Turns while walking among individuals with Parkinson's disease following overground locomotor training: A pilot study

BACKGROUND

Individuals with Parkinson's disease are challenged in making turns while walking, evidenced by reduced intersegmental coordination and reduced dynamic postural stability. Although overground locomotor training previously improved ambulation among people with Parkinson's disease, its effect on walking turns remained unknown. We sought to understand the effects of overground locomotor training on walking turns among individuals with mild-Parkinson's disease.

METHODS

Twelve participants with Parkinson's (7 Males/5 Females; Age: 68.5 ± 6.4 years) completed twenty-four sessions lasting approximately 60 min and over 12-15 weeks. Baseline and follow-up assessments included the ten-minute walk test using wearable sensors. Primary outcomes included changes to intersegmental coordination, measured by peak rotation and normalized peak rotation, and dynamic postural stability, measured by peak turn velocities in the frontal and transverse planes. Statistical analysis included one-tailed paired t-tests and Cohen's d effect sizes with α = 0.05.

FINDINGS

No effects of overground locomotor training on mean peak thoracic rotation (+0.23 ± 4.24°; Cohen's d = 0.05; P = 0.45) or mean normalized peak thoracic rotation (-0.59 ± 5.52 (unitless); Cohen's d = 0.10; P = 0.45) were observed. Moderate and small effects of overground locomotor training were observed on mean peak turn velocities in the frontal (+1.59 ± 2.18°/s; Cohen's d = 0.43; P = 0.01) and transverse planes (+0.88 ± 3.18°/s; Cohen's d = 0.25; P = 0.18).

INTERPRETATION

This pilot study provides preliminary evidence suggesting that individuals with mild-Parkinson's moderately improved frontal plane dynamic postural stability after overground locomotor training, likely attenuating the perturbations experienced while turning.

CLINICAL TRIAL REGISTRATION

NCT03864393.

Sport-Specific AMCaMP: New Modular Tools for Measuring Adolescent Self-Confidence In Sport-Specific Movement

Background

Despite increasing interest in psychological factors that affect the impact of self-efficacy on readiness to return to play, few clinical tools are available to assess self-confidence in performing sports-specific movement patterns in the pediatric/adolescent population.

Hypothesis/Purpose

The purpose of this study was to test the psychometric properties of sports-specific modules to supplement a general measure of movement self-efficacy, the Adolescent Measure of Confidence and Movement Performance (AMCaMP).

Study Design

Quasi-experimental cross-sectional validation.

Methods

After preliminary testing for readability and ease of administration, one of 12 sport-specific modules pertinent to the individual's sport (baseball, softball, basketball, football, gymnastics, cheerleading, soccer, ballet, swimming, lacrosse, tennis, and cross country) were administered to 14,744 patients, 11-18 years of age, drawn from 12 pediatric sports physical therapy facilities in a single health care system. Respondents completed the assigned sport-specific self-report questionnaire at initial visit and conclusion of the episode of care.

Results

Based on sample sizes, Bartlett's Test of Sphericity, and Kaiser-Myer-Olkin measures, nine modules (baseball, softball, basketball, football, gymnastics, cheerleading, soccer, ballet, and swimming) were deemed suitable for factor analysis. Each module sample was divided into test validation samples. Exploratory factor analysis revealed an underlying structure ranging from one to three factors depending upon the module. Subsequent confirmatory factor analyses fully supported the hypothesized factor structures for each module except swimming. Additional analyses to determine coefficient alpha (range=0.8-0.976), Standard Error of Measurement (range=1.12-2.33), and Minimum Detectable Change (range=3.1-6.47) confirmed the reliability of each of these modules.

Conclusion

AMCAMP sport-specific modules are reliable and valid self-report tools to capture self-confidence in performing sport-specific movements to supplement AMCAMP's evaluation of self-efficacy in performing the general movements of everyday life. The results of this study support using these modules as part of the overall clinical evaluation of psychological readiness to return to sport.

Level of Evidence

Level 3b.

Walking Endurance and Oxygen Uptake On-Kinetics in Individuals With Parkinson Disease Following Overground Locomotor Training

BACKGROUND AND PURPOSE

Poor walking endurance in Parkinson disease (PD) may be attributable to both bioenergetic and biomechanical factors, but locomotor training methods addressing both these factors simultaneously are understudied. Our objective was to examine the effects of overground locomotor training (OLT) on walking endurance in individuals with mild-to-moderate PD, and to further explore potential cardiorespiratory contributions.

METHODS

A single-arm, longitudinal design was used to examine the effects of 24 biweekly sessions of OLT in people with mild-to-moderate PD (n = 12). Walking endurance was measured as total distance walked during a 10-minute walk test (10minWT). Oxygen uptake (V˙ o2 ) on-kinetic profiles were determined using a monoexponential function. Perceived fatigability was assessed following the 10minWT using a self-report scale. Magnitude of change in primary outcomes was assessed using Cohen's d and adjusted for sample size (Cohen's d(unbiased) ).

RESULTS

Participants executed 3036 (297) steps and maintained 65.5% (8%) age-predicted heart rate maximum in a typical session lasting 56.9 (2.5) minutes. Medium effects in total distance walked-885.9 (157.2) versus 969.5 (140.9); Cohen's d(unbiased) = 0.54-and phase II time constant of the V˙ o2 on-kinetic profile-33.7 (12.3) versus 25.9 (15.3); Cohen's d(unbiased) = 0.54-were observed alongside trivial effects for perceived fatigability-4.7 (1.4) versus 4.8 (1.5); Cohen's d(unbiased) = 0.11-following OLT.

DISCUSSION AND CONCLUSIONS

These preliminary findings may demonstrate the potential for moderate-intensity OLT to improve walking endurance and enhance cardiorespiratory adjustments to walking activity in adults with mild-to-moderate PD.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A407 ).

The effects of the addition of mechanical traction to physical therapy on low back pain? A systematic review with meta-analysis

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) on the comparative effects of different types or parameters of lumbar traction in low back pain (LBP).

METHODS

CENTRAL, CINAHL, ISI Web of Science, PEDro, PubMed, and Scopus databases were searched from their inception to March 31, 2021. We considered all RCTs comparing different types or parameters of lumbar traction on adults who complained of LBP with or without lumbar radiculopathy (LR). Any restriction regarding publication time or language was applied. Two reviewers independently selected the studies, performed the quality assessment, and extracted the results. Meta-analysis employed a random-effects model.

RESULTS

Sixteen studies met the inclusion criteria for qualitative analysis, and five were pooled. Meta-analyses of results from five studies on LBP with LR showed no significant difference between diverse tractions modalities at short-term follow-up. Very low to low-quality evidence supports these results. High-force and low-force traction demonstrated clinically significant improvements in pain.

CONCLUSION

The literature suggests the short-term effectiveness of traction on pain in LBP with LR, regardless of the type or the dosage employed. Different effects of traction other the mechanical ones can be hypothesized. This systematic review may be relevant for clinical practice due to the similar effects of different traction types or dosages.

LEVEL OF EVIDENCE

Level I, Therapeutic Study.

Walking endurance, muscle oxygen extraction, and perceived fatigability after overground locomotor training in incomplete spinal cord injury: A pilot study

Objective: The purpose of this study was to examine the effects of overground locomotor training (OLT) on walking endurance and gastrocnemius oxygen extraction in people with chronic cervical motor-incomplete spinal cord injury (SCI).Design: Prospective single-arm pre-post pilot study.Setting: Human Performance Research Laboratory.Participants: Adult men with traumatic chronic cervical SCI (n = 6; age = 30.8 ± 12.5).Intervention: Twenty-four sessions of structured OLT.Outcome measures: Walking endurance was determined during a constant work-rate time-to-exhaustion treadmill test. Normalized perceived fatigability was calculated by dividing subjective ratings of tiredness by walking time. Cardiorespiratory outcomes and muscle oxygen extraction were analyzed using breath-by-breath gas-exchange and near-infrared spectroscopy.Results: OLT resulted in large effects on walking endurance (1232 ± 446 s vs 1645 ± 255 s; d = 1.1; P = 0.045) and normalized perceived fatigability (5.3 ± 1.5 a.u. vs 3.6 ± 0.9 a.u.; d = 1.3; P = 0.033). Small-to-medium effects on absolute (2.8 ± 2.5 a.u. vs 4.2 ± 3.5 a.u.; d = 0.42; P = 0.035) and isotime (2.8 ± 2.5 a.u. vs 3.8 ± 3.0 a.u.; d = 0.33; P = 0.023) muscle oxygen extraction were also observed after OLT.Conclusion: These findings provide preliminary data supporting the potential for improved walking endurance, enhanced muscle O2 extraction, and reduced perceived fatigability in people with chronic cervical motor-incomplete SCI following the OLT program described in this study.

Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment

Introduction

There is weak relationship between the presence of lumbar spondylolisthesis [SPL] and low back pain that is not always associated with instability, either at the involved lumbar segment or at different spinal levels. Therefore patients with lumbar symptomatic SPL can be divided into stable and unstable, based on the level of mobility during flexion and extension movements as general classifications for diagnostic and therapeutic purposes. Different opinions persist about best treatment (conservative vs. surgical) and among conservative treatments, on the type, dosage, and progression of physical therapy procedures.

Purpose and importance to practice

The aim of this Masterclass is to provide clinicians evidence-based indications for assessment and conservative treatment of SPL, taking into consideration some subgroups related to specific clinical presentations.

Clinical implications

This Masterclass addresses the different phases of the assessment of a patient with SPL, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components. Regarding conservative treatment, self- management approaches and graded supervised training, including therapeutic relationships, information and education, are explained. Primary therapeutic procedures for pain control, recovery of the function and the mobility through therapeutic exercise, passive mobilization and antalgic techniques are suggested. Moreover, some guidance is provided on conservative treatment in specific clinical presentations (lumbar SPL with radiating pain and/or lumbar stenosis, SPL complicated by other factors, and SPL in adolescents) and the number/duration of sessions.

Future research priorities

Some steps to improve the diagnostic-therapeutic approach in SPL are to identify the best cluster of clinical tests, define different lumbar SPL subgroups, and investigate the effects of treatments based on that classification, similarly to the approach already proposed for non-specific LBP.

Vertical traction for lumbar radiculopathy: a systematic review

Background

Only low-quality evidence is currently available to support the effectiveness of different traction modalities in the treatment of lumbar radiculopathy (LR). Yet, traction is still very commonly used in clinical practice. Some authors have suggested that the subgroup of patients presenting signs and symptoms of nerve root compression and unresponsive to movements centralizing symptoms may benefit from lumbar traction. The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) on the effects of vertical traction (VT) on pain and activity limitation in patients affected by LR.

Methods

We searched the Cochrane Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science and PEDro from their inception to March 31, 2019 to retrieve RCTs on adults with LR using VT to reduce pain and activity limitation. We considered only trials reporting complete data on outcomes. Two reviewers selected the studies, extracted the results, and performed the quality assessment using the Risk of Bias and GRADE tools.

Results

Three studies met the inclusion criteria. Meta-analysis was not possible due to the heterogeneity of the included studies. We found very low quality evidence for a large effect of VT added to bed rest when compared to bed rest alone (g = − 1.01; 95% CI = -2.00 to − 0.02). Similarly, VT added to medication may have a large effect on pain relief when compared to medication alone (g = − 1.13; 95% CI = -1.72 to − 0.54, low quality evidence). Effects of VT added to physical therapy on pain relief were very small when compared to physical therapy without VT (g = − 0.14; 95% CI = -1.03 to 0.76, low quality evidence). All reported effects concerned short-term effect up to 3 months post-intervention.

Conclusions

With respect to short-term effects, VT may have a positive effect on pain relief if added to medication or bed rest. Long-term effects of VT are currently unknown. Future higher quality research is very likely to have an important impact on our confidence in the estimate of effect and may change these conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00102-5.

Effectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-Analysis

OBJECTIVE

Lumbar radiculopathy (LR) is a pain syndrome caused by compression/irritation of the lumbar nerve root(s). Traction is a well-known and commonly used conservative treatment for LR, although its effectiveness is disputed. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effects of different types of traction added to or compared with conservative treatments on pain and disability.

METHODS

Data were obtained from CENTRAL, PUBMED, CINAHL, Scopus, ISI Web of Science, and PEDro from their inception to April 2020. All randomized controlled trials on adults with LR, using mechanical traction, and without any restriction regarding publication time or language were considered. Two reviewers selected the studies, evaluated the quality assessment, and extracted the results. Meta-analysis used a random-effects model. Eight studies met the inclusion criteria, and 5 were meta-analyzed.

RESULTS

Meta-analyses of results from low-quality studies indicated that supine mechanical traction added to physical therapist treatments had significant effects on pain (g = -0.58 [95% confidence interval = -0.87 to -0.29]) and disability (g = -0.78 [95% confidence interval = -1.45 to -0.11]). Analyses of results from high-quality studies of prone mechanical traction added to physical therapist intervention for pain and disability were not significant. These results were also evident at short-term follow-up (up to 3 months after intervention).

CONCLUSION

The literature suggests that, for pain and disability in LR, there is short-term effectiveness of supine mechanical traction when added to physical therapist intervention.

IMPACT

This systematic review may be relevant for clinical practice due to its external validity because the treatments and the outcome measures are very similar to those commonly used in a clinical context.

Carbon Dioxide Expiration and Performance Fatigability Following Aerobic Exercise Training: A Longitudinal, Observational, Pilot Study

Purpose

This study examined the influence of aerobic exercise training (AET) on components of carbon dioxide expiration (VCO2), cardiorespiratory function, and fatigability.

Methods

Twenty healthy adults completed peak cardiopulmonary exercise (CPX) and submaximal tests before and after a vigorous, 4-week AET regimen. Each test was followed by a 10-min recovery and endurance test at 70% of peak wattage attained during CPX. Fatigability was assessed using testing durations and power output. Respiratory buffering (excess VCO2) and non-buffering (metabolic VCO2) were calculated. Data were analyzed for significance (p<0.05) using regressions and paired t-tests.

Results

Significant improvements in all measures of fatigability were observed after AET. A significant increase in excess VCO2 was observed, though not in metabolic VCO2. Excess VCO2 was strongly predictive of fatigability measures.

Conclusion

Significant decreases in fatigability are often observed in clinical populations such as obstructive or restrictive lung disease or pulmonary hypertension following AET, even when peak cardiorespiratory function does not appear to adapt. Decreases in fatigability appear to predict longevity with no yet identified mechanism. These results suggest that respiratory buffering and metabolic components of VCO2 may adapt independently to AET, introducing foundational plausibility for an influence of respiratory buffering adaptation to AET on fatigability status.

Role of Respiratory Buffering in the Relationship Between Recovery and Performance Fatigability Following Aerobic Exercise Training: A Longitudinal, Observational, Pilot Study

Purpose:

This study characterized the influence of excess expired carbon dioxide (excess V̇co 2) in the relationship between recovery and fatigability.

Methods:

Twenty healthy adults completed peak cardiopulmonary exercise tests (CPXs) and constant work rate tests before and after a vigorous, 4-week aerobic exercise training (AET) regimen. Each test was followed by 10 minutes of recovery and an endurance test at 70% of peak watts attained during CPX. Fatigability was assessed by measures of time to exhaustion and power output. Metabolic and recovery capacity indices were obtained. Data were analyzed using correlations and regressions and compared pre/post AET using paired t tests.

Results:

Significant improvements in recovery and fatigability were observed after AET, along with significant increases in total and excess V̇co 2. Relationships between measures of recovery and fatigability were observed, although strengths of the relationships were diminished after controlling analyses for the effect of excess V̇co 2.

Conclusions:

This study suggests that the ionic buffering capacity may moderate the relationship between recovery and fatigability. These results could have implications regarding AET-induced buffering dynamics, and its role in fatigue resistance when performing activities above moderate intensities. This may be of particular importance in patients with cardiopulmonary complications, unable to improve peak aerobic capacity.

Fatigability and Cardiorespiratory Impairments in Parkinson's Disease: Potential Non-Motor Barriers to Activity Performance

Parkinson's disease (PD) is the second most common neurodegenerative condition after Alzheimer's disease, affecting an estimated 160 per 100,000 people 65 years of age or older. Fatigue is a debilitating non-motor symptom frequently reported in PD, often manifesting prior to disease diagnosis, persisting over time, and negatively affecting quality of life. Fatigability, on the other hand, is distinct from fatigue and describes the magnitude or rate of change over time in the performance of activity (i.e., performance fatigability) and sensations regulating the integrity of the performer (i.e., perceived fatigability). While fatigability has been relatively understudied in PD as compared to fatigue, it has been hypothesized that the presence of elevated levels of fatigability in PD results from the interactions of homeostatic, psychological, and central factors. Evidence from exercise studies supports the premise that greater disturbances in metabolic homeostasis may underly elevated levels of fatigability in people with PD when engaging in physical activity. Cardiorespiratory impairments constraining oxygen delivery and utilization may contribute to the metabolic alterations and excessive fatigability experienced in individuals with PD. Cardiorespiratory fitness is often reduced in people with PD, likely due to the combined effects of biological aging and impairments specific to the disease. Decreases in oxygen delivery (e.g., reduced cardiac output and impaired blood pressure responses) and oxygen utilization (e.g., reduced skeletal muscle oxidative capacity) compromise skeletal muscle respiration, forcing increased reliance on anaerobic metabolism. Thus, the assessment of fatigability in people with PD may provide valuable information regarding the functional status of people with PD not obtained with measures of fatigue. Moreover, interventions that target cardiorespiratory fitness may improve fatigability, movement performance, and health outcomes in this patient population.

Effect of repeated locomotor training on ventilatory measures, perceived exertion and walking endurance in persons with motor incomplete spinal cord injury

STUDY DESIGN

Pre-Post, Repeated Measures.

OBJECTIVES

To determine if a warm-up bout of exercise could elicit a phasic ventilatory response to constant work rate (CWR) exercise in individuals with incomplete spinal cord injury (iSCI) during unsupported CWR treadmill walking. Describe the changes in ventilatory kinetics, ventilatory variability and ratings of perceived exertion (RPE) before and after 12 and 24 weeks of overground locomotor training (OLT). Investigate the relationship among minute ventilation (V_E) variability, RPE, and walking endurance.

SETTING

Laboratory.

METHODS

A 6-min CWR was used as a warm-up preceding a CWR, at the same walking speed, until volitional fatigue or 30 min. Breath-by-breath ventilatory data were examined during the second CWR using a mono-exponential model. V_E variability was calculated as the difference between the observed and predicted values. Data were time-matched before and after 12 and 24 weeks of OLT. A Pearson's correlation was used for V_E variability, RPE, and walking endurance.

RESULTS

A warm-up CWR did elicit a phasic ventilatory response. OLT resulted in faster ventilatory kinetics. Ventilatory variability reduced after 12 weeks of OLT but returned to pre-OLT values after 24 weeks of training. The change in V_E variability was correlated with the change in RPE throughout the study. 12 and 24 weeks of OLT resulted in significant improvements in treadmill walking time.

CONCLUSIONS

SCI patients can achieve a phasic ventilatory response to walking if the exercise bout is preceded by a warm-up. OLT normalizes the ventilatory kinetics and improves walking endurance. The change in V_E variability is correlated to RPE.

EMG median frequency shifts without change in muscle oxygenation following novel locomotor training in individuals with incomplete spinal cord injury

Objectives: To examine the effect of muscle fiber recruitment patterns on muscle oxygen utilization during treadmill walking in a group of individuals who have incomplete spinal cord injury.Methods: 5 participants with motor incomplete spinal cord injury (Age; 42.2 ± 18.8 years, Male; n = 4) completed an over ground locomotor training program. Muscle utilization/oxygenation and activation of the medial gastrocnemius were measured by near infrared spectroscopy and surface electromyography pre- and post-over ground locomotor training during two separate treadmill walking bouts at self-selected speeds. Outcomes were changes in deoxygenation hemoglobin/myoglobin concentrations, and the change in median power of the power spectrum of the electromyography after training.Results: A significant increase in median power of the power spectrum of the electromyography signal was observed during both bouts of treadmill walking, 6-minute walking bout and longer fatiguing bout (49% p = 0.047 and 48% p = 0.035, respectively) post-over ground locomotor training. There was no significant change in muscle utilization/oxygenation post-over ground locomotor training. There was no significant effect of median power of the power spectrum on deoxygenation hemoglobin/myoglobin during either of the walking bouts.Conclusions: The main finding of the current study was that median power of the power spectrum significantly increased following 12 weeks of over ground locomotor training, with no significant change in deoxygenation hemoglobin/myoglobin. The recruitment of more and/or larger motor units was seen in conjunction with no changes in muscle oxygen utilization for the same walking task.Implications for RehabilitationThe reduction of skeletal muscle innervation in Spinal Cord Injury may adversely affect the orderly recruitment of motor units, which could in turn blunt the oxidative metabolic response during physical activity.Over-ground locomotor could be a useful tool in the rehabilitative process following an incomplete spinal cord injury.

Cardiopulmonary exercise test indices of respiratory buffering before and after aerobic exercise training in women with pulmonary hypertension: Differentiation by magnitudes of change in six-minute walk test performance

While aerobic exercise training (AET) has generally been shown to improve 6-min walk test (6MWT) distance (6MWD) in patients with pulmonary hypertension (PH), a substantial number of patients appear to adapt differently, with minimal or even negative changes in 6MWT distance being reported.

PURPOSE

To compare post-aerobic exercise training adaptations in cardiorespiratory functional capacity across three groups of patients with PH: those with high (HI), low (LI) and negative (NEG) post-training increases in 6MWD.

METHODS

Participants were 25 females (age 54 ± 11 years; BMI 31 ± 7 kg/m²) who completed a vigorous, 10-week, thrice weekly, supervised treadmill walking exercise program. Cardiopulmonary exercise tests (CPET) and 6MWT were completed before and after training. Ten of the 25 participants were classified as HI (range = 47-143 m), 11 were classified as LI (range = 4-37 m) and 4 were classified as NEG (range = -17 to -53 m).

RESULTS

Peak CPET duration, WR and time to anaerobic threshold (AT) were significantly higher (p < 0.05) after training in both the LI and HI groups but not in the NEG group. There was a significant improvement in VE/VCO₂ (p = 0.042), PETCO₂ (p = 0.011) and TV (p = 0.050) in the HI group after training, but not in the NEG or LI group.

CONCLUSION

These findings suggest that sustained ventilatory inefficiency and restricted respiratory buffering may mediate exercise intolerance and impede the ability to adapt to exercise training in some patients with PH.

Modulation of left ventricular diastolic filling during exercise in persons with cervical motor incomplete spinal cord injury

PURPOSE

To characterize left ventricular diastolic function during an exertional challenge in adults with incomplete cervical spinal cord Injury (icSCI).

METHODS

In this cross-sectional study, a two-group convenience sample was used to compare left ventricular LV diastolic performance during a 5-10 W·min-1 incremental arm ergometer exercise protocol, using bioimpedance cardiography. Subjects were eight males with cervical incomplete spinal cord injury (icSCI; C5-C7: age 39 ± 14 years) versus eight able-bodied males (CON: age 38 ± 13 years). Left ventricular (LV) diastolic indices included end-diastolic volume (EDV) and early diastolic filling ratio (EDFR). LV ejection time (LVET), inotropic index (dZ/dT2) and stroke volume (SV) were compared between the groups at peak exercise, and maximum workload for the icSCI group (isomax).

RESULTS

EDV (at peak exercise:131.4 ± 7.3 vs 188.78 ± 9.4, p < 0.001; at isomax: 131.4 ± 7.3 vs 169 ± 23, p = 0.0009) and EDFR (at peak exercise 73 ± 14% vs 119 ± 11%, p = 0.006; at isomax 94 ± 10; p = 0.009) were significantly reduced in icSCI compared to CON, respectively. Significant differences in LVET (icSCI: 273 ± 48 vs CON: 305 ± 68; p = 0.1) and dZ/dT2 (icSCI: 0.64 ± 0.11 vs CON: 0.85 ± 0.31; p = 0.1) were not observed at isomax, despite a significant decrease in SV in the subjects with icSCI (77.1 ± 6.05 mL vs 105.8 ± 9.2 mL, p < 0.00) CONCLUSION: Left ventricular filling was impaired in the subjects with icSCI as evidenced at both peak exercise and isomax. It is likely that restrictions on the skeletal muscle pump mechanized the impairment but increased left ventricular wall stiffness could not be excluded as a mediator.

Effect of overground locomotor training on ventilatory kinetics and rate of perceived exertion in persons with cervical motor-incomplete spinal cord injury

Study design

Pre-post, pilot study.

Objectives

To characterize ventilatory (VE) responses to exercise following warm-up walking in individuals with chronic incomplete spinal cord injury (iSCI) during constant work rate (CWR) exercise. Secondarily, to investigate VE and tidal volume (VT) variability, and ratings of perceived exertion (RPE) before and after overground locomotor training (OLT).

Setting

Research laboratory.

Methods

A 6-min CWR walking bout at preferred pace was used as a warm-up followed by 6 min of rest and a second 6-min CWR bout at above preferred walking pace. The second CWR bout was analyzed. Breath-by-breath ventilatory data were examined using a curvilinear least squares fitting procedure with a mono-exponential model. VE and VT variability was calculated as the difference between the observed and predicted values and RPE was taken every 2 min.

Results

Participants (n = 3, C4-C5) achieved a hyperpneic response to exercise in VE and VT. OLT resulted in faster ventilatory kinetics and reductions of 24 and 29% for VE and VT variability, respectively. A 30% reduction in RPE was concurrent with the reductions in ventilatory variability.

Conclusions

OLT may improve ventilatory control during CWR in patients with cervical motor-iSCI. These data suggest that in some participants with iSCI, ventilation may influence RPE during walking. Future research should investigate mechanisms of ventilatory variability and its implications in walking performance in patients with iSCI.

Effectiveness of a "Spring Pillow" Versus Education in Chronic Nonspecific Neck Pain: A Randomized Controlled Trial

BACKGROUND

Different types of pillows have been proposed for neck pain, but no previous randomized controlled trial has investigated the effectiveness of a "spring pillow" for adults with chronic nonspecific neck pain.

OBJECTIVE

We evaluated the effectiveness of using a pillow made from viscoelastic polyurethane and 60 independent springs compared with an educational intervention in individuals with chronic nonspecific neck pain.

DESIGN

This was a randomized controlled trial with crossover study design.

SETTING

The setting was the Occupational Medicine Unit, University Hospital, Bologna (Italy).

PARTICIPANTS

We recruited 70 adults with chronic nonspecific neck pain, of whom 64 completed the trial.

INTERVENTION

Participants were randomly assigned to 2 groups. One group used the spring pillow for 4 weeks, and the other group followed educational advice for 4 weeks while continuing to use their own pillows. After 4 weeks of treatment and 4 weeks of washout, groups were crossed over. Pain perceived in the neck, thoracic, and shoulder areas and headache were the primary outcome measures. In addition, disability, sleep quality, subjective improvement, and pillow comfort were assessed. Measures were captured at pretreatment, after 4 weeks, after the 4-week washout period, and 4 weeks after crossover. The mean differences (MD) in outcomes between groups were assessed.

RESULTS

Treatment with the spring pillow appeared to reduce neck pain (MD = -8.7; 95% confidence interval [CI] = -14.7 to -2.6), thoracic pain (MD = -8.4; 95% CI = -15.2 to -1.5), and headache (MD = -16.0; 95% CI = -23.2 to -8.7). Reductions in shoulder pain were not statistically significant between groups (MD = -6.9; 95% CI = -14.1-0.3). Neither the crossover sequence nor the period (first vs second intervention administration) significantly affected the results.

LIMITATIONS

Education may not have been the best comparator for the spring pillow; drug consumption, actual pillow use, and the implementation of the educational suggestions as prescribed were not controlled.

CONCLUSIONS

Use of the spring pillow in this study was more effective than an educational intervention for improving cervical, thoracic, and head pain. Whether a spring pillow is more effective than other ergonomic pillows remains to be tested.

Evidence for managing chronic low back pain in primary care: a review of recommendations from high-quality clinical practice guidelines

AIM

Chronic low back pain represents a major problem throughout the world which is increasing largely because of the aging world population. Clinical practice Guidelines can be powerful tools for promoting evidence-based practice, as they integrate research findings in order to support decision making. This study aimed to review recommendations for the management of Chronic low Back Pain in primary care based on high-quality recent and recently updated Clinical practice Guidelines.

METHODS

CINHAL, PubMed, EMBASE, PEDro, Google Scholar, Government websites, Scientific Association websites were searched until April 2019. The retrieved documents underwent several consecutive selection steps: semi-automated duplicate screening, documents selection based on title and abstract screening. Finally, three independent investigators screened the documents for the selected inclusion criteria and reviewed the retrieved documents by means of the AGREE II instrument.

RESULTS

A total of 3055 records were retrieved, of which 10 Clinical practice Guidelines met the inclusion criteria. The overall quality of these Clinical practice Guidelines was moderately variable. The recommendations of four Clinical practice Guidelines deemed as "excellent" were extracted and summarized. Although we tried to implement the most comprehensive research strategies, some Clinical practice Guidelines may be missing due to publication bias or incomplete indexing.

CONCLUSIONS

This study showed a partial progress in respect of the methodological quality of the Clinical practice Guidelines. Several AGREE II domains demonstrated low scores, particularly the "applicability" and "monitoring and auditing criteria" are the domains most susceptible to amendments in future.Implications for rehabilitationClinicians should be aware that among recently published/updated clinical practice guidelines for the management of chronic low back pain in primary care only few were deemed to have high quality.Increasing evidence suggests the efficacy for self-management to improve low back pain outcome.Physical treatments are recommended in order to improve low back pain outcome while many physical modalities such as TENS, ultrasound, laser therapy are not.Psychological treatments are recommended and should be included as part of a broader treatment plan.

Predicting outcomes within an innovative post-acute rehabilitation model for older adults

BACKGROUND

Understanding the provision of health services to community-dwelling older adults is of great importance due to regulatory changes within post-acute care. The aim of this study was to illustrate pathways by which older adults, within an innovative post-acute care delivery model, move to either independence or re-admission back into higher levels of care to maximize the value of rehabilitation delivery.

METHODS

Clinical data specific to an episode of care (n = 30,001) provided to Medicare beneficiaries treated via a rehabilitation house-calls model of care in their homes and senior living communites were separated into training and test sets. Classification trees were fit on the training set's administrative and clinical variables. Descriptive statistics were calculated for the overall sample, patient characteristics, clinical characteristics, and clinical outcomes.

RESULTS

Subjects were 83.3 years on average, 69.4% were female, and 62.2% were seen in their own homes while 37.8% were in senior living. The key variables predictive of progressing to independence were total number of visits, the presence of the Patient Specific Functional Scale (PSFS), PSFS score at discharge and change in PSFS. Prediction accuracy of the classification tree on the test set was 82.4%.

CONCLUSIONS

Older adults progress to a higher degree of independence, instead of higher levels of care, via several distinct pathways within a rehabilitation house-calls model of care. A mix of service utilization and outcome variables are key predictors of each pathway and may be used to maximize the value of service delivery. Further examination of the predictors of outcome using administrative datasets drawn from different sub-sets of older adults across the post-acute care continuum is warranted.

Effects of Performance-Based Training on Gait and Balance in Individuals With Incomplete Spinal Cord Injury

OBJECTIVE

To determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI).

DESIGN

Convenience sample, prepilot and postpilot study.

SETTING

Human performance research laboratory.

PARTICIPANTS

Adults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury.

INTERVENTIONS

Two 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary.

MAIN OUTCOME MEASURES

Berg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway.

RESULTS

Fourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P<.001). SCI-FAI scores showed a mean increase of 2.47±3.44 (P=.01). Spatiotemporal measures of gait showed no significant changes.

CONCLUSION

This pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.

Left Ventricular Function Before and After Aerobic Exercise Training in Women With Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a chronic debilitating illness. The effects of vigorous aerobic exercise training (AET) on heart function in PAH are poorly understood.

METHODS

Eighteen women with PAH (aged 56.2 ± 8.8 yr, body mass index: 28.8 ± 7.3 kg/m) underwent 10 wk of vigorous AET. Cardiac function was observed at rest and peak exercise using bioelectrical impedance cardiography before and after the AET. Cardiac function was observed in a small PAH subset (n = 7) for 10 wk before beginning the AET. A cohort of sedentary women (n = 19) served as healthy controls.

RESULTS

Left ventricular ejection fraction (48 ± 9.2 vs 61.5 ± 13.3%, P = .034) and the systemic vascular resistance index (2258 ± 419.1 vs 2939 ± 962.4 dyn·sec/cm·m, P = .008) were lower at supine rest in the baseline PAH group versus the healthy group, as were peak exercise heart rate (140 ± 13.3 vs 170 ± 13.8 beats/min, P < .001) and systemic vascular resistance index (828 ± 141.1 vs 824 ± 300.9 dyn·sec/cm·m, P = .050) after controlling for age and heart rate. Systemic vascular resistance index measured at peak exercise decreased in the PAH group after AET (828 ± 141.1 vs 766 ± 139.6 dyn·sec/cm·m, P = .020). Left ventricular early diastolic filling ratio worsened in the PAH subset prior to AET (95.9 ± 19.4 vs 76.2 ± 18.9%, P = .043) and remained unchanged after AET.

CONCLUSION

Vigorous AET was not associated with significant declines in left ventricular systolic or diastolic function in women with PAH. Aerobic exercise training may be beneficial for reducing afterload and may preserve left ventricular diastolic function.

Optimization of Movement: A Dynamical Systems Approach to Movement Systems as Emergent Phenomena

The term "movement system" has been defined as "represent(ing) the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts."5 Although we do not dispute the advantage of defining the "movement system" as a physiological system, we contend that how the profession is identified with a monolithic "movement system" is imprudent. We contend that our scientific expertise regarding "movement optimization" should move forward by reconsidering how movement is produced (and potentially optimized) as a behavioral phenomenon in itself and abandon further attempts to promote "the movement system" with a purportedly unique and static label. We believe that reframing diagnosis is possible if there is a move away from an exclusive emphasis on classification of anatomical and physiological deviations from "normal" based on organismic constraints when such data yield, at best, an incomplete insight into functional performance that includes environmental and task constraints. The recent application of complex systems approaches to disciplines as diverse as medicine, biology, economics, and meteorology warrants thoughtful consideration of the potential benefits of incorporating similar advances in conceptualization of the central questions in physical therapy.

Validity, Reliability, and Responsiveness of the Spanish Version of the OPTIMAL Instrument

BACKGROUND

The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a self-report instrument developed to measure the ability to perform mobility actions.

OBJECTIVE

To validate a Spanish version of the OPTIMAL instrument.

DESIGN

Cross-cultural adaptation and validation study.

SETTING

Primary and specialized outpatient care settings.

PARTICIPANTS

Three hundred seven patients beginning physical therapy treatment and 30 subjects from the general population.

METHODS

A 2-part study was designed based on guidelines for cultural adaptation of patient-reported outcome measures.

OUTCOMES

Reliability was estimated by internal consistency (Cronbach α), SE of measurement, and test-retest reliability (intraclass correlation coefficient) at 2 weeks. Confirmatory factor analysis was performed to examine structural validity. The association with the Physical Functioning Subscale was assessed with Spearman correlation coefficients. OPTIMAL scores across different groups were compared with Mann-Whitney U and Kruskal-Wallis tests. Effect size, standardized response mean, and minimal detectable change were determined for responsiveness.

RESULTS

The Spanish version of the OPTIMAL instrument showed a similar structure to the original English questionnaire. Cronbach α was 0.95 for the difficulty and confidence scales. Intraclass correlation coefficient was 0.91 (95% CI 0.87-0.94) for the difficulty scale and 0.90 (95% CI 0.85-0.93) for the confidence scale. The SE of measurement was 5.11 for the difficulty scale and 6.54 for the confidence scale. The association with the Physical Functioning Subscale was strong and significant (P < .001). The 2 scales showed significantly different scores for each of the established patient groups. The effect size was 0.61 (95% CI 0.48-0.74) for the difficulty scale and 0.53 (95% CI 0.38-0.69) for the confidence scale. The standardized response mean was 0.97 (95% CI 0.78-1.13) for the difficulty scale and 0.76 (95% CI 0.48-1.01) for the confidence scale. The minimal detectable change, of a possible score of 100, was 14.2 for the difficulty scale and 18.1 for the confidence scale.

CONCLUSION

The Spanish version of the OPTIMAL has appropriate reliability, validity, and responsiveness and it is an adequate self-report instrument for the assessment of mobility actions.

LEVEL OF EVIDENCE

III.

Cervical Radiculopathy: Effectiveness of Adding Traction to Physical Therapy-A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cervical radiculopathy (CR) is a common cervical spine disorder. Cervical traction (CT) is a frequently recommended treatment for patients with CR.

PURPOSE

The purpose of this study was to conduct a review and meta-analysis of randomized controlled trials (RCTs) on the effect of CT combined with other physical therapy procedures versus physical therapy procedures alone on pain and disability.

DATA SOURCES

Data were obtained from COCHRANE Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science, and PEDro, from their inception to July 2016.

STUDY SELECTION

All RCTs on symptomatic adults with CR, without any restriction regarding publication time or language, were considered.

DATA EXTRACTION

Two reviewers selected the studies, conducted the quality assessment, and extracted the results. Meta-analysis employed a random-effects model. The evidence was assessed using GRADE criteria.

DATA SYNTHESIS

Five studies met the inclusion criteria. Mechanical traction had a significant effect on pain at short- and intermediate-terms (g = -0.85 [95% CI = -1.63 to -0.06] and g = -1.17 [95% CI = -2.25 to -0.10], respectively) and significant effects on disability at intermediate term (g = -1.05; 95% CI = -1.81 to -0.28). Manual traction had significant effects on pain at short- term (g = -0.85; 95% CI = -1.39 to -0.30).

LIMITATIONS

The most important limitation of the present work is the lack of homogeneity in CR diagnostic criteria among the included studies.

CONCLUSIONS

In light of these results, the current literature lends some support to the use of the mechanical and manual traction for CR in addition to other physical therapy procedures for pain reduction, but yielding lesser effects on function/disability.

Fatigability, oxygen uptake kinetics and muscle deoxygenation in incomplete spinal cord injury during treadmill walking

PURPOSE

The purpose of the present study was to characterize hypothesized relationships among fatigability and cardiorespiratory fitness in individuals with chronic motor-incomplete SCI (iSCI) during treadmill walking. The theoretical framework was that exacerbated fatigability would occur concomitantly with diminished cardiorespiratory fitness in people with iSCI.

METHODS

Subjects with iSCI (n = 8) and an able-bodied reference group (REF) (n = 8) completed a 6-min walking bout followed by a walking bout of 30-min or until volitional exhaustion, both at a self-selected walking speed. Fatigability was assessed using both perceived fatigability and performance fatigability measures. Pulmonary oxygen uptake kinetics (VO₂ on-kinetics) was measured breath-by-breath and changes in deoxygenated hemoglobin/myoglobin concentration (∆[HHb]) of the lateral gastrocnemius was measured by near-infrared spectroscopy. Adjustment of VO₂ and ∆[HHb] on-kinetics were modeled using a mono-exponential equation.

RESULTS

Perceived fatigability and performance fatigability were 52% and 44% greater in the iSCI group compared to the REF group (p = 0.003 and p = 0.004). Phase II time constant (τp) of VO₂ on-kinetics and ∆[HHb] ½ time during resting arterial occlusion were 55.4% and 16.3% slower in iSCI vs REF (p < 0.01 and p = 0.047, respectively).

CONCLUSIONS

The results of the present study may suggest that compromised O₂ delivery and/or utilization may have contributed to the severity of fatigability in these individuals with iSCI. The understanding of the extent to which fatigability and VO₂ and Δ[HHb] on-kinetics impacts locomotion after iSCI will assist in the future development of targeted interventions to enhance function.

Overground Locomotor Training in Spinal Cord Injury: A Performance-Based Framework

Background: Locomotor training (LT) is the most commonly used treatment to improve walking performance following spinal cord injury (SCI). The advancement of LT treatments requires the addition of integrative models accounting for the numerous systems responsible for the recovery of walking function following SCI. Objective: This perspective monograph aims to (a) describe a performance-based framework for overground LT (OLT), (b) describe principles of adaptation and motor learning used to inform OLT program design, and (c) present an example OLT program based on the proposed framework. Methods: Individuals with chronic motor-incomplete SCI (7 male, 1 female) classified according to the American Spinal Injury Association Impairment Scale (AIS) as C and D were included. OLT included two 90-minute sessions performed over 12 weeks for a total of 24 sessions. Outcomes measures included overground walking speed, walking economy, pulmonary oxygen uptake, and muscle oxygen extraction measured via near-infrared spectroscopy. Results: Preliminary findings demonstrate the potential of OLT, as describe here, to increase overground walking speed, improve walking economy, accelerate processes associated with oxygen delivery and utilization at the rest-to-work transition, and lower oxygen extraction requirements of skeletal muscle during walking in individuals with chronic motor-incomplete SCI. Conclusion: The proposed framework offers a valuable template for LT program design in both clinical and research settings. Further research is necessary to better understand the effects of OLT and how principles of specificity, progressive overload, and variation within the performance-based framework can be manipulated to maximize function, health, and quality of life in SCI.

THE ADOLESCENT MEASURE OF CONFIDENCE AND MUSCULOSKELETAL PERFORMANCE (AMCAMP): DEVELOPMENT AND INITIAL VALIDATION

BACKGROUND

Although the relationship of self-efficacy to sports performance is well established, little attention has been paid to self-efficacy in the movements or actions that are required to perform daily activities and prepare the individual to resume sports participation following an injury and associated period of rehabilitation. There are no instruments to measure self-confidence in movement validated in an adolescent population.

PURPOSE

The purpose of this paper is to report on the development of the AMCaMP, a self-report measure of confidence in movement and provide some initial evidence to support its use as a measure of confidence in movement.

METHODS

The AMCaMP was adapted from OPTIMAL, a self-report instrument that measures confidence in movement, which had been previously designed and validated in an adult population. Data were collected from 1,115 adolescent athletes from 12 outpatient physical therapy clinics in a single healthcare system.

RESULTS

Exploratory factor analysis of the 22 items of the AMCaMP using a test sample revealed a three factor structure (trunk, lower body, upper body). Confirmatory factor analysis using a validation sample demonstrated a similar model fit with the data. Reliability of scores on each of three clusters of items identified by factor analysis was assessed with coefficient alpha (range = 0.82 to 0.94), Standard Error of Measurement (1.38 to 2.74), and Minimum Detectable Change (3.83 to 7.6).

CONCLUSIONS

AMCaMP has acceptable psychometric properties for use in adolescents (ages 11 to 18) as a patient-centric outcome measure of confidence in movement abilities after rehabilitation.

LEVEL OF EVIDENCE

IV.

Rasch Analysis of the Italian version of Pain Catastrophizing Scale (PCS-I)

OBJECTIVE

The aim of this study was to investigate the psychometric properties of the Italian version of the Pain Catastrophizing Scale (PCS-I) in patients with chronic low back pain.

METHODS

In a cross sectional study a total of 150 subjects with chronic low back pain were included. The Italian translation of the PCS was administered to all subjects. The properties of the Italian version of the PCS were explored by a Rasch analysis.

RESULTS

The PCS-I, by means of few modifications, fitted the Rasch model and passed the independent t-test for a unidimensional scale. The response categories for item 2 ``I fell I can't go on'' needed to be collapsed from 4 to 3 levels. Only the item 7 ``I keep thinking to of other painful events'' showed fit residual that exceeded the chosen thresholds of ± 2.5. No Differential functioning (DIF) was observed for age, sex, marital status, BMI and smoking.

CONCLUSION

The Italian version of PCS, with the purposed modifications, seems to reflect a unidimensional construct of Pain Catastrophizing. The scale seemed to be quite robust across age, sex, marital status, BMI and smoking. Targeting of the scale was moderate. A raw score to metric conversion was proposed.

The accuracy of pain drawing in identifying psychological distress in low back pain-systematic review and meta-analysis of diagnostic studies

The aim of this systematic review and meta-analysis was to estimate the accuracy of qualitative pain drawings (PDs) in identifying psychological distress in subacute and chronic low back pain (LBP) patients. [Subjects and Methods] Data were obtained from searches of PubMed, EBSCO, Scopus, PsycINFO and ISI Web of Science from their inception to July 2014. Quality assessments of bias and applicability were conducted using the Quality of Diagnostic Accuracy Studies-2 (QUADAS-2). [Results] The summary estimates were: sensitivity=0.45 (95% CI 0.34, 0.61), specificity=0.66 (95% CI 0.53, 0.82), positive likelihood ratio=1.23 (95% CI 0.93, 1.62), negative likelihood ratio=0.84 (95% CI 0.70, 1.01), and diagnostic odds ratio=1.46 (95% CI 0.79, 2.68). The area under the curve was 78% (CI, 57 to 99%). [Conclusion] The results of this systematic review do not show broad and unqualified support for the accuracy of PDs in detecting psychological distress in subacute and chronic LBP.