Rehabilitative Sciences

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    Qualitative Analysis of the Reasons People with Spinal Cord Injury Opt to Enroll in an Exercise Program and their Barriers to Participation
    (2019-03-05) Ochoa, Christa; Froehlich-Grobe, Katherine; Tiu, Cindy
    Objective: Understand why people with spinal cord injury (SCI) enrolled in an online exercise trial, what barriers to exercise they cited, and their plans to address these barriers. Design: Qualitative study of participant responses during a 16-week online exercise trial where they completed weekly online modules that included completing skill building activities. Participants/methods: Eligible individuals experienced a SCI [greater than] 6 months, required wheelchair use outside the home, and reported/week. Advertisements were disseminated through SCI-specific organizations across the U.S. Qualitative data from participant responses were analyzed by identifying themes that emerged from responses to online activities. Two researchers independently read and coded all responses. All disagreements were discussed and final coding decisions were unanimously achieved with the principal investigator. Results: Participants (n=111) average age was 49.6 years old and they lived average of 14.3 years post-injury. Health reasons emerged as the leading reasons participants enrolled in the exercise trial. Nearly two-thirds (64.9%) of participants stated they joined the program to improve their health while over half (56.8%) reported a desire to improve their function. Time was noted as the leading exercise barrier (53.8%) and a quarter (27.7%) reported accessibility issues. Participant-generated solutions to address time constraints included scheduling exercise (68.2%) or using friends or technology to support (15.9%) exercise efforts. Accessibility issue solutions included locating accessible facilities (30%) and obtaining equipment (25%) for home use. Conclusion: Health issues emerged as the primary reason people with SCI enrolled in the study. Health issues included those similar to the general population regarding improving cardiovascular health and longevity and SCI-specific issues, such as improving function related to activities of daily living. Exercise barriers followed a similar pattern, with the predominant concern being lack of time and the second most commonly cited barrier being accessibility problems. Accessibility issues included lack of accessible facilities, equipment, and need for self-advocacy. Intervention approaches to promote exercise for people with SCI should address issues faced by those in the general population as well as SCI-specific issues.
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    Does High Intensity Aerobic Exercise Improve Postural Control for Older Adults?
    (2019-03-05) Wilson-Garcia, Mary-Catherine; Salvatore, Michael F.; Bugnariu, Nicoleta; Watson, Taylin
    Purpose: While falls are a major source of disability in the aging population, walking has been linked to reduced risk of falls for older adults1-2. Treadmill walking has even been shown to positively impact muscle-strengthening, motor control, and balance3. The purpose of this investigation was to determine if a high intensity aerobic exercise program can improve postural control in older adults. Methods: Participants completed 36, 1-hour exercise sessions, 3 times a week over 3-4 months, consisting of 40 min fast pace walk/jog, with a 10 min warm-up and cool down. A high intensity at minimum 80% max heart rate was aimed for as long as possible in each session, and intensity was progressively increased during training. Postural control was assessed at baseline (V1), mid-point during exercise training (V2) and at the end of exercise training (V3) using a dynamic balance task. A V-GAIT dual-belt treadmill was used to create surface perturbations and a 12-camera Motion Analysis system collected body kinematics. Backward surface translation perturbations inducing a forward loss of balance were presented randomly at two levels (2 m/s2 and 5 m/s2). Primary outcome measures were: maximum Center of Pressure – Center of Mass (COP-COM) distance during the first compensatory step and reaction time for initiating the first compensatory step. Paired sampled t tests with significance set at p Results: Preliminary results show that maximum COP-COM distance during the first compensatory step increased significantly from an average of 9.87 ± 1.70 cm to 19.92 ± 2.40 cm as the level of perturbation increased. The reaction time for initiating the first compensatory step in response to the slowest perturbation decreased significantly between V1 (608 ± 63 ms) and V3 (543 ± 17 ms), with a similar trend but no significant change in response to the fastest perturbation. Conclusions: Larger COP-COM distances during the first compensatory step are indicative of a robust postural control.4 A high intensity aerobic consisting of walking/jogging exercise on a treadmill improved the reaction time for initiating the first compensatory step in response to balance perturbations by an average of 50 ms, which is clinically meaningful for preventing a fall.
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    Soft Robotic Glove for Post-Stroke/Cerebral Palsy Hand Rehabilitation
    (2019-03-05) Patterson, Rita; Robinson, Jacob
    Soft Robotic Glove for Post-Stroke/Cerebral Palsy Hand Rehabilitation Jacob Robinson, UNTHSC OMS-II; Rita Paterson, PHD UNTHSC Objective: The upper extremity plays a vital role in manipulation, communication and overall quality of life. Upper limb hemiplegia is one the most common presentations of stroke and cerebral palsy. Stroke is projected to increase dramatically as the over 65 population increases. Cerebral palsy (CP) is a non-progressive brain injury that occurs during the pre, peri, and post-natal periods of life, with an incidence ranging from 2-4 per 1000 live births. The purpose of this study is to evaluate the rehabilitative capacity of a pneumatically actuated soft and rigid hybrid actuator hand exoskeleton system called the REHAB Glove. Testing has been performed for post-stroke hand complications and a smaller pediatric version is also currently being tested to determine functional outcomes in cerebral palsy cases. Research Question: Does the Soft Robotic Glove for post-stroke hand rehabilitation meet the basic standards for rehabilitation, can it be used on a pediatric scale for Cerebral Palsy patients and is it practical for patient use in an in-home setting? Methods: Prior to glove use subject demographics were collected and subjects were prepped with instructions and safety. Post-stroke Subjects were timed and assessed for ease of donning the glove and then participated in continuous passive motion (CPM) of the hand using the glove. Post glove assessments consisting of hand evaluation and survey for ease of use were then collected. CP subjects are being tested in a similar fashion. Results: From observation of 2 post-stroke patients, it has been noted that their hands can be very difficult to manipulate. This has complicated the process donning the glove to begin therapy. Detaching the finger portions of the glove from the pneumonic actuator device has been shown to simplify this process. The time elapsed to complete this process prior to modification was much greater, approximately a 608 sec. Also, redness has been noted in both stroke patients and 1 control subject for the CP study. Conclusion: More modifications are necessary to simplify the process of gloving the hand and further testing and evaluation is necessary prior to establishing definitive results. Alterations in areas of increased pressure on the skin should also be considered to reduce redness. Adult stroke IRB# 2015-154 CP glove # 2016-087
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    Treatment of hyperbaric oxygen combine with cannabidiol promote recovery of brain damage in newborn rats with hypoxia-ischemia
    (2019-03-05) Miller, Haylie; Quan, Lijuan
    Objective: Hypoxic-ischemic (HI) encephalopathy is a severe disease seen commonly in clinical settings. However, there is a limited body of work on effective therapies to repair HI brain damage. To test the potential neuroprotective effects of cannabidiol (CBD) and hyperbaric oxygen (HBO) treatments against HI brain damage, we carried out series of experiments on newborn rats with brain damage induced by HI. Methods: We included 7-day-old newborn rats in this study. After creating the HI model, rats were grouped into an untreated HI model group, an HI+HBO-treated group, an HI+CBD-treated group, HI+HBO+CBD-treated group, and a sham control group. After one week of treatment, a subset of pups completed a T-maze task, and we collected CSF to measure the concentration of NSE and S100 β protein. Afterwards, the pups were sacrificed and we measured the concentration of MDA, SOD, TNF-a and IL-β and expression level of TNF-a and NSE in hippocampal tissue. The remaining pups completed the radial arm maze and foot fault test. Results: Two weeks after HI (P22), pups showed reduced correct responses to retraction in the T-maze test, and P30 pups with HI needed more time to visit 3 baited arms. The number of errors increased in the radial arm maze, and number of foot-faults also increased in the foot-fault test. Along with loss of brain weight, concentration of SOD was reduced and MDA, TNF-a, and IL-β were increased in brain tissue. NSE and S100 β protein concentration increased in CSF, as well as the expression level of TNF-a and NSE. Pups that were treated with HBO, CBD, or HBO+CBD showed less brain weight loss and better performance on behavioral tests. They also had increased SOD and reduced MDA, TNF-a, and IL-β level of brain tissue, as well reduced NSE and S100 β protein in CSF. The expression level of TNF-a and NSE were also reduced. HBO+CBD treatment exhibited better therapeutic effect than HBO or CBD alone. Conclusions: The combination treatment of HBO+CBD on rat pups with HI-induced brain damage achieved better results in reducing brain damage and preserving neurobehavioral performance than HBO or CBD alone. This novel therapeutic may be an appropriate avenue for exploration in other models, given its neuroprotective potential. Keywords: hypoxia-ischemia; cannabidiol; hyperbaric oxygen; brain damage; combination treatment; neuroprotective
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    Effect of Enhanced External Counter pulsation on Exercise Endurance of Different Populations
    (2019-03-05) Quiben, Myla; Liu, Howe; Zhao, Mingming
    Abstract Background and Purpose: Enhanced external counter pulsation (EECP)is a beneficial adjunct therapy used widely according to Cardiac rehabilitation guideline. However, the relationship between EECP and exercise endurance in non-cardiac disease people is still unknown. So, we design this study to explore the effect of EECP on exercise endurance of normal people, athlete, and chronic obstructive disease (COPD) patients, for providing potential intervention approach to improve the exercise endurance of these people. Methods: All volunteers (24 normal people, 24 sprinter athlete,24 COPD patients,72 subjects totally enrolled) who referred for EECP therapy (i.e., 35–36 one-hour sessions within a seven-week period) to Jiangbin Hospital, Guangxi, China from June 1st to Sept 1ST, 2018 were included. Demographic data, vital signs, quadriceps femoris muscle strength (QFMS) and baseline cardiopulmonary exercise test (CPET) data were collected. Exercise endurance and MS data before and after the treatment were compared. Results: All subjects in this study who had under-gone EECP had a positive clinical response. QFMS of normal group, athlete group and COPD group improved (p2), metabolic equivalent (Mets), oxygen pulse (O2-Pulse) at anaerobic threshold significantly increased in all three groups (p2, O2puls, Mets were increased after EECP (p<0.05). Conclusions: Enhanced external counter pulsation significantly improved QFMS and the exercise endurance of normal people, athletes and COPD patients.This study’s findings support the continued use of EECP therapy in these three kinds of people and provide one putative physiological mechanism to help explain the improvements in muscle and exercise endurance. Key Words: enhanced external counter pulsation; normal people; low endurance athletes; COPD; exercise endurance
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    The Effect of Exercise Programs on Children with Autism Spectrum Disorder (ASD): A Review of Current Literature
    (2019-03-05) Rohani, Carmel; Bow, Emily; Miller, Haylie; Mobley, Rachael
    Purpose Autism Spectrum Disorder (ASD) is characterized by challenges with social skills and delays in motor skills (Bremer, Balogh, & Lloyd, 2014; Caçola et al., 2019). Children with ASD tend to have a greater need for therapy compared with other children with special healthcare needs, but accessing services can be expensive, time-consuming, and difficult (Benevides, 2015). It is important for families to have motor intervention options without barriers of financial resources, transportation, or access. A home exercise program, for example, could be completed with the family at convenient times in a familiar environment. This approach may increase the likelihood of intervention adherence, allowing children with ASD to improve their motor skills without experiencing many of the common barriers to care. Our objective is to identify trends and gaps in literature regarding exercise programs for children with ASD, and to determine the most beneficial exercises to improve motor skills in ASD. Methods We completed a literature search using a combination of terms with Boolean operators including: (autistic disorder OR autistic OR autism OR Asperger’s OR ASD OR pervasive developmental disorder) AND (motor intervention OR movement intervention OR movement therapy OR motor therapy OR exercise OR physical therapy OR PT OR HEP OR home exercise program). We limited our search to articles published in English within the last ten years. Three independent reviewers screened the articles to determine relevance. Results The search yielded 609 results, of which 20 empirical articles and 3 systematic reviews were relevant to the effects of exercise on ASD. Preliminary results show an emphasis on cognitive and behavioral effects of exercise, rather than motor benefits. Additionally, the majority of exercise programs were school-based; few included parent involvement in the exercise program. Conclusion The existing body of work suggests that exercise has significant benefits regarding behavior, cognitive function, and motor skills. However, there is a lack of research validating home exercise programs and parent involvement in exercise for children with ASD. We plan to identify a set of targeted, age-appropriate exercises and create a home exercise program for children with ASD designed to improve motor skills. This approach may be of greater value to the community than clinic or school-based motor interventions, given the commonly-reported barriers to care experienced by families.
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    Soft Robotic Exoskeleton for Cerebral Palsy Rehabilitation
    (2019-03-05) Haghshenas-Jaryani, Mahdi; Patterson, Rita; Schnell, Brittany; Antony, Dona; Carrigan, Katie; Cruz-Lugo, Maria; Wijesundara, Muthu; Baset, Neshat
    Purpose: This work presents development of a soft robotic exoskeleton to provide active and passive therapeutic-assistive hand motion for children between the ages of 5-12 suffering from Cerebral Palsy (CP) while recording and adapting to the current state of the hand. Cerebral Palsy is a birth related brain injury; studies have shown that 60-83% of children with CP have some form of upper extremity limitations that lead to reduced hand functions and quality of life. Soft robotic devices show promise as a therapy extender needed for motor learning while reducing the safety issues involved in conventional robotic systems. The developed soft exoskeleton is integrated with sensors that measure finger trajectory (inertial measurement units) and force (in-line pressure) associated with finger extension and flexion. Finger trajectory and associated forces will provide a quantifiable means for tracking therapy progression. Methods: The robotic exoskeleton includes five hybrid soft-and-rigid robotic digits attached on top of a wearable attachment. The soft robotic digits was designed based on the measurements from 16 children’s hands (7 girls and 9 boys in the range of 5-12 years old) to fit the children's range of hand sizes while it satisfies the kinematic compatibility with finger joint range-of-motion and center-of-rotation. The robotic digit is comprised of three inflatable bellow-shaped structure sections and four semi-rigid sections in an alternating order which correspond to the anatomy of a human finger. Fabricated with 3D printed injection molds and over molding techniques, the soft robotic digits were made using silicone rubber material. The robot is actuated using pressurized air, where it was successfully tested so that it can provide full range of motion with inflation pressure of 200 kPa. Results: Soft robotic exoskeletons in a small, medium and large size has been developed by assembling the robotic digits into the wearable attachment. Initial feasibility testing have been carried out on one healthy child (a 6 years old boy with medium hand size) to evaluate the operation, ease-of-use, and level of comfort provided by the robot. Results from the preliminary test and the feedback from the subject through the questionnaire indicated the ease-of-use, safety, and effective operation of the robot. Conclusions: We plan to extend this pilot study to CP patients to evaluate the effectiveness of the soft robotic exoskeleton on this population.
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    Hand Force Measurement Using A Human-Powered Linear Movement
    (2019-03-05) Baset, Neshat; Haghshenas-Jaryani PhD, Mahdi; Wijesundara PhD, Muthu; Patterson PhD, Rita; Schnell, Brittany
    Abstract Background: Cerebral Palsy (CP) is a neurological disorder that affects many motor functions, such as muscle tone. 60-80% of children born with CP neurological movement disorders have functional limitations in the upper extremity, depriving them of the opportunity of experiential learning through repeated reaching, grasping and manipulating objects. To help give the necessary mobility of hand function to those with CP, a therapist must be able to see if the current therapy methods are improving the range of motion. Currently, there are plenty of devices that test the amount of isometric hand strength but, not how much resistance to hand opening there is due to spasticity. Objective: Determine the amount of force it takes to open a subject’s hand, who has Cerebral Palsy. Starting from a closed fist position (0 degrees) to a fully extended position using a human powered mechanism. To test this force measurement device on all grade levels of CP hand function. Hypothesis: The load applied across a cylindrical handle, as it is being pulled away from the subject, will give an accurate readout of how much force it takes to open the hand of a subject with Cerebral Palsy. Method: The amount of force will be measured using a cylindrical handle with a load cell attached at either end. As the study conductor pulls the device away from the subject, via a handle on the opposite end and attached wheels, the hand is forced open causing a load to output. Results: A manual powered car will be pulled by a handle attached to the front of the car. On the opposite end of the car, a handle with an internal load cell at each end will read the amount of force it takes to open the hand. The subject will rest their arm on a 3D designed wrist stabilizer to prevent noise in the output. Conclusions: The current design will be able to provide an objective measure of hand stiffness that can be used to track rehabilitation progress. Future studies on the device’s ability to measures stiffness in other hand impairments are planned.
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    Biomechanical Assessment of TCC-EZ® Kits for Diabetic Foot Ulcers
    (2019-03-05) Monga, Aakshita; Richardson, Mike; Schwarz, Brandy; Garrett, Alan; Nyguyen, Dong; Quiben, Myles; Salem, Yasser; Lavery, Lawrence; Yavuz, Metin; Ersen, Ali
    Purpose: Diabetic foot ulceration has been tied to elevated plantar pressures and the presence of neuropathy. Traditional Total-Contact Casting (tTCC) is considered the gold standard for treating diabetic foot ulcers (DFUs). However, this intervention is not applicable to some patients with active ulcers. The tTCC application also requires expertise which may not be available in all healthcare facilities, a limiting factor in its widespread implementation. Many physicians prefer the alternative route in treating DFUs which entails the use of off-the-shelf off-loading devices, such as diabetic boots. While diabetic boots are subject to patient compliance issues, they also have advantages such as being practical to implement. There are also new products such as TCC-EZ® kits on the market that offer a user-friendly casting process for healthcare providers. To the best of our knowledge, comparison of the offloading characteristics of TCC-EZ and tTCC has not been done. The purpose of this study was to determine whether plantar pressures, gait speeds, and cast weights are different between the two modalities (TCC-EZ vs. tTCC). Methods: In this ongoing pilot study, 14 individuals (nine male, five female; median age of 47.8 (40.5 to 66.1)) participated, ten were healthy and four have diabetic neuropathy. Participants were casted and instructed to complete three 30-meter walking trials at a comfortable pace with two modalities on the day of testing in a randomized order. Time to traverse the path was captured using automated photogate sensors (Dashr Systems, Lincoln, NE), and plantar pressures were measured using Pedar (Novel, Munich, Germany) pedobarographic insoles. Paired t-tests were used to compare peak pressures, gait speed, and cast weights across the two modalities. All study procedures were approved by the North Texas Regional Institutional Review Board (IRB) prior to recruitment and testing, and informed consent was obtained from subjects prior to testing. Results: Gait speed was significantly higher (0.96±0.20m/s vs. 0.85±0.26m/s; p=0.014) whereas cast weight (1.79 ± 0.17 kg vs. 2.09 ± 0.25 kg; p=0.001) was significantly lower in the TCC-EZ group. No difference was detected (p=0.935) in peak pressures (296±84kPa vs. 295±84kPa) between the two modalities. Conclusion: The prefabricated kit of the TCC-EZ and its ease of application has the potential to reach a wider patient population while offering noticeable pressure reduction to patients with DFUs. Based on our results, faster walking speeds indicate that the product may improve patients’ ability to walk who prefer a more active lifestyle. Further work is needed to evaluate the activity, durability, rate of DFU healing and adverse events associated with these two modalities.
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    (2019-03-05) Fahmy, Mostafa; Liu, Howe; Quiben, Myles; Yavuz, Metin; Salem, Yasser; Aggarwal, Sonali
    Purpose: Cerebral palsy (CP) is the most common cause of childhood physical disability. The purpose of this systematic review was to examine evidence regarding the potential benefits of aquatic exercise for children with CP. Safety, outcomes, and applications are addressed. Methods: Electronic databases used were PubMed/MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Physiotherapy Evidence Database (PEDro), and Scopus. Additionally, we performed a hand search of the reference lists of relevant studies. Studies were included if they met the criteria of diagnosis (any form of CP), population (aged 0-21), and intervention (aquatic exercise). Quality of the included studies was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale. Results: Of the 17 studies, three were randomized controlled trials, three were cohort studies, seven were quasi-experimental design, one was a prospective time series group design, two were case reports, and one was a case study. The sample sizes for the included studies ranged from 1 to 46 subjects. In total, 319 children with CP were analyzed. The duration of treatment ranged from 6 weeks to 6 months, with frequency of sessions varying between 1 to 3 times a week, and length of sessions averaging between 30 to 60 minutes. A range of aquatic exercises and techniques were used to address multiple impairment areas, including upper and lower extremity strengthening and stretching, balance, aerobic capacity, water adjustment skills, and gait. Various outcome measures were used to assess effectiveness of aquatic exercises including gross motor function, ROM, balance, gait, energy expenditure, social acceptance, and self-esteem measures. Conclusion: The evidence suggests that aquatic exercise programs may be effective in the short term for improving gross motor function, gait parameters, social function, and self-esteem in children with CP ages 0-21. The evidence also suggests that aquatic exercise is a safe and fun treatment option for this population, with no reports of adverse effects. The overall body of evidence is inconclusive due to a lack of high-quality evidence, small sample sizes. There is significant variability between studies in intervention parameters (frequency, duration, intensity, etc.), disease severity of subjects, and outcome measures used to document changes.
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    Spontaneous Regression of a Cervical Disc Herniation: A Case Report
    (2019-03-05) Paslay, Emily
    Abstract Background and purpose: The purpose of this report is to highlight a case of a cervical disc herniation and spinal cord compression that regressed spontaneously following conservative treatment. The natural history and positive likelihood of spontaneous regression of disc herniation in the lumbar spine have been well documented.1,5.6However, the clinical course of cervical disc herniation remains poorly established.2-4Due to the concern for spinal cord injury, patients with signs of cord compression are often referred for surgery.3This case, along with others mentioned in the literature, suggests the possibility of disc regression and symptom improvement with conservative treatment. Case Information: The patient was a 34-year-old female who presented to her primary care physician with nontraumatic onset of neck pain and right upper extremity tingling and pain one month prior. Magnetic resonance imaging (MRI) of the cervical spine revealed a four-millimeter, paracentral disc extrusion at C6-7 with migration to the body of C7 and spinal cord flattening. The patient was referred to a neurosurgeon who recommended surgical intervention due to evidence of spinal cord compression and risk of myelopathy with future injury. The patient refused surgical intervention at that time. Following conservative treatment, an MRI performed six months later revealed spontaneous regression of the C6-7 herniation from four millimeters to two millimeters with no evidence of spinal cord compression. Right upper extremity symptoms resolved and neck pain significantly decreased, with the greatest improvement occurring in the first two months. Conclusions: In cases of cervical disc herniation with spinal cord compression, the treatment course historically favors surgical intervention; however this report reveals a case of cervical disc herniation with spinal cord compression that spontaneously regressed in six months resulting in resolution of upper extremity radicular symptoms. There are similar case reports in the literature, though only two known cases have been reported within the last ten years. Future studies should be designed to capture higher level evidence of the natural history of large cervical disc herniation with cord compression. References Chiu CC, Chuang TY, & Chang KW. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation. 2014; 29(2), 184-195. Wong JJ, Cote P, Quesnele JJ, et al. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. The Spine Journal. 2014; 14(8),1781 – 1789. Pan H, Xiao LW, Hu QF. Spontaneous regression of herniated cervical disc fragments and its clinical significance. Orthopaedic Surgery. 2010; 2(1), 77-79. Kim SH, Park MY, Lee SM, et al. Acupuncture and spontaneous regression of a radiculopathic cervical herniated disc. Journal of Pharmacopuncture. 2012; 15(2): 36 – 39.