by ptfadmin | Nov 28, 2022 | Health Tips
by Tyler Tice, PT, DPT, MS, ATC
Introduction:
Over the last few decades, the treatment options for Parkinson’s disease (PD) has significantly improved, resulting in effectively prolonged period of time people with PD live with disability. Due to this, the role of effective physical therapy (PT) and rehabilitative management for people with PD has greatly increased. PD affects dopamine within the brain, resulting in the presence of motor symptoms such as tremors and bradykinesia (slow movement) and non-motor symptoms such as changes in mood and changes in sense of smell. Diagnosis of PD is usually made after the classical motor signs of bradykinesia, rigidity, tremor, and postural instability (balance issues) emerge. Currently, there is no neuroprotective treatment for PD available so medical treatment is focused on treating the symptoms. As PD is projected to continue affecting higher numbers of our population as well as younger individuals, there is a need for effective non-pharmacological treatment early in the course of the disease. This review investigates the effects of a variety of modes of exercise and PT in the treatment of PD.
Aerobic Training:
Moderate to high intensity aerobic training may be the most beneficial in managing motor symptoms, improving physical function, and reducing disability in persons with PD. Studies where treadmill training was completed demonstrated better results regarding improvements in walking, most likely due to the intensity in which it could be completed, however, cycling is a viable option for persons with PD where walking may not be a safe option when initially beginning aerobic exercise. Additional research needs to be completed regarding the effect of aerobic exercise on non-motor symptoms, however existing research is promising as one study showed an improvement in executive function (higher level thinking needed to plan and carry out tasks), attention, and memory after one month of treadmill training.
Resistance Training:
Moderate to high intensity resistance exercise focused on movement speed or muscle power production may be beneficial in reducing disease severity, improving physical function, and reducing disability. One study demonstrated an improvement in cognition in addition to strength and mobility after the 2-year course of the study, suggesting long-term motor and non-motor benefit of participating in resistance exercise. Multiple studies also demonstrated benefit of resistance exercise when specific functional limitations such as climbing stairs or standing from a chair were targeted. Additional research is still needed to investigate the benefit of resistance exercise, especially in relation to their effects on non-motor symptoms.
Balance Training:
For persons with mild to moderate PD, balance training has demonstrated a significant ability to reduce fall rates. Additionally, studies that were clinic-based rather than home-based provided a greater level of supervision and intensive training, resulting in greater reductions in fall rates. Balance training also improved non-motor symptoms such as reductions in pain, depression, and apathy. However, it is important to note that in patients with severe PD appeared to have an increase in falls rate following participation in balance training. What causes this increase is unknown but may be attributed to increased gait-related mobility without an improvement in postural control or increased exposure conditions that challenge the individual’s balance without having the skills to manage these challenges.
Gait Training:
Gait training is effective in improving various aspects of walking in persons with PD. Treadmill training and moderate intensity overground walking have been shown to improve gait speed, walking capacity, and step/stride length. This is important as gait is not primarily impacted by current pharmacological treatments for PD. Providing cueing while ambulating has also been shown to improve various aspects such as giving auditory cues for gait speed or auditory and visual cues for freezing of gait. Dual-tasking such as walking and talking or walking and carrying an object is an aspect of ambulation that can be difficult for persons with PD. Practicing dual-tasking in a safe and controlled environment is effective in improving walking under dual-tasking conditions.
Physical Therapy:
Despite the evidence that supports early and regular exercise intervention in persons with PD, the utilization of PT services in the US is remarkably low. There are many factors that may contribute to this such as insurance coverage and other medical provider knowledge on the benefit of exercise and PT in persons with PD. Typically, to justify the need for PT to insurance companies, the patients must demonstrate functional improvement in order to continue with PT, however, policy and guideline changes have been implemented to improve access to PT for persons with PD. By initiating PT earlier in the disease process, more preventative measures can be taken, which ultimately will positively impact the quality of life of the individual.
Secondary Prevention Model:
Once initially diagnosed with PD, patients consult with a PT with expertise in PD. The PT performs what is referenced as a clinical battery of tests to establish a baseline level of function that can be tracked throughout the disease course. In the first few visits, the PT will prescribe an exercise program that is tailored to the individual and give them the tools to be success in consistently completing the program. A critical element of this approach is regular follow-up visits. Just as regular visits to the neurologist are necessary for reassessment of PD symptoms so appropriate adjustments to medication can be made, regular follow-up visits to a PT allow for reassessment of functional status and necessary adjustments to their exercise program to address changes in symptom presentation. There has also been an increase in community-based exercise programs, which further expands access to physical activity. These exercise programs can vary in intensity, however regular follow-up visits to PT can allow PTs to assist in finding programs that appropriately challenge their patient.
Take Home Message:
Regular exercise is highly beneficial for persons with PD. The advantage of beginning PT early in disease progression is that it can help mitigate the extent to which the motor and non-motor symptoms impact daily life. Additionally, if there were to be a change in function, receiving PT treatment can directly help with being able to successfully complete functional tasks such as climbing stairs to promote safe independence of persons with PD.
Article Reference:
Ellis, T. D., Colón-Semenza, C., DeAngelis, T. R., Thomas, C. A., Hilaire, M. S., Earhart, G. M., & Dibble, L. E. (2021). Evidence for Early and Regular Physical Therapy and Exercise in Parkinson’s Disease. Seminars in neurology, 41(2), 189–205. https://doi.org/10.1055/s-0041-1725133
by ptfadmin | Nov 21, 2022 | Health Tips
by Tyler Tice, PT, DPT, MS, ATC
Introduction:
Over 700,000 total knee arthroplasty (TKA) surgeries are performed each year in the US with this number expected to increase to over 3 million by 2030. A TKA is typically performed to reduce knee pain as well as self-reported physical function ability. However, even when considered full recovered 12 months after surgery, patients’ physical function when formally measured by performance-based measures and quadriceps strength are rarely improved compared to pre-surgery function. As shown in previous research, post-op protocols that include strengthening and functional exercises that are progressed based on clinical milestones promotes better outcomes compared to protocols that lack these interventions. However, there is no current research that compares patients who completed a progressive strengthening post-op protocol to healthy age-matched peers, which makes it difficult to determine whether these protocols are effective in fully restoring physical function. As younger, more active populations begin to undergo TKA surgeries, it’ll be imperative to know whether these progressive strengthening interventions are effective in restoring the level of physical function required to return to physically demanding occupations and recreational activities.
Methods:
This study investigated at 205 participants who underwent a unilateral primary TKA for knee osteoarthritis (OA). Additionally, 88 participants were recruited to serve as the healthy age-matched control group. Exclusion criteria for both groups can be found in the original article. Participants who underwent a TKA were randomized into one of three groups: progressive strengthening rehabilitation, progressive strengthening rehabilitation plus neuromuscular electrical stimulation for the quadriceps, or standard of care. All participants received inpatient rehabilitation in the hospital, followed by home and outpatient PT. Participants in the progressive strengthening rehabilitation groups completed at least 12 outpatient PT visits at the University of Delaware Physical Therapy clinic. Treatment focused on addressing the physical impairments after TKA as well as progressive strengthening exercises that targeted muscle groups in the lower extremity. Participants in the standard of care group attended other physical therapy clinics in the community and completed an average of 23 outpatient PT sessions with no set guidelines for clinicians to follow. Treatment primarily consisted of range of motion (ROM) exercises, stationary cycling, and various straight-leg exercises.
Outcome measures:
The Knee Outcome Survey – Activity of Daily Living (KOS-ADL), active knee ROM, maximal voluntary isometric contraction (MVIC) of the quadriceps, the Timed Up and Go (TUG), stair climbing time (SCT), and 6-minute walk (6MW) test were measured 12 months following surgery as well as in the control group to compare between groups.
Results:
There was a significant between-group effect for all clinical variables.
A higher proportion of participants in the progressive strengthening group achieved the lower bound cut-off for knee extension ROM, quadriceps strength, and SCT compared to the standard of care group.
Participants in the progressive strengthening group were 2-4 times more likely to achieve performance above the lower bound of the of the confidence interval of the control group for knee extension angle, performance on SCT, and quadriceps strength.
The percentage of participants in the progressive strengthening group that achieved the lower bound cutoff in at least one of the seven variables analyzed was greater compared to the standard of care group (67% vs. 47.5%).
Discussion:
Similar to previous research, participants who underwent a TKA demonstrated worse self-reported scores, greater physical impairments, and lower performance-based outcomes compared to the control group. However, a greater proportion of patients in the progressive strengthening protocol achieved what could be considered normal clinical and functional scores when evaluating the outcomes individually. This suggests that patients who follow a progressive strengthening protocol post-TKA may improve their likelihood of achieving normal age-matched outcomes. Also, a greater proportion of participants in the progressive strengthening group achieved the lower bound cut-off for quadriceps strength, knee extension angle, and SCT, suggesting progressive exercises may be more effective in optimizing outcomes after TKA.
It’s important to note that all participants still had substantial impairments 12 months after surgery compared to the control group. Failing to restore function by 12 months after surgery may overall impact the patient’s ability to achieve normal function as progress measured by outcome measures typically plateaus around 12 months post-surgery. There are many factors that may contribute to this such as pre-operative function, lack of consensus between providers regarding rehabilitation protocol and surgical procedure. Regardless, this highlights the importance of including the inherent limitations of the surgical procedure and post-op rehabilitation at restoring normal function for patients with end-stage OA when educating patients.
Take Home Messages:
TKA is a surgery that is becoming increasingly more common as time goes on and research has consistently showed that after surgery, it is difficult for patients to achieve pre-surgery function that can be comparable to age-matched peers without knee pathology. As more active patients begin to undergo this surgery, it’ll be important that they are able to achieve pre-surgery function to enable them to participate in recreational activity or more physically demanding occupations. While this study showed that overall, all participants demonstrated worse functional outcomes compared to the control group, participants in the progressive strengthening group demonstrated better functional outcomes compared to the standard of care group. This suggests that the inclusion of these exercises may be beneficial to the functional recovery of TKA patients. There are still many other factors that may be contributing to why TKA patients have difficulty recovering to their pre-surgery function, which emphasizes the role of patient education in the recovery process to set realistic expectations for these patients while also enabling them to recover to their greatest ability.
Article Reference:
Pozzi, F., White, D. K., Snyder-Mackler, L., & Zeni, J. A. (2020). Restoring physical function after knee replacement: a cross sectional comparison of progressive strengthening vs standard physical therapy. Physiotherapy theory and practice, 36(1), 122–133. https://doi.org/10.1080/09593985.2018.1479475
by ptfadmin | Nov 14, 2022 | Health Tips
Reviewed by Mark Boyland PT, DPT, CSCS
This study sought to explore the effect times of manual therapy alone vs therapeutic exercise alone as well as to break down and compare the effects of these two interventions in the short and mid term.
The authors compared visual analog scale, pressure pain threshold, cervical disability through the Neck Disability Index Outcomes. These values were assessed at evaluation, week 1, week 4, and week 12.
The participants were split into 1 of 3 intervention groups; Manual Therapy, Therapeutic Exercise, or Sham. At the end of the trial the study was able to analyze date across 67 participants, 22 in the Manual Therapy Group, 23 in the Therapeutic Exercise Group, and 20 in the Sham treatment group. Demographic date was relatively similar between groups, however there were more female participants than males.
The interventions were listed for each group. The manual therapy group included frequency of interventions, grading of mobilizations/manipulations, speed of mobilization, duration of mobilization, and sets of mobilizations. The therapeutic exercise group include progressions of exercises from week 1 and 2 and the exercises after week 2. Exercise descriptions included patient position with equipment required, and duration/frequency of exercises. The authors also provided a description for how the sham treatment was provided. It is noted that the sham treatment group did receive either manual therapy or therapeutic exercise interventions only after completion of the study. The study was conducted by researchers from the University of Seville, Seville, Spain and potential mistranslations may be present when reviewing the applied interventions.
The intervention groups had significant improvements in VAS at weeks 1,4, and 12. Both intervention groups had significant changes for the NDI at weeks 1 and 4. However, the manual therapy group was able to maintain these improvements into week 12 with no statistical difference and the therapeutic exercise group had a poorer score relative to the 4 week evaluation however the 12 week score was still lower than the patient’s initial score. The pain pressure threshold was only reduced in the manual therapy group at 4 weeks, however at 12 weeks both intervention groups showed improvements. The control group demonstrated no significant changes throughout the study.
In regards to selection of these interventions as stand alone treatments, therapeutic exercise may improve function more quickly whereas manual therapy may improve pain more quickly, both interventions can have similar results in the mid term. The authors note that a larger sample size may refute their findings and that treatment of chronic non specific neck pain should include multiple interventions not limited to only manual therapy and therapeutic exercise but could also include patient education and pain science education. The authors also note that there is no method that guarantees patients complete their home exercises.
For patients: Physical therapy for non specific chronic neck pain can be treated with hands on and an exercise approach and there can be significant changes made within just 4 weeks that can last up to twelve weeks but there is some work on your part that has to be done as well in the short, mid, and long-term
by ptfadmin | Nov 7, 2022 | Health Tips
Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS
Background:
Patellar tendinopathy (PT) is a common chronic tendon injury that not only effects a high percentage of the athletic population, but also a number of people that participate in physically demanding work. Currently, there is no known direct cause of PT, making it difficult to determine first-line treatment as not all people respond the same way to the same treatments. Eccentric exercise therapy (EET) is one line of treatment that has strong evidence supporting its effectiveness for PT, however, EET can be pain-provoking. Additionally, the onset of pain with this mode of treatment makes its use debatable during the competitive season for athletes as they are less likely to adhere to treatment. Recent research proposes the utilization of progressive tendon-loading exercises (PTLE) within the limits of “acceptable” pain, however, there is no current comparison between EET and PTLE. This study compares the effectiveness of PTLE with EET in patients with PT.
Methods:
This study looked at 76 recreational, competitive, and professional athletes with clinically diagnoses and ultrasound-confirmed PT that were randomly assigned to receive either EET (control group) or PTLE (intervention group) for 24 weeks. Most participants (82%) had previously underwent treatment for PT but failed to recover fully. PTLE consisted of 4 stages: 1. daily isometric exercises, 2. isometric and isotonic exercises, 3. plyometric loading and running exercises, and 4. sport-specific exercises. Progression through these stages was determined by individual progression criteria based on pain provocation during a single-leg squat. EET consisted of 2 stages: eccentric exercises performed 2x/day for 12 weeks followed by sport-specific exercises for 12 weeks if the participant was compliant to stage 1. Both groups received exercises targeting risk factors for PT such as flexibility exercises and hip strengthening exercises.
Outcome measures:
The primary outcome was the VISA-P questionnaire. Secondary outcomes were return to sport rate, subjective patient satisfaction, and exercise adherence.
Results:
The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 points vs. 18 points).
There was a trend towards a higher return to sports rate in the PTLE group (43% vs. 27%).
The percentage of patients with an excellent satisfaction was significantly higher in the PTLE group (38%) than in the EET group (10%).
There was no significant difference between subjective patient satisfaction and exercise adherence between the PTLE and EET groups after 24 weeks.
Discussion:
This study demonstrated improved performance in the PTLE group compared to the EET group that was both important and clinically relevant. Additionally, as this study included participants who had received prior treatment for PT but did not improve, the findings of this study also indicate that PTLE is still beneficial to this population. Other findings from the PTLE group are that there was a higher return to sports rate compared to the EET group and participants in the PTLE group reported that the exercises were significantly less painful to perform. However, it should be noted that in the PTLE group, less than half of the patients returned to sports at a preinjury level after performing PTLE for 24 weeks. This indicates the need for further improvements on the PTLE program. Both groups demonstrated improvements in pain, function, and ability to play sports, suggesting the importance of exercise therapy in general as a form of conservative management for patients with PT.
Take Home Messages:
Patellar tendinopathy is a chronic condition that affects a large number of people, however there is constant research being conducted to investigate what forms of conservative treatment are the best to trial prior to more invasive procedures. At the time this study was conducted, eccentric exercise training, or training done where the muscle is loaded during the phase where its length is increasing, had strong evidence supporting the effectiveness in PT. The difficult part regarding EET is that it is pain-provoking and its beneficial use during a competitive season for an athlete was uncertain. Another challenge of PT is that one treatment doesn’t work for all patients diagnosed with PT, resulting in several patients having gone through an unsuccessful bout of physical therapy, which only adds to the frustration surrounding the rehabilitation process. This study demonstrated that progressive tendon loading not only worked the same, if not better, than EET and was less pain-provoking, but also was successful in participants who had gone through unsuccessful bouts of treatment for their PT. For clinicians, this means that utilization of progressive tendon loading should be trialed in patients with longer-standing PT or previously failed bouts of treatment. For patients, this means progressive tendon loading is worth trialing, regardless of chronicity or history of treatment, as a form of treatment for PT.
Article Reference:
Breda, S. J., Oei, E., Zwerver, J., Visser, E., Waarsing, E., Krestin, G. P., & de Vos, R. J. (2021). Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine, 55(9), 501–509. https://doi.org/10.1136/bjsports-2020-103403
by ptfadmin | Oct 27, 2022 | Health Tips
Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS
Background:
Eccentric exercise is the most commonly prescribed exercise for the treatment of tendinopathy, however, is often too painful to complete. In the competitive season, athletes are less likely to adhere to an eccentric loading program due to increased pain and experiencing either no benefit or worse outcomes, however they may be more compliant with pain reduction strategies that enable ongoing sports participation. Few interventions reduce patellar tendinopathy (PT) pain in the short term. Isotonic exercise has been shown to be as effective as eccentric loading in PT, however there is little to no current research demonstrating this form of exercise’s effect on pain. Isometric exercise has been shown to reduce pressure pain thresholds in normal populations but has not been studied in PT. This study compared the effect of a short bout of isometric and isotonic quadriceps loading on PT pain, maximum contraction strength of the quadriceps, and the neurophysiology of the two exercises.
Methods:
This study looked at six male volleyball players with PT pain. Three players had unilateral pain and the other three had bilateral pain. Immediate and 45-minute effects following a bout of isometric and isotonic muscle contractions were compared. Complete inclusion and exclusion criteria can be found in the original article. Below are the loading protocols utilized in the study.
Outcome measures:
PT pain during the single leg decline squat (SLDS), quadriceps strength on maximal voluntary isometric contraction (MVIC), and measures of corticospinal excitability and inhibition.
Results:
Isometric contractions reduced pain with SLDS from 7.0±2.04 to 0.17±0.41 and isotonic contractions reduced pain with SLDS from 6.33±2.80 to 3.75±3.28.
Isometric contractions released cortical inhibition from 27.53%±8.30 to 54.95%±5.47, but isotonic contractions had no significant effect on inhibition.
Condition by time analysis showed pain reduction was sustained by 45 minutes post-isometric but not isotonic condition.
The mean reduction in pain scores post-isometric was 6.8/10 compared to 2.6/10 post-isotonic
MVIC increased significantly following the isometric condition by 18.7%±7.8, and was significantly higher than baseline and isotonic condition, and at 45 minutes post-intervention.
Discussion:
Isometric exercise immediately reduced patellar tendon pain with the effect sustained for 45 minutes while isotonic exercise had a smaller magnitude immediate effect on patellar tendon pain that was not sustained. There were also no non-responders to isometric exercise regardless of pain severity or length of time of symptoms while there was variable pain reduction experienced following isotonic exercise that was no sustained. Individuals with PT have higher amounts of cortical muscle inhibition for their quadriceps and heavy isometric exercise reduced this inhibition, which may be a factor in the mechanism of pain reduction. The clinic implication of this is isometric exercise may be an important option for clinicians to offer in tendons that are difficult to load without aggravating symptoms. This study had multiple limitations, one of which was the small sample size that was comprised of men, which makes it difficult to determine if the results are generalizable to all patellar tendon pain. Another limitation of the study was participants were diagnosed with patellar tendinopathy so it is difficult to determine if the same effects would be observed in other cases of anterior knee pain. This study also lacked a control group, or group where no intervention was performed, which would further qualify observed results of the study.
Take Home Message:
One of the most well-known interventions for tendinopathy in the world of physical therapy is to eccentrically load the tendon to an individual’s pain tolerance, however what interventions are you left with when the patient is unable to participate because of high levels of pain? The findings from this study give clinicians an alternative intervention for their patients that have more painful tendons by reducing the patient’s pain in the short-term, which would then allow them to tolerate other interventions that may have previously been too painful. As stated in the article, the use of isometric exercise for pain reduction in patellar tendinopathy is a great option for in-season athletes who may not want to stop participating because of their pain but would still benefit from short-term pain reduction. This study had a handful of limitations, such as a small sample size, however this shouldn’t deter clinicians from utilizing isometric exercise as a tool for pain management for PT pain.
Article Reference:
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine, 49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386
