Rehabilitative Sciences

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    Effectiveness of Sternal Precautions after Median Sternotomy: A Systematic Review
    (2017-03-14) Quiben, Myla PT, PhD, DPT, GCS, NCS Associate Professor; MacDonald, Marie
    Purpose: The purpose of this systematic review is to analyze the current scope of literature on the effectiveness of sternal precautions or specific movement restrictions to reduce risk of sternal complications following a median sternotomy. Methods: A systematic database search was completed using PubMed, MEDLINE Complete, PEDro, Scopus, and Cochrane. Each database was searched using the key words: “sternotomy”, “sternal precautions”, “sternal restrictions” AND “sternal stress”. Articles published in English between 2010 & 2014 based on the use of sternal precautions in patients’ after sternotomy as one of the primary interventions, experimental designs comparing the forces applied on the sternum, and systematic reviews were included. Articles were excluded if interventions did not include use of sternal precautions. Two articles where further identified through searching the studies cited in the current reviews. After duplicate articles were excluded, 7 articles were left for screening of the abstract for relevance on sternal precautions. Six articles satisfied the criteria for full text screening. One article was excluded due to lack of access to the full text. Results: The current evidence suggests that significant variations in the use of sternal precautions or specific movement restrictions after a median sternotomy exist. There is no consensus on the clinical definition of these precautions causing wide variation in the application of sternal precautions. To date, paucity of evidence exists in supporting the use of restrictive sternal precautions. Conclusions: The body of evidence on the use of sternal precautions is scarce. While the risk of complications and predictors of risk following a median sternotomy are thoroughly studied on a physiological level, the movement factors influencing recovery have little to no evidence. Further research is needed to investigate if these movement restrictions are necessary and if they influence outcomes, recovery, and quality of life. Clinicians must consider the patient’s unique characteristics including comorbidities, impairments, functional limitations, and prior level of activity when prescribing sternal precautions, rather than restricting functional and physical activities based on a protocol applied homogeneously to all patients after median sternotomy.
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    Atypical eye movements and postural control in Autism Spectrum Disorders (2017)
    (2017-03-14) Miller, Haylie; Bugnariu, Nicoleta; Mattingly, Laura; Green, Kaitlyn
    Hypothesis: Research shows a link between pursuit eye movements, visual processing, and postural control; current evidence suggests these links are different in individuals with Autism Spectrum Disorder (ASD). For those with ASD, few studies quantitatively examine visuomotor integration and its influence on postural stability. The purpose of this study was to observe individuals with ASD and those with typical development (TD) in order to identify and characterize differences in how visual information and eye movement are used for postural control. Materials/Methods: This study was conducted in community sites in the Dallas-Fort Worth metroplex. Five adolescents with ASD and 5 age matched TD controls completed the study. The experiment consisted of balance testing, including the Limits of Stability (LOS) and The Clinical Test for Sensory Integration (CTSIB), on a force plate while wearing the ETG 2.0 eye tracking system. The CTSIB requires quiet standing with eyes open, eyes closed, and wearing a translucent dome. The LOS requires a shift in center of pressure (CoP) to reach 9 target positions displayed on the screen. Data were analyzed with t-tests. Results: ASD adolescents had higher sway and stability indices than TD across all conditions of the CTSIB. During LOS testing the ASD group had lower postural control than the TD group in 5 of the 9 target positions. Overall, ASD group took a longer time to complete the task, which is a proxy for movement accuracy, since the task advances when participants meet “hit” criteria for each target. Pursuit eye movements and stabilization of targets showed greater variability in ASD group compared to TD. Moreover, the ASD participants did not improve their performance across the 3 trails of the LOS. Conclusions: These preliminary data support our hypothesis that individuals with ASD would have greater postural instability than TD controls. These impairments may be linked to increased variability and less accuracy of pursuit eye movements. When visual context was eliminated, individuals with ASD demonstrated markedly greater impairment in stability. When LOS were tested, the ASD group showed greater difficulty maintaining postural control during CoP shift. Preliminary eye movement data suggests that atypical gaze patterns relate to impairments in stability. Further studies are necessary to investigate this atypical visiomotor integration and its possible role as a fundamental feature of ASD.
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    A Matter of Balance Service Learning Activities Positively Impact both Physical Therapy Students and Seniors Confidence
    (2017-03-14) Bugnariu, Nicoleta; Kinzler, Brenda
    Purpose/Hypothesis: The purposes of this study were to investigate the impact of Service Learning (SL) activities consisting of A Matter of Balance (AMOB) classes on: 1) physical therapy (PT) students’ self-perceived confidence in working with older adults and 2) seniors’ attitude towards fear of falling. We hypothesized PT students will have an increase in confidence working with seniors after participating in SL activities. Secondly, we hypothesize seniors who participate in the fall prevention course will have a decreased fear of falling as well as an increase in physical activity levels. Materials/Methods: The PT department established a collaborative relationship with Senior Citizen Services (SCS), an organization which identified a community need for senior education regarding fall risk reduction. The SL activities consisted of 86 PT students from two consecutive cohorts of a first-year geriatrics course: 1) attending an 8-hour training class in AMOB: A Fall Prevention Course and 2) leading 8 classes of AMOB workshops at senior community centers in Tarrant County, TX. PT students completed a 25-question questionnaire rating self-perceived levels of competence at pre-training, post-training and post workshops. 490 older adults ranging from 62-96 years of age, whom voluntarily signed up for a fall prevention course through the Senior Citizens Service (SCS) completed a questionnaire addressing their fall concerns and fears; pre and post AMOB workshops. The questionnaires for the older adults were collected over the course of a two-year period by the SCS. Results: Both student cohorts had similar confidence levels at the beginning of SL activities. All students reported increased confidence in essential competencies for assessing and mediating the risk for falls in older adults post AMOB trainings. Conclusions: Integrating SL into a first-year geriatric course improved students’ confidence and competence when working with the older adult population. PT students will apply this confidence in the clinical setting and will be prepared to effectively evaluate and treat the growing older adult population. Providing education regarding fall reduction may improve the safety and wellness for older adults, possibly leading to injury reduction and hospitalization.
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    Soft Robotic Devices for Hand Rehabilitation: A Narrative Review
    (2017-03-14) Patterson, Rita; Chu, Chia-Ye
    Objective: The debilitating effects on hand function from a number of a neurologic disorders has given rise to the development of rehabilitative robotic devices aimed at restoring hand function in these patients. To combat the shortcomings of previous traditional robotics, soft robotics are rapidly emerging as an alternative due to their inherent safety, less complex designs, and increased potential for portability and efficacy. While several groups have begun designing devices, there are few devices that have progressed enough to provide clinical evidence of their design’s therapeutic abilities. Therefore, a global review of devices that have been previously attempted could facilitate the development of new and improved devices in the next step towards obtaining clinical proof of the rehabilitative effects of soft robotics in hand dysfunction. Methods: A literature search was performed in SportDiscus, Pubmed, Scopus, and Web of Science for articles related to the design of soft robotic devices for hand rehabilitation. A framework of the key design elements of the devices was developed to ease the comparison of the various approaches to building them. This framework includes an analysis of the trends in portability, safety features, feedback augmentation, actuation systems, active DOF, device weight, evaluation metrics, and modes of rehabilitation. Results: In this study, a total of twenty-seven articles representing twenty unique devices were identified and summarized according to the framework we developed to compare different design aspects. By far, the most common type of device was a Flexion Pneumatic System (80%). However, the remainder of our framework elements yielded more heterogeneous results. Consequently, those results are summarized and the advantages and disadvantages of many design choices as well as their rationales were highlighted. Conclusions: The past three years has seen a rapid increase in the development of soft robotic devices for hand rehabilitative applications. These mostly preclinical research prototypes display a wide range of technical solutions which have been highlighted in the framework developed in this analysis. More work needs to be done in actuator design, safety, and implementation in order for these devices to progress to clinical trials. It is our goal that this review will guide future developers through the various design considerations in order to develop better devices for patients with hand impairments.
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    Effects of Aerobic Exercise for Children with Down Syndrome: A Systematic Review of Literature
    (2017-03-14) Jay, Natalie; Cook, Rachael; Liu, Howe; Salem, Yasser; Downing, April
    Purpose: The purpose of this study is to examine evidence regarding the potential benefits of aerobic exercise for children with DS. Safety, benefits, and application are addressed. Methods: This systematic review identified thirteen articles that met our inclusion criteria. Electronic databases used were PubMed, PEDro, CINAHL, and Scopus. Key words included Down syndrome, trisomy 21, aerobic, aerobic capacity, cardiovascular, cycling, fitness, exercise, endurance, running, and swimming. Our initial search yielded 154 potential articles, which we screened for selection criteria. In total, 464 children with DS were studied in our thirteen final research articles. Results: A total of thirteen articles were examined and met our inclusion criteria for aerobic exercise in children with DS. Of the included articles, eleven were randomized controlled trials, one was a quasi-experimental design, and one was a cohort study. Across all 13 studies, 464 children with DS were participants. The sample size for each study ranged between 16 and 92 children. All of the studies showed a significant improvement in one or more positive outcome, including bone mineral density, body composition, pulmonary function, lower extremity muscle strength, joint kinematics, reaction time, and balance. None of the studies reported any adverse events or changes in health status during their interventions. Only two of our included studies (15%) included follow up. Conclusions: This systematic review adds to the body of literature that supports aerobic exercise for children with DS. Studies included support the beneficial effects of aerobic exercises for children with DS. Further studies are needed to determine long term effects of any intervention. Available literature on aerobic exercise in children with DS suggests that there are beneficial effects without adverse outcomes, which means it is a reasonable treatment option for children with DS.
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    Resistance Training for Activity Limitations in Older Adults with Skeletal Muscle Function Deficits: A Systematic Review
    (2017-03-14) Papa, Evan; Dong, Xiaoyang; Hassan, Mahdi; Hummel-Kerbs, Hillary
    Objective: Resistance training (RT) is defined as any strength training program in which participants exercise a muscle against an external force that is set to a specific intensity. RT is a critical component of rehabilitation programs for preserving functional activity in older adults. Skeletal muscle function deficits, such as sarcopenia, can be improved with RT. The purpose of this systematic review was to provide an overview of the current knowledge on RT for older adults with sarcopenia and offer recommendations for clinical practice to improve functional mobility for patients. Methods: This study was conducted according to the Methodology to Develop Systematic Reviews of Treatment Interventions developed by the American Academy for Cerebral Palsy and Developmental Medicine. A search was performed in PubMed with the following inclusion criteria: average age 60+, RT as the only intervention, and functional mobility as the primary outcome measure. Exclusion criteria included absence of supplementary training measures, absence of chronic neurological conditions, any article that was published prior to 2008. Articles were limited to publications in the English language. Articles were summarized and effect sizes were calculated using Cohen’s d for each intervention. Results: Eleven articles were included in this systematic review. There was a general consensus that one-hour training sessions on alternate days of the week, 2-3 times per week was enough time to make significant improvements in function. The articles with the highest effect sizes were an average of 10.5 weeks; the shortest being 6 weeks and longest being 13 weeks. Two studies examined core strengthening which showed an average effect size of 1.13 on the Functional Reach Test (FRT). Seven studies focused on the strengthening the large muscle groups in the lower extremities. These articles described notable effect sizes in functional outcomes such as eyes closed single leg balance (0.81), Timed Up and Go (1.45), 10-meter walk test (0.85), timed chair rise (2.42), FRT (5.28), and maximal lateral lean (0.88). Conclusions: Resistance training can attenuate age-related changes in muscle function. To improve functional outcomes in older adults with sarcopenia we recommend a 60-minute RT exercise program to be performed 2-3 times per week. RT sessions should be dosed at 2-3 sets of 8-12 reps, with a 2-minute rest between sets.
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    Comparison of Trunk and Leg Sway During Single Leg Stance
    (2017-03-14) Liu, Howe; Dillard, David; Baker, Stephen; Pennucci, Matt
    Purpose/Hypothesis: A force platform is a commonly used instrument to evaluate body sway. However, such a platform is not able to analyze how different body parts respond during static single-leg stance. The purpose of this study was to use a small wearable gyroscope-based balance assessment instrument, Balance Gear, to investigate how different body parts respond during static single-leg stance. We hypothesized that measurements at the knee would exhibit more sway than measurements taken at the lumbar level. Materials and Methods: Nineteen (10 males and 9 females) healthy young graduate students from the principal investigator’s institution were screened and recruited for this study. The Balance Gear (BG) was secured at two locations: L4 level (LUM), and popliteal fossa (KN) of the dominant leg. Testing location was randomized in order to avoid fatigue effect. Subjects were asked to perform static single-leg stance on the dominant leg for 30 seconds. Data of the subject’s body sway (direction, range, velocity, and acceleration) were recorded and transmitted wirelessly to a computer for data storage and analysis. Paired t-tests were used for data processing. Results: Subjects with the BG at KN showed a statistically significant difference in body sway range, velocity, and acceleration in the antero-posterior plane (p.05). Also, both LUM and KN sway posteriorly, but KN showed significantly larger range, velocity and acceleration compared to sway at LUM (all p Conclusions: It is the very first time the sway of different body parts were assessed during static single-leg stance. During stance, the KN is larger in range, velocity, and more posterior direction than the LUM sway.
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    A Novel Cooling Wheelchair Design as a Proof-Of-Concept Study
    (2017-03-14) Liao, En-Szu; Foster, Veronica; Hankins, Christopher; Martin, Sloane; Adams, Linda; Richardson, Mike; Yavuz, Metin; Ersen, Ali
    Background: For many wheelchair users, the combination of reduced mobility and impaired sensation, including but not limited to neurological insults, vascular issues, decreased cognition, and morbid obesity, results in a life-time risk of pressure ulcer development. Pressure ulcers are a type of wound that results from a breakdown of tissue over bony prominences due to localized ischemia caused by constant pressure. The compromised blood circulation along with reduced airflow results in an accumulation of heat in the tissue over the bony prominence which accelerates the tissue breakdown. In recent years, wheelchair cushions employed thick foam type materials, which provided a higher quality of pressure distribution but poorer heat dissipation. Purpose: In this study, we designed a custom-built cushion that circulated chilled water. We measured buttocks surface temperatures and peak pressures around the ischial tuberosity, with a targeted maximum temperature and pressure of 28°C and 60mmHg, respectively. Methods: In this ongoing study, we recruited one subject so far. The subject was asked to sit and actively propel the wheelchair with the aforementioned cushion for 30 minutes. Thermal images of the participant’s buttocks were collected before and after wheelchair use and temperatures were collected in 10 minute intervals while seated, using thermocouples (K-type). Pressure distribution was captured at the end of the wheelchair use using a Tekscan ConforMat, which was placed on top of the cooling cushion. All study procedures were approved by the institutional review board (IRB) prior to recruitment and testing, and informed consent was obtained from subjects prior to testing. Results: The results indicated that the cooling wheelchair cushion was capable of cooling the tissue from 28.1°C to 24.9°C. The chilled water temperature ranged from 21.5-21.8°C during wheelchair use. Peak pressure occurred at the right ischial tuberosity and was quantified as 115mmHg. Conclusions: The custom-built cooling wheelchair cushion maintained temperatures of the buttocks below 28°C but failed to lower the peak pressure to below 60 mmHg. Further modification and testing of the cushion design are warranted to achieve the pressure reduction goal. Another improvement will be adding a closed-loop control system to prevent overcooling of the tissue.
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    The Impact of Hearing Loss on Older Adult’s Postural Control and Gait Function
    (2017-03-14) Kowalewski, Victoria; Thibodeau, Linda; Patterson, Rita; Bugnariu, Nicoleta; Fox, Jordan
    Purpose: We investigated the relationship between hearing loss and postural control and balance in older adults using a dual task paradigm in a realistic virtual environment. We also evaluated the effect of two types of Hearing Aid (HA) technologies on measures of balance and gait. We used a regular HA that amplifies sound from all directions and frequencies and a Frequency Modulator (FM) system designed to work in conjunction with the regular HA and to selectively amplifies only one frequency of interest and not the ambient noise. Materials/Methods: 12 adults newly diagnosed with hearing loss, without vestibular or other neurologic impairment; 12 age- and gender- matched healthy controls. Participants were tested for balance, gait and functional activities, at the time of hearing loss diagnosis and enrollment in the study and after two months accommodation to a hearing aid. Outcome measures included: standing center of pressure sway during quiet standing, performance of dual task involving balance + auditory standardize testing, and self- selected gait speed on flat and uneven terrain in the virtual environment. Testing conditions were: No HA, HA, Ha + FM; auditory task conditions either listening only or repeating back sentences form standard audiology tests. Clinical tests of DGI, TUG, ABC Scale and Short Physical Performance Battery were also administered. ANOVA was conducted for each of the dependent variables with respect to group, condition of HA, and condition of auditory task. Results: Center of pressure sway variability in both A/P and M/L direction was increased (p Conclusions: Hearing loss negatively impacts postural control particularly in dual-task conditions when individuals attend to both auditory and postural tasks. Use of hearing aids, especially the FM system, significantly improves not only speech recognition but also measures of balance and gait, and ability to successfully perform dual tasks.
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    Rehabilitation of Hand Impairment in Children With Spastic Cerebral Palsy: A Narrative Review
    (2017-03-14) Patterson, Rita PhD; Jordan, Nicolas
    Purpose: A broad range of rehabilitative therapies are currently being used and/or researched to improve functionality and prevent complications in hand impairments due to spastic cerebral palsy in children. However, outcomes are highly variable and no ideal rehabilitation strategy exists. The purpose of this research was to identify the current state of non-surgical therapies for spastic cerebral palsy in children, and to offer recommendations for the development of new treatment modalities. Methods: Articles were identified through searches of Pubmed and Scopus. Medical Subject Headings (MeSH) terms and key words were used as follows: (1) cerebral palsy, AND (2) child OR adolescent, AND (3) hand, AND (4) therapy OR rehab*, AND (5) randomized controlled trial OR random sampling OR double blind method OR single blind method OR systematic review. Results: In this study, a total of forty-one articles representing six approaches to therapy were reviewed. The approaches were traditional occupational therapy, hand-arm bimanual intensive therapy (HABIT), constraint-induced movement therapy (CIMT), botulinum toxin injections, mirror visual feedback, and robotic assisted motion. Additionally, this review identified key factors of therapy that are relevant to patient outcomes, including the age of the patient, intensity of therapy, and compliance of at-home training. Conclusions: Traditional therapy relies heavily on the frequency, duration, and consistency of the therapy. Thus, patient ability to attend sessions can limit the effect of therapy. HABIT, CIMT, and mirror visual feedback are effective approaches, but they are only applicable to unilateral impairments. Patients given Botulinum toxin injections show significant improvement, but injections every three to six months are a costly addition to therapy. Soft robotic rehabilitation is a promising extension of therapy; specifically, it could target the critical developmental window and fill the need for an easy-to-use device to improve at-home training compliance and intensity. Additionally, soft robotic rehabilitation would be applicable to a wide variety of clinical presentations. Regarding development of soft robotic devices, comfort and ease of use are of the upmost importance to encourage compliance. Additional considerations must be made for the target population; for example, the device must accommodate growth spurts and skeletal maturation.
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    Effects of Muscle Fatigue on Postural Control in Neurologically-Impaired Populations
    (2017-03-14) Wigley, Ryan; Papa, Evan; Jeffers, Trey
    Purpose: Research has shown that acute muscle fatigue alters postural control in neurologically healthy young and older individuals, but there is little research on the effects of muscle fatigue on neurologically impaired individuals. The purpose of this literature review was to examine the effects of short-term muscle fatigue on postural control as it relates to neurologically impaired populations. We hypothesized that muscle fatigue would cause declines in postural control in persons with neurological impairment such as stroke, Parkinson’s disease (PD), and Cerebral palsy. Subjects: N/A Methods: A literature review using the key words “muscle fatigue” and “postural control” was performed in PubMed and PTNow. Twenty titles and abstracts were reviewed in order to exclude subjects without neurologic disease. After checking the available abstracts four full text articles were evaluated. Data Analysis: N/A Results: 4 articles were included aimed at the effects of muscle fatigue on postural control in neurologically-impaired persons. Individuals with stroke showed a statistically significant decline in maximum walking speed (pre = 0.97±0.5 m/s; post = 0.71±.4 m/s, P post fatigue measurement, time effect, P Conclusions: The results of this study indicate that persons with neurological impairments are negatively affected by muscle fatigue. Similar effects have been found in neurologically healthy adults. Individuals with stroke showed declines in maximum walking speeds and hip flexion velocity and range of motion compared to their healthy counterparts after fatiguing exercise. There was a correlation between walking speed and paretic leg variability; slower walkers had greater fluctuations in motor output. Children with Cerebral palsy displayed a deterioration in postural control after fatigue, demonstrated by the increase in path length and range of the COP. Muscle fatigue had a minor effect on lower extremity joint kinematics in persons with PD. Clinical Relevance: Acute bouts of muscle fatigue have negative consequences on gait and postural control in individuals with neurologic disease. Physical therapists should be aware of the potential for decreased postural control following acute bouts of intense exercise in clinical care settings.
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    Whole Body Vibration Therapy for Patients with Multiple Sclerosis – A Review
    (2017-03-14) Cramer, Courtney; Cramer, Caitlin; Holmes, Clayton; Salem, Yasser; Liu, Howe; Caldwell-Webster, Tyler
    Background and Purpose: Whole body vibration (WBV) therapy has been used more frequently for patients with multiple sclerosis (MS) in last 10 years, but the results seem to be inconsistent. The purpose of this review is to analyze how different variables including intervention parameters and outcome assessment instruments might affect the results of WBV therapy on patients with MS. Methods: PubMed and Scopus were used for searching literature published in English from 1996 - 2016. Key words were: whole body vibration (WBV), vibrotherapy, and multiple sclerosis. Included articles had to be prospective longitudinal studies. Results: Fourteen studies were qualified including 12 randomized control trials and 2 single-group studies. The studies found that, regardless of standing statically (without moving at all - 11 studies) or dynamically (feet stable with trunk and arms incorporated in exercise – 3 studies) on the vibration platform, younger aged patients (yrs) and/or less disabled patients (as measured with Expandable Disability Status Scale – EDSS 45 yrs) and more disabled patients (EDSS [greater than] 5.0) showed no difference from regular exercises. For WBV the most frequent intervention parameters were 3/week (7/11 articles, ranged 1- 5/week) for frequency, 3 weeks or 8 weeks (3/13 articles, respectively, ranged from 1 - 20 weeks) for duration, and 5 min per session (6/10 articles, ranged from 5 – 10 minutes as a single intervention, or from 30-50 minutes as part of a combined study). These parameters demonstrated inconsistent results. Of the vibration parameters mentioned in 7 studies, 1-3 mm in amplitude with on-off time ratios at 1:1 (45 sec on: 45 sec off) and frequency from 2 - 50 Hz were identified. It revealed that different frequencies of vibration created inconsistent results in terms of patient’s balance, mobility, and endurance. However, muscle strength was consistently improved in high frequency ([greater than] 11Hz), but not in lower frequency (Hz). Conclusions: Younger aged patients (yrs) and/or patients with low EDSS score (