Chronic Inflammatory demylinating polyneuropathy (CIDP) is a little studied, often misdiagnosed, neurological condition. Little is known about causes of CIDP or the impact of physical therapy interventions on the functional outcomes of these patients. This longitudinal case study focuses on the physical therapy interventions provided over a 5 year period along with standard medical intervention to provide the patient with significant gains in function. This patient was provided intermittent skilled physical therapy intervention as well as weekly community group exercise program supervised by physical and occupational therapists. This case study shows how functional mobility and balance can continue to improve with medical management and physical therapy even 4-5 years post initial illness. Close monitoring of CIDP patients with reintroduction of physical therapy as changes are seen may improve the long term outcomes for the CIDP population.
Cancer survivors may experience many side effects of cancer and cancer-related treatments. Among those are issues that may greatly affect their balance and safety with daily activities. Specifically, common peroneal neuropathy has been documented in past studies to have a relative risk of 3.4 when compared to patients without cancer. This review was prompted by the cases seen by the author in the clinic in order to investigate the presence of this diagnosis throughout this group of patients. Factors that may predispose one to common peroneal neuropathy will be described in this presentation. Among these are weight loss and nutritional deficiencies. When decreased adipose tissue is present to protect the peroneal nerve at the fibular head, compression occurs more easily and has been documented well in a population of bariatric patients who experience rapid weight loss with intervention. Also documented is the significant weight loss that occurs with some types of cancer, including head/neck cancers and gastrointestinal cancers. The presence of chemotherapy-induced peripheral neuropathy and paraneoplastic neuropathy might also cause more noticeable issues if neural transmission is already impaired. The purpose of this presentation is to raise awareness of an issue that may cause significant safety issues for patients when it presents. Patients who are already compromised with cancer-related fatigue and/or chemotherapy-induced peripheral neuropathy may be at further risk for injury. In a population that may already have multiple issues affecting their mobility, prevention/treatment of peroneal neuropathy is warranted to improve their functional mobility and safety and quality of life. Interventions may include nutrition counselling and instruction in the avoidance of leg crossing or pressure to fibular head when weight loss is a factor.
THE BENEFITS OF CONTINUOUS LONG TERM PHYSICAL THERAPY FOR A PATIENT AND HIS FAMILY
Background and Purpose: Long term physical therapy treatment has been shown to promote significant outcomes in patients with traumatic brain injury (TBI). Unfortunately, therapy in the outpatient setting is often discontinued due to limited patient gains and lack of insurance coverage. The purpose of this study was to describe the effect of ongoing outpatient physical therapy (PT) on restoring functional mobility in a patient with TBI and decreasing caregiver burden. Case Description: One patient that suffered a TBI in May 2014 and was treated in outpatient PT in January 2015 after receiving PT in an inpatient and day rehab setting. Patient initially presented in a wheelchair (w/c) with limited functional mobility skills. Patient required continuous care from his wife. Outcomes: Initial evaluation completed on 1/21/15. Examination findings as follows: bed mobility contact guard assist (CGA); sit to stand from w/c with hemi-walker min/mod assist; ambulation 65 feet with hemi-walker, min assist and L ankle foot orthotic (AFO); Romberg stance time 1 second and independent standing for 1 minute. Patient’s wife was assisting with all ADL’s, transfers, and functional mobility. Patient’s therapy included gait training indoors and outdoors, dynamic balance activities, proprioceptive and plyometric training, lower extremity strengthening, core stabilization, and floor transfers. After 5 months of treatment, two times per week, patient ambulated 250 feet with small based quad cane (SBQC) on level surfaces and ambulated short distances on uneven surfaces with AFO and contact guard assist (CGA). After 11 months of treatment, patient progressed to using a straight cane (SC) indoors with AFO and CGA. After 14 months of treatment, one time per week, patient progressed to using SC outside on level surfaces without AFO with CGA. After 21 months of treatment, patient was ambulating ½ mile per day with standard cane (SC) and no AFO outside on uneven surfaces including walking on the beach, modified independent. After 11 months of treatment, patient was assisting with meal preparation. After 16 months of treatment, patient was preparing meals independently and no longer required 24 hour supervision. After 21 months of treatment, patient showed an increase in Patient Specific Functional Scale scores (PSFS) from 0-8/10 for stairs and 5-7/10 for balance outside. Also after 21 months of treatment, Romberg stance progressed from 1 second to 29 seconds. Discussion: Bed mobility, transfers, gait, and ADL’s all improved with PT. Of note, the burden of care for patient’s wife decreased from 24/7 dependent care to patient being completely independent with gait, ADL’s and IADL’s such as toileting, bed mobility, meal preparation, and household chores. Patient progressed from being home bound to being able to travel with his wife and participate in family and community functions. This could not have been accomplished without the commitment of the patient and his wife to his treatment plan. His wife’s continued support and motivation were an integral part to the patient’s recovery and goal achievement. Although uncommon to receive 138 visits of outpatient PT, the duration of therapy, focused treatment on patient and family goals, and family involvement greatly changed the quality of life for the patient and his family.
OVERCOMING BARRIERS TO RESEARCH PARTICIPATION: A FOLLOW-UP SURVEY OF PEDIATRIC PHYSICAL THERAPISTS
Background and Purpose: Research evidence is essential for providing the highest quality patient care. In a previous study, pediatric physical therapists reported the lack of time, collaborative assistance, financial and institutional support, and research training as the main barriers to their research participation. The purpose of the current follow-up study was to survey pediatric physical therapists in order to 1) explore their perceptions and opinions regarding possible ways to remove barriers to their participation in conducting clinical research; 2) determine common characteristics of clinical settings supportive of research participation; and 3) explore the respondents’ attitudes toward research related continuing education offerings. Hypotheses: We hypothesized the following: 1) Respondents exposed to research in their entry level physical therapy education would be more likely to participate and be interested in conducting clinical research during their professional career; 2) Respondents with low exposure to research participation would be more interested in continuing education related to the IRB processes and research methods, while those with greater exposure would be more interested in data analysis and grant writing workshops; and 3) At least 30% of respondents would provide additional solutions to the previously identified barriers to their research participation. Methods: A 7-part, 58-question survey was created on SurveyMonkey.com, with a link distributed to 364 pediatric physical therapists via e-mail (N=100) and paper flyers (N=264). Survey questions targeted the participants’ demographics, participation in and comfort level with research, possible solutions to barriers to research participation, and their opinions of the survey. Results: Fifty-five respondents completed the survey, with an overall response rate of 15%. Fifty-two participants received the survey link via e-mail, with a response rate of 52%. The highest-ranked solutions to resolving barriers to research participation included establishing collaborative relationships between individual clinicians and active researchers, and between clinical facilities and academic institutions; designating specific time for research; and altering clinical productivity requirements. In clinical settings supportive of research, clinicians reported on being involved in research, including recently; having a higher comfort level with obtaining an IRB approval; and having access to an IRB. Majority of participants (61.9%) reported being interested in research-related continuing education offerings. Results mostly supported hypotheses # 1, partially supported hypothesis # 2, and did not support hypothesis # 3 as only 8% to 19% of respondents provided additional comments regarding the identified barriers. Conclusion: Barriers to performing clinical research in pediatric physical therapy may be overcome by creating collaborative relationships between clinical facilities, researchers, and academic institutions; providing clinicians with an access to IRB; adjusting schedules and productivity requirements for therapists involved in research; and offering continuing education appropriate for their research participation experience and needs.
INJURIES AMONG ULTIMATE FRISBEE PLAYERS IN THE USA: OCCURRENCE, TYPES AND ASSOCIATED FACTORS
Background: Ultimate Frisbee (Ultimate) is a fast growing, non-contact sport, primarily regulated in the United States by the United States Ultimate Association (USA-U), which helps to organize and promote the sport across all age levels, and across men’s, women’s and co-ed divisions. Although participation is growing, little is known regarding the types of Ultimate-related injuries sustained by players and when and how they occur. Health professionals need more information about Ultimate players’ injuries to aid in prevention and management. Purpose: To characterize types and causes of injuries to Ultimate players and to explore factors associated with injury Study Design: Descriptive study using an online survey Participants: Male and female members of USA-U at least 18 years old Methods: An e-mail from USA-U described the study and consent process and invited participants to complete an online survey. Information was collected on demographics, play experience, and types/circumstances of injuries experienced in the year prior to data collection. 1794 complete surveys of 2147 attempted were analyzed. Analyses included means or frequencies for descriptive data, t-tests or the chi-squared statistic for associations. Results: Respondents reported 2268 injuries. The most common injuries were to the foot (plantar fasciitis, turf toe, stress fracture), ankle (sprain, shin splints, stress fracture), knee (patellar tendinitis, patello-femoral pain, anterior cruciate ligament tear) and shoulder (rotator cuff tendinitis, dislocation, rotator cuff tear). Repetition and overuse accounted for 34.1% of all injuries; traumatic events, especially pivoting on a fixed foot and performing a layout, accounted for 65.9%. Tournament play accounted for 43.7% of injuries; others occurred during practice (35.5%) or recreational play (20.8%). Younger age (t = 5.44; p<.001), more frequent play (t = -4.70; p<.001), collegiate competition (X^2 = 12.47; p=.01) and previous injury (X^2 = 16.61; p<.001) were associated with injury. Discussion: Playing frequently at intense levels, as occurs in collegiate and tournament play, increases exposure to injury. Collegiate play may occupy a longer portion of the year than other levels of play. Collegiate teams often have peer coaches who are inexperienced with safe training practices and who lack the authority to remove an injured player from a game. Players are at higher risk of a new injury when they have already sustained a similar injury. Frequent play and previous injury suggest a role for fatigue and inadequate healing time prior to resuming play. Inadequate training may explain some of the injuries experienced by the respondents. Practicing the correct performance technique of skills such as a layout could help prevent injury. In the absence of on-site coaching from trained personnel, Internet sources can provide instructions on the preferred method. Players could also benefit from knowledge of appropriate general conditioning, training and warm-up programs for game preparation. Cross training could limit repetitive stresses that lead to overuse injuries; strength training to related musculature could help protect from sudden internal or external forces, and general conditioning could reduce the level of fatigue. Limitations: The data presented in this study cannot be interpreted as an injury rate for Ultimate Frisbee players. The study may reflect errors associated with self-reported data.
Conclusions: The major factor contributing to injuries among Ultimate players appears to be exposure. Tournament play, collegiate play, frequent play, history of a previous injury and age all represent frequent opportunities for injury to occur. Health professionals can discuss the importance of taking days off and allowing injuries to recover prior to resuming play. Appropriate training programs can be initiated to help prepare players with appropriate physical conditioning and knowledge of performance of relevant skills.
HEAD INJURIES AMONG ULTIMATE FRISBEE PLAYERS
Background: Ultimate Frisbee is now recognized by the International Olympic Committee and played in over 80 countries, with over 50,000 players in the United States alone. The available research examining injuries related to Ultimate Frisbee includes little information about head injuries and concussions. Research into the short- and long-term effects of sports-related concussions has highlighted the importance of concussion recognition, management, and prevention. Organizing committees of some sports, including United States Ultimate Association (USA-U), have implemented standards of care for events they sanction, but little is known about head injuries and concussions experienced by Ultimate Frisbee players and their post-injury care. Purpose: To examine among Ultimate Frisbee players the frequency and causes of head injuries/concussions, initiation and availability of health care, and injury prognosis. Study Design: Descriptive study using an online survey Participants: Male and female members of USA-U at least 18 years old who reported having received a head injury while playing during the year prior to data collection Method: USA-U sent its members an email describing the study and consent process and inviting participants to complete an online survey, collecting information on demographics, injury circumstances, symptoms and health care used. Of 2147 surveys attempted, 1794 were completed; 152 from respondents who reported head injuries were analyzed. Analyses included means or frequencies for descriptive data and the chi-squared statistic for associations. Results: 77 women and 75 men reported receiving a head injury (mean age 23.4 yrs, sd=4.5). 71.1% of these injuries were due to collisions, and 17.1% resulted from performing a layout and striking the ground. Head injury occurrence was significantly associated with playing at the collegiate level (χ2 = 36.71, p<.001); 58.5% occurred during collegiate tournaments or practices. Respondents reported that on site athletic trainers were available frequently or always for USA-U sanctioned college (59.2%) and club tournaments (51.3%), respectively, contrasted with 22.3% and 19.1% for non-USA-U-sanctioned college and club tournaments. Medical attention, when sought (78.3% of respondents), was provided by emergency personnel or a primary care provider for 48.7% of injured respondents and by athletic trainers on site for another 38.8%. Of those injured, 67.1% were examined for concussion on the same day or within the same week as the injury, but 28.9% were never examined, primarily because the player did not deem it serious enough. Of the 152 reporting a head injury, 89 were diagnosed as having a concussion, 81 of which were examined the same day or week. Headache was the most common immediate symptom (83.1%), followed by feeling in a fog (71.9%) and disorientation (70.8%). 61.8% reported that symptoms lasted 3 weeks or less, but 37.1% reported that symptoms lasted over a month. Discussion: A substantial proportion of Ultimate Frisbee players appears to experience persistent concussion symptoms lasting longer than the 10-14 days anticipated for adults. USA-U guidelines for sanctioned events require that trainers be on site or that a medical plan be in place. At informal events where medical personnel may not be available, such as non-sanctioned games or recreational play, players may not be aware of the need to terminate play and be medically examined following a head injury. Evidence exists that players who continue to play following a head injury are more likely to have prolonged symptoms than those who are removed from a game and receive care. Limitations: The data presented cannot be interpreted as a head injury rate for Ultimate Frisbee players, and the data provided may reflect errors associated with self-reported data. Conclusions: Ultimate Frisbee players, team organizers and coaches would benefit from an educational program and policies stressing the need for head-injured players to cease play, receive prompt screening for concussion and receive rest and monitoring for at least 24-48 hours after injury.
OUTCOMES IN AN INTERDISCIPLINARY COMPREHENSIVE PAIN MANAGEMENT PROGRAM: A RATIONALE FOR COMBINING A BATTERY OF OBSERVED FUNCTIONAL TESTS AND SELF-REPORT STANDARDIZED OUTCOME MEASURES
Introduction: Chronic pain is an epidemic in the United States. The National Pain Strategy calls for patient-centered integrative pain management practices. Most research on outcomes of integrative comprehensive pain management programs (CPMP) utilizes self-report outcomes only and there is a paucity of observed functional testing measures for this population. The objective of this study was to determine if a battery of observed functional tests (BOFT) are correlated to self-reported functional measures for patients with chronic pain participating in an integrative CPMP and if this BOFT can provide useful outcomes information not obtained from self-report measures. Methods: 164 consecutive patients participated in an integrative Comprehensive Pain Management Program. The program consisted of cognitive behavioral therapy, therapeutic exercise, neuro re-education, psychology and pain education. Patients completed a 30-minute BOFT that included lifting, walking, sit to stand and step up tests as well as several standardized self-report functional outcome measures at the beginning and conclusion of the program. Results: Patients made significant improvements on self-report measures including Patient Specific Functional Scale, Modified Oswestry Disability Index, and Neck Disability Index (P<0.001). Patients also made significant improvements on each of the components in the BOFT (P<0.001). Global Rating of Change mean score was +3.9 (scale -7 to +7) with SD of 1.9. No significant correlations were found between any the self-report measures and the BOFT. Conclusions/Discussion: The results of this study provide evidence that the CPMP was effective in improving both self-report and observed measures. The fact that these measures were not correlated, suggests that both types of measures have value in providing a more descriptive picture of patient outcomes than either type alone.
THE IMMEDIATE EFFECTS OF TRIGGER POINT RELEASE THERAPY O PRESSURE PAIN THRESHOLD, MUSCLE PERFORMANCE, AND RANGE OF MOTION
Background: Myofascial trigger points (MTrPs) are hyperirritable bands of a muscle that are painful to applied pressure and pressure applied to them can elicit local and referred sensory, motor, and autonomic symptoms. Latent MTrPs send referral pain only when pressure is applied directly to them but can become activated through prolonged stress or repetitive low-loading of the muscle or prolonged ischemia. Latent MTrPs have been associated with changes in muscles performance and sensitivity to pain, and multiple interventions have been used in an attempt to inactivate them. The purpose of this study was to examine the immediate effect of a sustained manual pressure treatment on latent myofascial MTrPs in symptom-free subjects. Methods: A single blind design was used, and 18 subjects were pseudo-randomly allocated to either a Sustained Pressure (SP) group or a Placebo (P) group. Latent MTrPs were located in both trapezius muscles of each subject and baseline measures of pressure pain threshold (PPT), cervical range of motion (CROM), trapezius muscle strength and deep neck flexor muscle endurance were obtained. The SP group received 90 seconds of compression to the identified MTrP on the dominant side and the P group received 5 minutes of sham ultrasound. Baseline measures were repeated post-treatment. A 2-by-2 repeated-measures analysis of variance was used with time (pre, post-intervention) as the within subject factor and group (P, SP) as the between subject factor. Effect sizes were calculated using Cohen’s d. Results: There was a variable response in PPT to both treatments from study participants with no significant between group differences. The effect of treatment on CROM was also variable among both groups, but several measures in both groups showed significant increases in CROM pre to post. There were no statistically significant changes in upper, middle, or lower trapezius strength post-treatment for either group. Effect sizes were generally small. Discussion: A single bout of sustained pressure treatment did not produce meaningful immediate changes in sensitivity, range of motion or muscle strength relative either to a placebo treatment or to baseline. Although there were no statistically significant effects for any of the variables, understanding the variability in responses can provide insight into the expected responses following the use of sustained pressure for the treatment of myofascial trigger points and inform future clinical trial development.
A CORRELATIONAL STUDY OF THE BORG RATING OF PERCEIVED EXERTION (RPE) AND EXERCISE INTENSITY AS MEASURED BY OXYGEN SATURATION AND HEART RATE (HR) DURING SUBMAXIMAL TREADMILL EXERCISE
Jeffrey Damaschke, PT, DPT, PhD, OCS; Patrick Withrow, PT, DPT, GCS; Murtaza Aziz, SPT; Daniel Harenberg, SPT; Benjamin Heuser, SPT; Kenneth Kells, SPT; Derek Peake, SPT; Jaob Perotto, SPT; Morgan Sayre, SPT; James Schafer, SPT; Erynn Schuh, SPT; Jonathan Wilson, SPT
Purpose: Intensity of exercise is important to ensure that rehabilitation activities are appropriately prescribed and carried out for patients undergoing physical therapy. The Borg RPE scale is often used in physical therapy home health, inpatient, and outpatient settings to evaluate the intensity of exercise or how hard a patient is working while exercising. The purpose of this study was to examine the possible correlation between the Borg RPE scale, oxygen saturation, and HR in healthy individuals. Number of Subjects: The study was conducted at Rosalind Franklin University of Medicine and Science (RFUMS) with a total of 22 participants consenting to participate in the study. Methods: The study gathered data from healthy participants while they exercised at a submaximal level on a treadmill. A specific treadmill protocol was followed and participants walked and ran on the treadmill at six different speeds for a specified amount of time. Following two minutes of walking or running at a specific speed, the participant reported their RPE using an RPE scale, oxygen saturation was measured, and HR was measured. Oxygen saturation was measured using a finger-tip pulse oximeter and HR was measured using a Polar heart rate monitor. The RPE, oxygen saturation, and HR were recorded for all six treadmill speeds. Results: The results of the study revealed that there was a significant correlation between RPE and oxygen saturation and between RPE and HR. The Spearman Rho Correlation Coefficient between RPE and oxygen saturation was r = -0.425 with a p-value of 0.000008 (α = 0.05). A regression analysis demonstrated a negative, inverse relationship between RPE and oxygen saturation as defined by y = 99.819 – (0.284x), where y is oxygen saturation and x is RPE. The Spearman Rho Correlation Coefficient between RPE and HR was r = 0.772 with a p-value of 0.000002 (α = 0.05). A regression analysis demonstrated a positive, direct relationship between RPE and HR as defined by y = 7.767x + 50.85, where y is HR and x is RPE. Conclusions: The results of this study demonstrated a significant correlation exists between RPE and oxygen saturation (negative correlation) and between RPE and HR (positive correlation) in healthy individuals while performing submaximal exercise on a treadmill at a variety of speeds. These results suggest that obtaining a Borg RPE score while performing exercise can be used to estimate a healthy individual’s oxygen saturation and HR. Clinical Relevance: The clinical relevance of this research has demonstrated that oxygen saturation and HR may be estimated by using a patient’s RPE in healthy individuals during submaximal exercise training. This may be especially useful in the home health environment or any setting where specialty monitoring equipment may be unavailable. If a practitioner is able to accurately gauge these vital parameters, exercise can be modified or terminated; or further referral can be performed, which may potentially prevent exercise-related adverse events.
FUNCTIONAL OUTSOMES FOR A PATIENT WITH WEST NILE VIRUS ENCEPHALITIS RECEIVING PHYSICAL THERAPY IN THE LONG TERM ACUTE CARE HOSPITAL: A RETROSPECTIVE CASE REPORT
Background and Purpose: West Nile virus (WNV) was first introduced into the United States in 1999 and continues to be an annual epidemic, particularly in the Midwest region. Approximately 1% of WNV cases are neuroinvasive. The subtypes of neuroinvasive WNV include encephalitis, meningitis and acute flaccid paralysis. The purpose of this case report is to describe the physical therapy plan of care and functional outcomes for a 54 year old female patient with West Nile virus encephalitis in the long term acute care hospital (LTACH). Case Description: The patient was a 54 year old Caucasian woman in good health who became acutely ill. The patient was diagnosed with West Nile virus encephalitis with respiratory failure and presented with debility, generalized weakness and flaccid paralysis in her left upper extremity. She was admitted to the long term acute care hospital for ventilator weaning and physical therapy was introduced to address the patient’s functional limitations. Outcomes: After receiving care for 19 days and participating in 9 physical therapy sessions, the patient’s functional status improved from being non-ambulatory and unable to tolerate standing to ambulating 24 feet with a rolling walker. There was a clinically significant improvement in the patient’s AM-PAC ͞6-Clicks͟ Basic Mobility score and an improvement in her FIM score, although not clinically significant. Following care in the LTACH, the patient advanced to an acute inpatient rehabilitation facility. Discussion: The patient’s improvements in bed mobility and transfers are promising indicators that functional mobilization helped increase endurance and strength necessary for these activities. Further research may help determine preferred treatment options for patients with West Nile encephalitis (WNE) and the possibility of post-West Nile virus poliomyelitis syndrome.
ACUTE DIZZINESS EVIDENCE BASED CLINICAL PRACTICE TOOL
Acute dizziness may be benign and easily treated, but it can also be an indication of serious pathology.1 Differential diagnosis can be challenging, as symptoms are generally non-specific and a clinical practice guideline has yet to be established; however, research shows specific physical examination is an effective approach.2 With over four million patients presenting to Emergency Departments, and with associated annual costs exceeding four billion dollars in the US,3 Physical and Occupational Therapists developed an ͞Acute Dizziness Clinical Practice Tool͟for interdisciplinary use at an independent, medium-sized, community-based hospital. This evidence-based tool is comprised of an examination checklist, which standardizes the evaluation process, and a treatment algorithm, which aids in interpretation of exam findings. Therapists must fulfill specific competency requirements prior to independently utilizing the tool bedside. The objectives of integrating the tool in clinical practice include: standardization of acute dizziness patient evaluations, facilitation of accurate diagnosis, and delivery of cost effective care with improved patient outcomes. The tool guides clinicians in a comprehensive, objective analysis of results from subjective report, neurological exam and functional mobility assessment, as well as oculomotor, vestibular, and positional testing to aid diagnosis and intervention. This poster aims to foster discussion among clinicians assessing acute dizziness in order to refine the tool and invite collaboration for future research.
PHYSICAL THERAPY MANAGEMENT OF A 68 YEAR OLD MALE WHO UNDERWENT REVERSE SHOULDER ARTHROPLASTY FOLLOWING A COMMINUTED PROXIMAL HUMERAL NECK FRACTURE: A CASE REPORT
Background and Purpose: Reverse shoulder arthroplasty is indicated for an increasing number of conditions, but evidence is limited regarding a post-operative physical therapy protocol for these individuals. The purpose of this case report is to describe the physical therapy intervention provided for treatment of a patient who received a reverse total shoulder arthroplasty following a proximal humerus fracture. Case Description: The patient was a 68-year-old male who underwent a right reverse total shoulder arthroplasty after sustaining a comminuted right humeral neck fracture during a fall. The patient presented with limitations in range of motion, strength, upper extremity function and disability. Outcomes: Patient completed 16 outpatient physical therapy treatment sessions and demonstrated improvements in range of motion, strength, and shoulder function and disability, demonstrated by improved scores on the QuickDASH. Discussion: There is limited data supporting the use of any rehabilitation protocol following a reverse total shoulder arthroplasty. The outcomes of this case report suggest that the implementation of a structured physical therapy protocol may be beneficial in improving function for these patients. Further research is warranted with larger sample sizes to evaluate the efficacy of implementing any particular physical therapy protocol for patients following RSA.
VIDEO GAIT ANALYSIS USED IN THE ‘RETURN TO SPORT’ DECISION FOR AN INJURED RUNNER
Background: Lower extremity injury rates range from 19% to 79% in runners. 1 Growing research has supported gait retraining and addressing altered running mechanics in the rehabilitation of the injured runner. 1,2,4 Video gait analysis is often used to determine mechanical flaws that may be contributory to the development of pain. Case Description: A 35 year old male runner presented to outpatient physical therapy with referral for Right Iliotibial Band Syndrome. The patient reported 8/10 lateral knee pain that began with training for a marathon for which the patient’s goal was to finish in under 3 hours. During objective examination, noteworthy right sided impairments included the patient’s decreased quadriceps strength, inability to perform greater than 10 supine straight leg raises due to quadriceps fatigue, and right knee hyperextension with ipsilateral ilium elevation during right stance phase of walking gait (FIGURE 1). Due to unilateral quadriceps weakness, the patient was screened for lumbar involvement thru testing including range of motion, neural mobility, dermatome changes, and upper and lower motor neuron reflex changes. All lumbar and neurological screening was negative. After 2 weeks of rest from running, lateral hip strengthening, and quadriceps activation exercises, the patient had elimination of symptoms. Due to lack of remaining symptoms, the patient requested to return to running. However, the patient was still limited to 20 straight leg raises before fatigue and had no change in above walking gait mechanics. At this point, running gait mechanics were assessed with use of treadmill and smartphone application, Hudl Technique. Normal running biomechanics suggest that runners should demonstrate around 45 degrees of knee flexion during absorption period of stance phase. 5 Because the vertical ground reaction force during running can reach a magnitude of 2.2 times body weight, this period of the running gait cycle also corresponds to when the quadriceps muscle group is most active. 3,5 The patient’s running evaluation revealed 25 degrees knee flexion on the involved side (FIGURE 2), which was significantly less than his uninvolved side. This lack of sufficient knee flexion correlates with the patient’s decreased quadriceps strength, fatigue of repeated straight leg raises, and walking gait abnormalities seen on involved side during initial exam. Based on running analysis, the patient was not recommended to return to running. Instead, he performed progressive quadriceps recruitment and strengthening exercises, including single leg stance, single leg squats, single leg hopping, and single leg jump down activities as appropriate. Outcomes: With 3 weeks of above progressive quadriceps training in addition to running gait retraining with use of video feedback, the patient was able to consistently demonstrate between 40-45 degrees of knee flexion during absorption period of running gait cycle (FIGURE 3) while running short distances in clinic and therefore recommended to progressively increase running distance and speed. Upon discharge, the patient reported being able to run painfree for 8 miles at 7:30 minute per mile pace. Objective exam on day of discharge revealed symmetricalquadriceps strength, symmetrical straight leg raise endurance, and consistent maintenance of corrected running biomechanics. Patient reported outcomes included Lower Extremity Functional Scale change from initial score of 58/80 to discharge score of 80/80. The patient also reported 6+ on Global Rating of Change Scale indicating the injured body part felt ͞a great deal better͟ since the start of treatment.
PHYSICAL THERAPY INTERVENTIONS FOR A 91 YEAR OLD MALE IN INPATIENT REHABILITATION STATUS POST FALL AND THE CORRELATION OF ANXIETY TO FALLS IN THE ELDERLY: A RETROSPECTIVE REPORT
Background: With falls in the elderly being an epidemic in our country, investigation has begun as to what could decrease the prevalence or recurrence of falls. According to the CDC, ͞older Americans experienced 29 million falls causing seven million injuries, costing an estimated $31 billion in annual Medicare costs,͟ as our population ages this can have drastic socioeconomic implications. An estimated mean cost of hospitalization is $17,483 for a 7.6 day stay after a fall injury and with the majority of these falls being ͞accidental͟, this could be a largely preventable expense. Case Description: We related manual muscle test scores, gait distance, and numeric pain rating score to changes in scores on the falls efficacy scale and correlated it to functional gains or limitations according to the functional independence measure. Outcomes: The patient was able to show improvements in quality measures scoring for the motor component from evaluation to discharge improving from Max assist or total assist for transfers to contact guard assist. Also the patient was able to increase ambulation distance from 10ft with total assist to 100ft with SBA using a rolling walker. Also seen in our test and measures our patient left with a falls efficacy scale score of 35/100 which correlates to a low fear of falling as a score of 70 or greater shows the person has a fear of falling. Discussion: This case study will take a look at a gentleman who presented to the emergency department after ͞accidentally falling backwards͟as he was trying to move out of the way of his daughter and the correlation between falls efficacy and scoring on the Functional Independence Measure
RELIABILITY OF CLINICAL TESTS TO MEASURE COMPONENTS OF THE OCULAR TILT REACTION IN NORMAL ADULTS
Background. Measuring vertical misalignment with Maddox rods and prisms or phoria cards in the upright and supine position would provide clinicians a simple and quick measure of skew. Measuring skew deviation as part of the oculomotor screening examination may assist in differential diagnosis of peripheral and central vestibular dysfunction and vestibular dysfunction from trochlear nerve palsy. Purpose. The purpose of this study is to determine the reliability of clinical tests to measure vertical and horizontal misalignment of the eyes in normal adults wearing monocular trial prisms to create skew deviation and vertical diplopia. Hypothesis. The reliability (95% confidence intervals) will be good for measuring the amount of vertical and horizontal misalignment of the eyes with a Maddox rod and prism bar or with a phoria card with subjects positioned in the upright and supine position.Subjects. 30 healthy young adult subjects with no prior history of strabismus surgery or vision loss. Methods. A standard oculomotor examination was performed. Participants randomly wore trial lenses with a 1, 2, 4, or 6 diopter monocular prism and plain glass. Examiners were blinded to trial lenses. In short sitting and supine in the recumbent position, measurements of eye alignment in primary gaze were taken in the vertical and horizontal plane with a Maddox rod and prism bars (diopters) 12 and with Maddox rod and phoria card for near vision (diopters). 12 Two examiners measured the misalignment of the eyes. Results. 30 subjects underwent 20 measurements by each examiner. A 4 diopter variation was allowed between examiners. Of the 1200 total measurements, there was incongruency between examiners in 48 measurements (4%). Twenty-two of the 48 measurements (46%) occurred with use of the 6 diopter prisms. The percent disagreement for the 6 diopter prisms was 6.9% and for the 1, 2, and 4 diopter prisms combined 2.6%. All of the variation occurred in the horizontal plane. There was no variation in the vertical plane. Discussion. The variability of measurement within the horizontal plane may be due to variability in the individuals’ ability to reduce retinal disparity and fatigue. The processing of retinal disparity is of greater complexity in the horizontal versus vertical plane which may be associated with the variability. Conclusion. Artificially created vertical and horizontal misalignment of the eyes in normal adults may be reliably measured with Maddox rod and prism bars and with Maddox rod and phoria card. These techniques may be used by physical therapists to screen for misalignment of the eyes in patients with ocular tilt reaction due to vestibular dysfunction or trochlear nerve palsy. Identification of vertical misalignment or large horizontal misalignment may result in referral to optometry or ophthalmology for further evaluation
TREATING A PATIENT WITH FUNCTIONAL NEUROLOGICAL DISORDER COMPLICATED BY DRUG INTERACTIONS: A CASE REPORT
Background: Functional Neurological Disorder (FND) is defined by the DSM-5 as neurological symptoms involving altered motor and/or sensory function leading to significant impairment that cannot be explained by any recognizable neurological condition. It is typically treated with antidepressants and cognitive behavioral therapy. As the number of medications used to manage symptoms increases, risk for drug interactions increases. Patients taking multiple serotonergic medications may develop serotonin syndrome (SS). Serotonin syndrome is an alteration in serotonin levels and/or receptors leading to multisystem complications and risk of death. Purpose: The purpose of this case report was to describe the evaluation and management of a patient diagnosed with FND that was potentially complicated by polypharmacy resulting in SS due to anti-depressant medication interactions. Subject: This study was approved by an IRB and the subject provided written, informed consent. The patient was 42-year-old female with a past medical history that included depression, endometriosis surgery, and sexual abuse. She was taking thirteen prescription medications and smoked a pack of cigarettes per day. She was administered six outcome measures including the Berg Balance Test (BBT), Timed Up and Go (TUG) and an 11-point numerical pain scale. Examination indicated impaired balance, gait, and lower extremity coordination, plus deconditioning, muscle weakness, and pain. Methods: Physical therapy treatment focused on improving gait, posture, coordination, muscular strength, and balance. The clinical impression was that some findings such as weakness, ataxia, non-epileptic seizures, tremors, and tics were consistent with FND; however, other symptoms such as palpable trigger points in the abdominal region, ͞menstrual-like͟ cramping, tachycardia, and blood pressure changes were not consistent with FND. Treatments were selected based on day by day presentations of pain, ataxia, and the patient’s affect. Results: After 21 visits over 14 weeks, the patient improved greater than the minimal detectable change on the BBT (23-point improvement), the TUG (7 second improvement) and the pain scale (4-point improvement) as well as on other measures. Outcome measures showed that the patient benefitted from physical therapy treatment. Residual symptoms may have been due to drug adverse reactions and were consistent with SS.Discussion: Patients with co-morbidities being treated with multiple pharmaceuticals are at risk of drug interactions. Interactions may result in additional medical conditions such as SS. Physical therapists treating patients with psychological diagnoses and/or comorbidities should be alert to potential drug interactions. Therapists suspecting drug interactions should discuss concerns with other members of the healthcare team and refer to appropriate medical professional for re-assessment to prevent these complications from interfering in care or limiting recovery.
IMPROVED KNEE FUNCTION WITHIN 4 WEEKS IN ELDERLY PATIENT WITH TENNIS LEG: A CASE REPORT
BACKGROUND: A general description of common symptoms and impairments related to tennis leg have been presented in the literature. However, little has been written about specific treatment guidelines and possible intervention options in treating cases of tennis leg in elderly populations. CASE DESCRIPTION: A 70-year-old male, retired tennis coach was self-referred to physical therapy for acute left knee and calf pain after a quick stop during a recreational tennis match. The pain was preventing him participating in tennis and was bothering him when walking. Examination of the knee did not reveal any abnormal findings beyond slight swelling and loss in knee ROM. Additional examination of the proximal kinetic chain revealed muscular imbalances and strength and ROM deficits in the hip and knee. Seven sessions of physical therapy were provided to target these impairments. OUTCOMES: The patient was able to ambulate functional distances and complete activities of daily living (ADL) without pain. He was also able to participate in tennis activities low intensity and volume. DISCUSSION: This case describes possible intervention strategies to treat impairments resulting from acute tennis leg in active, elderly male patients
THE IMPACT OF A SUPPORTIVE PARTNER ON STROKE SURVIVOR EXERCISE ADHERENCE AND ENDURANCE: A PILOT CASE STUDY
Background (purpose): The majority of individuals recovering from a stroke are left with residual disability and activity limitations, ultimately leading to a lower quality of life and decreased levels of participation. In community-dwelling stroke survivors, cardiorespiratory fitness ranges from 26% to 87% of the expected value in age and gender-matched healthy individuals. In other health conditions, the use of social support has been found to be of benefit to adherence and attendance to an exercise program. It appears that there is limited evidence within the literature regarding social support and adherence to physical activity in stroke survivors. Therefore, the primary aim of our study is to determine the impact of social support on improving adherence to an exercise program in stroke survivors. In addition, the secondary aim of our study is to determine the impact of social support on endurance and mobility in stroke survivors following an exercise program. Hypothesis: The authors hypothesize that the use of social support partners in circuit training exercise will enhance adherence to the exercise programs, participation in home exercise program, and improved endurance with mobility. Subjects: Participants were recruited through multiple outpatient clinics and a stroke support group in the rehabilitation hospital network. Inclusion criteria for the participants include: (1) 6 months to 5 years post stroke, (2) ability to ambulate ten meters with modified independence, and (3) ability to cognitively understand testing procedures. Two participants participated in the pilot study with their significant others as supportive partners. Participant 1 is a male in his 60s that experienced an ischemic stroke 2.5 years ago and has resultant L hemiplegia and vision deficits. Participant 2 is a female in her 60s that experienced an ischemic stroke that transitioned into a hemorrhagic stroke with resultant R hemiplegia and expressive aphasia. Methods: The program was conducted by a licensed physical therapist and three physical therapy students at a free-standing rehabilitation hospital. The program consisted of baseline testing, a circuit training program, completion testing and 9 week follow-up testing. The primary outcome measures included completion of a home exercise diary and six minute walk test. The secondary outcome measures included the Timed Up and Go (TUG), 5 times Sit to Stand, the Stroke Impact Scale (SIS), and Carer Quality of Life (completed by supportive partner). Each participant participated in a structured circuit training program with their supportive partner. The circuit training program included one hour sessions, held twice a week in the evenings for a total of three weeks. Evenings were chosen based on availability of the fitness center and to allow the supportive partners to participate without impacting work schedules. The circuit training program addressed three domains: walking endurance, balance, and strength. It consisted of a ten to fifteen minute warm up and stretching, eleven exercise stations, and ten to fifteen minute cool down and stretching. On the first session, participants were provided with home exercise diaries to keep records of their daily exercise and three different home/gym programs to choose from. Results: Both stroke survivors and their partners participated in all 6 training sessions and completed a home exercise program on 80-90 percent of the days following the circuit training sessions. From initial testing to follow-up participant one demonstrated an improvement from 11.49 seconds to 10.66 seconds on the TUG, 12.44 seconds to 11.02 seconds on the 5 times sit to stand, 1408 feet to 1487 feet on the six minute walk test, and 239/290 to 259/290 on the Stroke Impact Scale. From initial testing to follow up participant two demonstrated an improved from 30.12 seconds to 30.05 seconds on the TUG, unable to perform to 23.33 seconds on the 5 times sit to stand, 411.1 feet to 498.7 feet on the six minute walk test, and 171/290 to 182/290 on the Stroke Impact Scale. Discussion: One of the largest improvements was for Participant two who was unable to complete the 5 times sit to stand at initial testing, completed it in 30.43 seconds at completion, and 23.33 seconds at follow up. These gains were more significant than the ambulation or endurance outcome measures which may mean that the training protocol influenced strength and trunk control during transitions more than endurance. In addition, there were a significant number of questions from both participants about ongoing deficits and health considerations demonstrating an ongoing need for education opportunities for individuals long after the stroke. Conclusion: This case report demonstrates that it was feasible to perform a circuit training program with stroke survivors and a supportive partner in which all participants were able to participate in the exercises together. All participants adhered to the program and continued exercises following the short training period. The impact on strength and balance during transitions may be greater than endurance for the stroke survivor.