lung capacity using a Spiropet, and rib cage expansion circumference. X-ray analyses were performed prior to treatment to determine laterality, levels of involvement, Cobb angle, apex, and Schroth curve classification. Patients received outpatient physical therapy once per week for 10-12 weeks or twice a day for one week. All patients received a home exercise program, based on their Schroth curve type. Patients were to choose 3-4 exercises daily from their packet of exercises and perform at least 5 days per week for 20-30 minutes.

Results: Overall, patients demonstrated improvements in outcome measures (Table 1). Post therapy, average reported disability was reduced from moderate to mild, pain scores were lower, SRS-22r scores improved in all functional/self-image/mental health/satisfaction domains, most self-ratings on spinal appearance stayed the same or were mildly improved except for self-image and chest expansion; and lung capacity demonstrated positive gains. Eleven of the 14 patients consistently showed good compliance with their SSE home exercise programs.

Discussion: SSE for youth with AIS is an intense program of motor learning, education, postural self-awareness, flexibility and strength training. There were five additional patients who dropped out of the program because they could not comply with the home exercise demands and attend all the needed therapy sessions. The combined averages of these 14 patients with mild to moderate AIS showed overall gains in all the outcome tools pre and post SSE therapy. The patients reported satisfaction with their care, a better understanding of their diagnosis and treatment, and the majority had good compliance with the regimen of exercises. In addition, the patients demonstrated improvements in the physical exam with improved symmetry in their trunk, improved trunk strength and improved trunk and hamstring flexibility. Several reported a reduction in pain and improved comfort and endurance throughout the school day and during physical activities. Most notably, patients indicated improved participation in P.E. class or sports related activities and in prolonged sitting tolerance throughout the day at school. Additionally, several patients indicated an improved tolerance to prolonged standing and walking. Overall, SSE has been shown in this study to improve pain, postural symmetry, function, and quality of life.

Conclusion: This pilot study has demonstrated that scoliosis-specific exercises over 10-12 sessions along with compliance with a home exercise program can improve outcomes for patients with AIS at least on a short-term basis. Further research is needed to evaluate the long-term results of SSE therapy and a multi-center study with a larger number of subjects is indicated.

Exercise Strategies to Improve Head Position and Function in Persons with Forward Head Posture: A Rapid Evidence Assessment

George Zakharia, SPT; Kathy D. Hall, PT, EdD

Background: Forward head posture (FHP) is defined as chronic, excessive anterior positioning of the head in relation to the centerline of the body. The head accounts for 14% of the overall body weight; its weight, therefore, exerts more force on supporting structures in individuals with FHP compared with those having optimal posture. The resulting strain may lead to pain and disability. Over 60% of patients with neck pain are also reported to have FHP. Multiple forms of exercise have been shown to improve FHP, which may lead to decreased pain and disability. Although it has been established that some forms of exercise can improve FHP, guidelines for specific types of exercise and dosage have not been established. The purpose of this rapid evidence assessment is to synthesize the current literature regarding effective exercise strategies to improve FHP, including exercise modes and exercise parameters.

Methods: Selection of studies was performed by 1 reviewer (GSZ) using multiple databases including CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and SPORTDiscus from 2008 through 2018. Selected studies were checked by a reviewer (KDH) and quality appraisal was conducted using the PEDro scale.

Results: A total of 9 moderate quality studies were included in this rapid evidence assessment (average 6.44 out of 10 on PEDro scale). These studies used strategies that included training for 20-30 min/day, 3 days/week, for 4-8 weeks which led to significant improvements of FHP and pain/disability. Strategies included periscapular strengthening, deep neck flexor strengthening, pectoral stretching, cervical stretching, and posture awareness activities. Strengthening parameters included 3 sets of 10 for each activity, and the total duration of stretching activities ranged from 50-105 sec per muscle group.

Discussion: Although overall significant improvements in FHP and pain/disability have been made with these exercise strategies, limitations from the studies exist and the results must be viewed with caution. Lack of rationales given for the exercise parameters chosen within each study led to the possibility that the parameters were chosen arbitrarily. Although the chosen parameters did lead to significant change, it is possible that the parameters may not have been optimal. The strength of the evidence was only moderate and sample sizes were relatively small within each study. Therefore, further research is warranted to evaluate the effectiveness of specific exercise strategies on FHP and pain/disability.

Conclusion: Periscapular strengthening, deep neck flexor strengthening, pectoral stretching, cervical stretching, and posture awareness activities serve as a safe and effective means to improve FHP and potentially associated symptoms.

Defining Elements of a Therapeutic Alliance for Adults with Brain Injuries during Post-acute Rehabilitation: A Systematic Review of Literature

Paola Solis, SPT; Rebecca Wojcik, PT, EdD, GCS; Maryleen Jones, PT, MPT, CLT, NCS

Background: Among chronic neurological illnesses, brain injuries are reported as the leading cause of death and disability in children and adults with every individual posing the same risk for injury regardless of age, race, gender, socioeconomic background, and educational levels. More than 3.3 million diagnoses of brain injury occur per year with an annual cost to society in excess of $100 billion. Therapeutic alliance (or working alliance) is a term commonly cited in psychotherapy literature as the collaboration between the client/patient and therapist in their efforts to combat the client’s problems. Current literature has reinforced the concept of a positive therapeutic alliance or working alliance correlating with treatment adherence and outcomes in both general medicine and psychotherapy settings; however, there is limited support to describe how the therapeutic alliance and patients’ compliance or awareness develop and interact during the process of post-acute brain injury rehabilitation (PABIR).

Objective: To systematically identify and evaluate studies within the body of literature utilizing the Cochrane guidelines to determine elements and/or factors associated with a therapeutic alliance for adults with brain injuries during post-acute rehabilitation.

Search methods: Databases, including Cochrane Library, PubMed, CINAHL Complete, PEDro, and PsycINFO from January 2006-October 2018, reference list of articles, and distinct papers were searched and yielded a total of 767 titles.

Selection criteria: Retrospective, research, prospective, longitudinal, and case studies of adult patients with brain injuries participating in post-acute rehabilitation programs inclusive of physical therapy services with at least one measure of therapeutic alliance and treatment outcome were selected for this systematic review. Two authors independently reviewed and screened all full-text, eligible studies.

Data collection: One author independently extracted relevant data from each included study into tables. Risk of bias was assessed using ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) tool.

Main results: Six studies involving approximately 1,435 participants were included. Various treatment outcomes were measured, including caregiver and family perceptions and functioning (discord or support), emotional distress, awareness, compliance, disability, functional status at discharge, cognitive functions, and client-therapist interactions. The therapeutic alliance was most often measured with the short form Working Alliance Inventory, modified California Psychotherapy Alliance Scale, and Working Alliance Scale, where clients and therapists provided ratings over 2 weeks of treatment. The results indicated a strong therapeutic alliance is associated with the (1) role of caregiver and/or family perceptions and functioning and (2) client-therapist interactions aided by communication strategies.

Authors’ conclusions: From this review, an alliance between individuals participating in PABIR and therapists has both a positive and negative influence on treatment outcomes after a brain injury. Further research is needed provide a working definition of therapeutic alliance with appropriate clinometric properties to solidify the understanding of elements and/or factors that influence a therapeutic alliance in adults with brain injuries during post-acute rehabilitation.

The Addition of Pelvic Floor Subjective Screening to the Initial Systems Review for Female Athletes Presenting to Physical Therapy with Chronic Low Back Pain; A Retrospective Case

Anne Best, SPT; Dale Schuit. PT, PhD, MS; Maryleen Jones, PT, DHSc, MPT, CLT, NCS

Background and Purpose: Chronic low back pain is a common musculoskeletal condition treated by physical therapists. An association between chronic low back pain and pelvic floor dysfunction in female athletes was made in recent literature however the current clinical practice guidelines for the treatment of low back pain continue to exclude pelvic floor assessment and intervention. The purpose of this case report is to describe a need for the addition of pelvic floor subjective screening to augment the initial systems review for female athletes presenting to physical therapy with chronic low back pain in order to provide optimal care and subsequent outcomes.

Case Description: This case describes the physical therapy care delivered to a 20 year old Caucasian female with a medical diagnosis of chronic low back pain. The patient’s chief complaints were constant 4/10 low back pain, inability to stand long durations, run distances >1 block, and bend over to lift objects. Patient has experienced chronic low back pain for four years but other past medical and surgical history were unremarkable. Radiographs of the patient’s lumbosacral spinal region was found to be insignificant for pathology. During the course of treatment the patient noted pelvic floor dysfunction was described as pain with vaginal penetration & changes in bowel/bladder.

Outcomes: Both low back pain and pain with vaginal penetration was relieved, functional movement was restored, pelvic floor dysfunction resolved with normalcy in bowel/bladder and return to work/weight-lifting activities resumed following 13 weeks of physical therapy. Manual therapy (joint mobilizations & trigger point releases), core stabilization & strengthening, Pilates and the addition of pelvic floor training were essential in restoring functional capacity and reducing painful symptoms in all aspects of patient care.

Discussion: A potential relationship between chronic low back pain and pelvic floor dysfunction in female athletes may be considered. The initial examinations for physical therapy should therefore be inclusive of subjective screening specific to pelvic floor function. The outcomes in this patient’s specific case began to improve remarkably after subjective screening and the addition of pelvic floor intervention. This retrospective case study demonstrates a need for pelvic floor subjective screening questions during an initial systems review in order to provide holistic and comprehensive care to optimize outcomes.

Integration of Cervical Mobilization and Scapular Stabilization for a Patient with Medial Epicondylitis: A Retrospective Case Report

Nicole Herkert, SPT; Dale Schuit, PT, PhD, MS; Dave Diers, PT, EdD, MHS, ATC

Background and Purpose: An initial correlation has been described between medial epicondylitis and cervical radiculopathy. There have been no follow up studies indicating whether one pathology leads to the others or whether treating cervical radiculopathy affects the concomitant medial epicondylitis. The purpose of this case report is to outline a treatment program for individuals with cervical radiculopathy and concomitant medial epicondylitis.

Case Description: The patient was a 54-year-old, Hispanic female who presented with complaints of right-sided, medial elbow pain as well as grip, wrist, and elbow weakness. At evaluation, the patient also presented with symptoms consistent with cervical radiculopathy, including numbness in her fingers in the morning. The patient reported a past medical history that included right shoulder adhesive capsulitis and bilateral lateral epicondylitis.

Outcomes: After four weeks and a total of 7 visits, the patient’s pain and numbness were eliminated, cervical symptoms were resolved, elbow and wrist strength were returned to full strength, and functional activity improved based on the patient’s QuickDASH score.

Discussion: Treating concomitant cervical radiculopathy in a patient with medial epicondylitis appeared to be a safe and effective intervention program for decreasing elbow pain and improving grip strength. The presenting case report may be useful in helping clinicians determine the optimal plan of care for patients with “golfers elbow”. Future randomized control trials should evaluate the relationship between cervical radiculopathy and medial epicondylitis as well as whether treating cervical radiculopathy improves patient outcomes in those with “golfers elbow”.

The Impact of a Multi-Treatment Approach in a Young Child with Low Lumbar Myelomeningocele: A Retrospective Case Report

Alexsandra Brasen, SPT; Roberta O’Shea, PT, PhD, DPT; Amy Bala, PT, DPT, WCC, CWS

Background and Purpose: Myelomeningocele is the most common form of spina bifida and is associated with many secondary medical complications. Over the last 30 years, the survival rate of infants born with this condition has increased causing myelomeningocele to become a cause of chronic disability in adolescents and adults. The physical therapy techniques of neurodevelopmental treatment (NDT) and task-specific interventions are well documented in children with cerebral palsy, but have not been analyzed in children with myelomeningocele. As these children grow, physical therapists have an important role in providing individualized early intervention services based on the patient’s functional abilities utilizing many different treatment approaches including NDT and task-specific interventions to maximize functional outcomes. The purpose of this retrospective case report is to investigate the impact that a multi-treatment early intervention physical therapy approach on the progression of delayed gross motor milestones.

Case Description: The patient was a 9-month-old Caucasian female with a medical diagnosis of L5 myelomeningocele. The patient underwent myelomeningocele correction 22 hours after birth and is closely followed by specialists at a spina bifida clinic associated with a children’s hospital in Chicago for secondary complications of bilateral cerebral ventriculomegaly, Chiari II malformation, neurogenic bladder, patent foramen ovale (PFO) and a bicuspid aortic valve. She qualified for Early Intervention services at birth and received weekly physical therapy and biweekly occupation therapy. At initial evaluation at 2 months of age, the patient was found to have a 50% delay in the reflexes and stationary gross motor subsets of the Peabody Developmental Motor Scales-2 and was in the 35% percentile for her chronological age indicating a mild delay. She had lower extremity weakness contributing to her gross motor delays. The patient’s parents goal for their child was for to her meet developmental milestones as close to normally as possible and to be independently mobile as she grows.

Outcomes: After 7 months of weekly physical therapy sessions utilizing NDT concepts and task-oriented interventions the patient’s reflexes and stationary gross motor subsets decreased from a 50% delay to a 0% delay with an age equivalent of 8 and 9 months respectively. Her locomotion subset increased from a 0% delay to a 12.5% delay and an age equivalent of 7 months. Her developmental quotient was within normal limits and she was in the 50th percentile for her chronological age. After another month of weekly therapy sessions, she remained at a 0% delay in the reflexes and stationary subset categories and a 12.5% delay in the locomotion subcategory. Her developmental quotient was within normal limits.

Discussion: This decrease in locomotor gross motor skills can be attributed to the significant increase in the amount of movement that typically occurs in the 7 months of growth and development that had passed between her initial evaluation and present day. Due to her diagnosis and level of impairment, we expected delays in the locomotion gross motor sub-category. Therapy focused on improving the quality of her movement patterns and the level of assistance required for developmental transitions. The patient progressed from a 66.67 developmental quotient (mild delay) at her initial evaluation to a developmental quotient of 100 (within normal limits) for her chronological age. These improvements demonstrate the progression of the patient’s gross motor skills indicating improved strength in her upper extremities, trunk, and available lower extremity muscles, improved ability to transition in and out of functional positions, and functional mobility related to her chronological age. This retrospective case study demonstrates the benefits of multi-treatment approach utilizing NDT techniques in combination with task-specific interventions for an individualized physical therapy treatment plan for a young child with low lumbar myelomeningocele.

Comprehensive Physical Therapy for an Older Adult 2-Years Status Post Low Back Surgery

Mitchell Anderson, SPT; Kent Irwin, PT, DHS, GCS

Background and Significance: Obtaining successful physical therapy (PT) outcomes in patients with chronic low back pain (CLBP) status post surgery greater than one year is quite challenging. Comorbidities such as hypertension, diabetes, and obesity can negatively impact the recovery process in these complex individuals. Knowledge of lumbar fusion recovery, risk factors, age-related changes, and valid outcome measures can prepare physical therapists to evaluate and treat patients with CLBP. The purpose of this case report is to describe successful outpatient PT for an older adult patient with CLBP who was 2-years status post lumbar fusion surgery.

Case Description: The patient was a 63-year-old, Caucasian male referred to PT with CLBP with lumbar degeneration; he originally underwent L4-L5 lumbar fusion surgery approximately 2 years prior to this recent episode of PT. The patient had difficulty working at his sedentary office job, executing household maintenance, and performing functional activities. The patient had diabetes, hypertension, and obesity (BMI = 35.9 kg/m2). The PT examination indicated pain with all functional mobility tasks as well as decreased lumbar range of motion, lower extremity muscle performance, hamstring flexibility, multifidus activation, and joint mobility. The Oswestry Disability Index (ODI) and Veterans RAND 12 Item Health Survey (VR-12) revealed that the patient was moderately disabled, physically below average, and mentally healthy. The recent episode of PT began in May 2018.

Intervention: The PT interventions included soft tissue mobilization, joint mobilizations, hamstring stretching, gluteal and core strengthening, functional mobility, functional endurance, and education on improving fear avoidance behaviors due to pain. Initial muscle performance activities focused on neuromuscular reeducation of the multifidi, transversus abdominis, and erector spinae muscles which were required for stability during functional activities. Exercises were progressed to more challenging functional activities relevant to the patient’s daily needs (e.g., stair negotiation, treadmill walking, lifting weight from the floor, etc). Continuous patient education and a comprehensive home exercise program ensured proper body mechanics, appropriate physical activities, and optimal functional improvement.

Outcomes: The patient completed 7 weeks (20 sessions) of PT and reported a return to full household maintenance and work activities. Improvements in the following body structures/functions and functional activities were noted at discharge: lumbar range of motion, lower extremity muscle performance, ascending/descending stairs, emptying the dishwasher, making the bed, overhead tasks, sleeping longer than 6 hours, squatting, and walking. The patient’s 15th session ODI improved from 36% to 24% (MCID=12.8%). The patient’s 15th session VR-12 physical component score improved from 27/100 to 32/100 but was still considered below average.

Discussion: The current case report illustrates the importance of providing fear avoidance behavior education and progressive functional activities to effectively treat patients with CLBP following surgery greater than 1-year post operation. Comprehensive PT programs for patients with CLBP following lumbar surgery can effectively improve functional abilities and societal participation.

Weaning from opioids can improve patient outcomes in an interdisciplinary comprehensive pain management program.

Lisa Schwarz, PT, MHPE, OCS; Silpa Katta, MD

Purpose: To determine if weaning from opioids has an effect on outcomes in an interdisciplinary cognitive behavioral comprehensive pain management program (Null hypothesis: weaning from opioids does not have an impact on outcomes in a comprehensive pain management program)
Background/Significance: CDC data indicates that as many as 1 in 5 people receive prescription opioids long-term for non-cancer pain in primary care settings. More than 40% of US opioid overdose deaths in 2016 involved prescription opioids. Patients with chronic pain often have central sensitivity. There is a growing body of literature that supports the phenomenon of opioid-induced hyperalgesia (OIH) which may exacerbate the symptoms of central sensitivity. Given the current opioid epidemic and OIH, it’s important to wean patients off opioids with goals to regain function without reliance on opioids.

Subjects: 31 consecutive patients who entered an outpatient 21-day Interdisciplinary Comprehensive Pain Management Program (CPMP) on opioids.

Methods and Materials: All 31 patients were encouraged to wean from opioids under the direction and supervision of a physician as part of the CPMP. 19 patients chose to wean (W), 12 patients chose not to wean (NW). All patients participated in the cognitive behavioral CPMP that included group and individual PT and psychology, physician oversight, daily education, social work and spiritual care.

Analyses: Descriptive statistics were completed including % of occurrence, frequency, change scores, means.

Results: The average decrease in Morphine Equivalent Dosage (MED) for the W group was 52.6% (initial MED 92.9, discharge(DC) MED 48.9). Their mean pain was 5.8 (Numerical Pain Rating Scale 0= no pain, 10= worst pain imaginable), decreased to 3.6 at DC and 2.5 3-months post DC. The NW group (mean MED 51) had a mean initial pain of 6.9, DC 6.2 and 3-months post DC 6.2. The W group improved in their subjective physical ability score (1= very low, 2= low, 3= pretty good, 4= good, 5 = very good) from a mean of 2.1 to 3.9 while the NW improved from a mean of 1.7 to 2.8. Between group differences were significant (p≤ 0.05). Improvements on Patient Specific Functional Scale and Global Rating of Change were above Minimal Detectable Change (MDC) and Minimally Clinically Important Difference (MCID) respectively for the W group and did not meet those thresholds for the NW group.

Conclusions: The results of this study suggest that weaning from opioids while undergoing a CPMP may improve outcomes regarding pain and perceived physical ability as compared to patients who choose not to wean. This may be due to OIH.

Physical Therapy Clinical Decision Making, Interventions, and Outcomes of a Patient with Cervicogenic Dizziness: A Retrospective Case Report

Melissa Koehl, PT, OCS, COMT, Roberta O’Shea, PT, DPT, PhD

This case report describes the physical therapy clinical decision-making, interventions, and outcomes of a 66-year old woman referred to PT with the medical diagnosis of dizziness, found during the PT evaluation to have signs and symptoms consistent with cervicogenic dizziness (CGD). This report includes discussion of the pertinent patient history and clinical testing performed by a physical therapist in order to investigate for red flag symptoms that would warrant referral to a physician, as well as for possible differential diagnoses such as cervical arterial dysfunction (CAD), benign paroxysmal positional vertigo (BPPV), unilateral vestibular hypofunction (UVH), Meniere’s disease, central vestibular disorders, and cardiovascular sources of dizziness. The use of published clinical decision making guidelines for CGD are discussed. Physical therapy interventions for this patient included manual therapy and therapeutic exercise to address cervical spine and postural dysfunction, vestibular exercises (gaze stabilization), and functional cervical proprioceptive training. This report describes, in detail, the multimodal treatment approach used with this patient, which resulted in complete resolution of the patient’s dizziness in 6 sessions, including an improvement on the Dizziness Handicap Inventory from 56/100 to 0/100 and Global Rating of Change score (GROC) of +6, which represents “a great deal better.” Suggestions for future research on clinical testing for cervicogenic dizziness, as well as the role of a multimodal treatment approach combining manual therapy, vestibular exercises, and functional cervical proprioceptive training are discussed.

Reconsidering Post-Maneuver Postural Restrictions in the Treatment of BPPV : A Systematic Review

Tyler van Acker, SPT; Janet Helminski, PT, PhD

Background: The findings of 1 clinical practice guideline and 2 meta-analyses of the literature suggest post-maneuver postural restrictions are not necessary following treatment of benign paroxysmal positional vertigo (BPPV). However, most of these studies do not address patient compliance with post-maneuver postural restrictions at time of follow-up. Self-imposed post-maneuver postural restrictions or lack of compliance may impact reported outcomes.

Purpose: The purpose of this systematic review was to determine if post-maneuver postural restrictions are necessary to enhance the therapeutic effect of a particle repositioning maneuver (PRM) in the treatment of posterior canal (PC) BPPV taking into account self-reported compliance at time of follow-up.

Data Sources: Cochrane database of systematic reviews, Medline, Pubmed, Google Scholar, and CINAHL databases were searched from 1966 through August 2018.

Study Selection: Study topics were randomized controlled trials (RCTs), quasi-RCTs; diagnosis of PC BPPV; treatment with a PRM; Dix-Hallpike test; and post-maneuver postural restrictions.

Data Extraction: Study descriptors, post-maneuver instructions to participants, compliance at time of follow-up, and descriptive statistics.

Data Synthesis: Eight studies were included 5 RCTs and 3 quasi-RCTs. Only two RCTs determined sleep position with experimental and control groups at time of follow-up to determine compliance with activity restrictions and no restrictions. The odds in favor of resolution of BPPV were 2.01 times and 2.4 times higher in people receiving the post-maneuver postural restrictions than people with no restrictions. One study reported people with no restrictions on AVE received 1 more treatment session.

Limitations: Limitations included methodological quality of the studies, lack of reporting of compliance with postural restrictions and no postural restrictions, and small sample size.

Conclusions: BPPV clinical practice guidelines suggest patients do not need postural restrictions following a PRM. The literature does not consider the variability of patient behavior after leaving the clinic. Compliance with postural restrictions and participant’s self-imposing postural restrictions needs to be determined to establish effectiveness of postural restrictions. Postural restrictions may be considered for persistent BPPV.

Complex Regional Pain Syndrome Limits Functional Outcome of Reverse Total Shoulder Arthroplasty: A Case Report

Austin Kramer, SPT; Janet Helminski, PT, PhD

Background: Type-1 complex regional pain following a surgical procedure complicates recovery and post-operative management increasing probability of worse functional outcomes. Early diagnosis and treatment is crucial to minimize complications such as associated swelling, atrophy, osteoporosis, pseudo-arthritis, joint stiffness, and tendon adhesions. With delays in diagnosis and treatment, progress is still possible.

Purpose: The purpose of this case report was to describe the delayed and complicated recovery of shoulder function of an individual who developed Type-1 complex regional pain syndrome (CRPS) following a reverse total shoulder arthroplasty (RTSA). Type-1 CRPS was diagnosed 10 months following RTSA.

Case Description: A 72-year old African American female was referred to an out patient physical therapy clinic 10 months following a right RTSA surgery. Following the surgical procedure, the patient received 6 weeks of out patient physical therapy. Ten months following surgery, she presented with severe right shoulder weakness (2/5 abduction and flexion: 3/5 external and internal rotation), reduced active range of motion (0-40° of flexion and abduction), average pain intensity of (6/10), and limited function as measured by the QuickDASH (61.3% impaired). Patient was diagnosed right UE type-1 complex regional pain syndrome. Treatment was modified to accommodate complaints of pain and hypersensitivity.

Outcomes: Patient was discharged after 20 weeks of physical therapy (2 times per week for 60 minutes). Improvements noted in right shoulder weakness (4+/5 flexion and 4/5 extension), active ROM (0-90° of flexion and 0-80° of abduction), average pain intensity (2/10), and functional ability measured by the QuickDASH (56% impaired). Improvement in function of the right UE not clinically significant.

Discussion: Development of type-1 CRPS complicated patient’s right RTSA recovery. Treatment was modified and progress was delayed and limited due to complaints of pain and hypersensitivity. Increase in strength and ROM of shoulder were made and reduced pain was noted. However, with a reduction in impairments there was still limited functional carry-over. This suggests the functional measures were not sensitive to change or there may have been some other unidentifiable limiting factor.

Utilization of spinal manipulations as an adjunct to a post-surgical protocol following Shoulder LatarJet Procedure in a patient with history of chronic shoulder instability

Sravanthi Kandula, PT, Jennifer Nunn, PT, DPT, Dillon Thomas, PT, DPT, Anthony Marquez, PT, DPT

ABSTRACT BODY: Background & Purpose: The purpose of the case study is to highlight the utilization of spinal manipulation in a post-surgical patient with restrictive protocol in initial phases of rehabilitation. Application of spinal manipulation has been shown to be effective in management of the shoulder girdle pathology; however, early application of these techniques in a post-surgical shoulder patient has not been widely assessed. This study explored the utilization of spinal manipulation as a means of facilitating motor recruitment, pain reduction and normalization of movement patterns. Specifically, in this case cervical, thoracic, and lumbar joint manipulations were performed in order to effectively restore function of the shoulder to be able to perform overhead sports.
CASE DESCRIPTION: The patient is a 16 year old male swimmer who presented to physical therapy following Latarjet procedure in June 2018 to provide anterior stability to the shoulder following history of recurrent subluxations. Patient began having daily subluxations and dislocations without specific mechanism prior to this procedure. Patient pertinent medical history includes bilateral shoulder arthroscopies 2016 following failure of conservative management, traumatic dislocation and SLAP repair 2017. On initial assessment post-operatively he presented with associated mobility dysfunction in both cervical and thoracic spine determined with active range of motion and segmental assessment. Additionally, shoulder assessment findings showed scapular postural dysfunction at rest, altered muscle tone and restricted mobility of periscapular tissues. Therapy interventions included: Implementation of the post-surgical rehabilitation guidelines provided by the surgeon (see Appendix A of attached), along with performing cervical, thoracic and lumbar manipulations.