PRIMARY INDICATORS FOR DISCHARGE TO SHORT-TERM REHABILITATION FOLLOWING CARDIAC SURGERY
Rydingsward J, Rehabilitation Services, Brigham and Women's Hospital, Ashland, MA
PURPOSE/HYPOTHESIS: Cardiac surgery is faced with decreasing lengths of stay in the acute care hospital and inpatient rehabilitation services are more frequently tasked to assist with rapid discharge planning. Identifying predictors of the need for ongoing therapy in a rehabilitation setting at discharge will enable the generation of more appropriate acute care PT consultations, allowing for early identification of those patients with skilled PT needs after discharge. NUMBER OF SUBJECTS: Three hundred forty. MATERIALS/METHODS: Patients undergoing cardiac surgery from 2001 to 2016 at Brigham and Women's Hospital, Boston, MA had data collected for patient demographics, prior general health and level of function, hospital course including peri-operative complications, and discharge destination. Patients were stratified by length of stay for the purposes of analysis, less than 8 days, 8 to 12 days and greater than 12 days based upon observed patterns in patient characteristics and discharge patterns. Bivariate and multivariate analyses of predictors of discharge to short-term rehabilitation were performed, using JMP (version 10; SAS Institute, Cary, NC). RESULTS: Of 2028 enrolled patients, 340 patients were discharged to a rehabilitation hospital. Longer in-patient length of stay was associated with an increased chance of discharge to rehab (<8 days, 9%; 8–12 days, 20%; >12 days, 42%). There was a marked decline in rehab admissions over the study period despite an increase in patient acuity (2001–2004, 25%; 2005–2009, 13%; 2010–2015, 11%). Regardless of length of stay or surgery date, age >80 (P < .0001), female gender (P < .001), being single or unmarried (P < .001), having Federal or State funded insurance (P < .0001) and living alone prior to admission (P < .0001) were most strongly associated with discharge to rehab. In multivariate analyses stratified by inpatient LOS; in the <8 day group, discharge to rehab was more frequent for women (OR = 2.5, P = .001), patients with age >80 (OR = 124 P < .0001), not having a partner (OR = 3.5, P < .0001) and having a postoperative neurological event (OR = 7.1, P = .04). In the 8 to 12 days LOS group, discharge to rehab was more frequent for women (OR = 1.8, P = .035) and not having a partner (OR = 3.6, P < .0001). In the >12 days LOS group, the strongest additional predictor of discharge to rehab was a post-operative neurological adverse event (OR = 2.9, P = .029). CONCLUSIONS: After cardiac surgery, female patients of older age, who are single or unmarried, living alone prior to admission, and with Federal or State insurance and having a postoperative adverse neurological event are most likely to be discharged to a short-term rehab. CLINICAL RELEVANCE: Prioritizing patients based on these findings can improve efficiency of PT consultations to better utilize services and provide therapy to patients who will more likely require rehab in a timely manner. These findings indicate the potential benefit of creating a scoring system to identify patients who benefit most from rehabilitation services.
FUNCTIONAL OUTCOME MEASURES IN PATIENTS UNDERGOING EXTRACORPOREAL MEMBRANE OXYGENATION
Hellyer N, Balch S, Hagen R, Nieman J, Woodberry N, Pyfferoen MD, Hollman JH, PM&R, Mayo Clinic, Rochester, MN
PURPOSE/HYPOTHESIS: Early physical therapy and mobilization is increasingly accepted as safe and beneficial for patients in intensive care units. However, few reports describe physical therapy (PT) outcomes for patients on extracorporeal membrane oxygenation (ECMO) support. The purpose of the present study is to describe characteristics of patients on ECMO who received physical therapy during and after ECMO support and to analyze the associated functional outcomes. NUMBER OF SUBJECTS: A retrospective chart review was performed on 280 patients who received veno-arterial or veno-venous ECMO as an inpatient at a tertiary care facility between the years 2009 and 2015. IRB approval was granted for this study. MATERIALS/METHODS: The number of PT visits before, during and after a trial of ECMO was recorded for each patient. Patients who received physical therapy were retrospectively assigned AM-PAC “6 Clicks” scoring for evaluation and discharge sessions as a measure of patient function. To describe the average patient in our study, we recorded the summary statistics of several key demographic and outcome variables. We primary analyzed the relationship between therapeutic intervention during or following ECMO support and functional status as analyzed by AMPAC “6-Clicks.” We also analyzed the relative provision of physical therapy during ECMO support, hospital length of stay, discharge location, and re-admittance rates utilizing correlational statistics. Correlations were analyzed with multiple and partial regressions using IBM SPSS 21.0 software. Significance was defined as P-value < .05. RESULTS: Patients ranged from 18 to 92 years of age (average 57 ± 16 years old) with 61% being male. Of 280 patients, 140 patients survived to hospital discharge, 114 received no physical therapy, 15 received therapy while on ECMO, and 143 received therapy following ECMO removal. For patients who received physical therapy after removal from ECMO, AM-PAC “6-Clicks” scores showed a mean 6.8 point change from therapy evaluation to discharge. Discharge scores were significantly correlated with age (partial r = −0.34, P < .001) and baseline scores (partial r = 0.30, P < .001). No adverse patient events occcured during physical therapy interventions. CONCLUSIONS: Patient receiving physical therapy while on ECMO generally show functional improvement as measured by the AM-PAC “6-Clicks” with no apparent adverse risks. However, it is unclear why so few of these patients receive physical therapy and further research is need to investigate this. Complex medical conditions and low survival rates of patients who receive ECMO greatly skew patient outcomes and the analyses of physical therapy effectiveness, but relate to age and prior functional status. CLINICAL RELEVANCE: The provision of therapy to patients on ECMO treatement is not consistently provided and requires further investigation. Clinical guidelines need to better standardize the appropriate early referral of patients on ECMO to physical therapy services and more comprehensively document dosing of physical therapy and functional measures of patients on ECMO.
M-LEARNING TO FACILITATE LEARNING OF PULMONARY EVALUATION TECHNIQUES AND CLINICAL REASONING IN PHYSICAL THERAPIST STUDENTS: A MULTI-CASE STUDY
Smith N, McDonald K, Hine K, Bartlett AS, Winston Salem State University, Winston Salem, NC; Nazareth College, Rochester, NY
PURPOSE/HYPOTHESIS: Mobile learning or m-learning can be defined as using mobile devices to promote situational learning. Currently, there are few studies that evaluate the effectiveness of m-learning in physical therapist education programs. Therefore, the purpose of this cross-case study was to evaluate the utility of a mobile application in facilitating psychomotor skills and clinical reasoning abilities related to pulmonary evaluation in physical therapist students. NUMBER OF SUBJECTS: Two physical therapist student participants were chosen via purposive sampling who had not completed any cardiopulmonary rehabilitation coursework. MATERIALS/METHODS: Both participants' initial clinical reasoning strategy was elicited prior to use of the mobile application via a think aloud. Subsequently, participants attended a class in which pulmonary evaluation techniques were taught. Next, each participant completed a lab practice session with access to classroom notes, and no access to the mobile application. Following this first lab, participants completed 2 practice sessions with access to the mobile application and classroom notes. After all practice sessions were completed, each participant had an interview about the mobile application and second subsequent think aloud to elicit clinical reasoning strategies. DATA ANALYSIS: Across case themes were obtained from think alouds using deductive a-priori coding (codes derived from Gilliland [2014] and the hypothesis oriented algorithmic framework). An inductive coding approach was used to establish across case themes from interviews about the application. This study utilized member checking and peer debriefing to ensure trustworthiness of findings. RESULTS: The first theme derived across case related to application support was that the mobile application was preferred over utilizing notes from instructional sessions for support of psychomotor skills. The second theme was that the mobile application was equally as supportive as lecture material in the acquisition of knowledge of outcomes of tests and measures. Analysis from think aloud data revealed that participants utilized a hypothetical deductive and reasoning about pain clinical reasoning strategy pre-intervention. Post intervention, both participants utilized a pattern recognition strategy. CONCLUSIONS: These findings show that a mobile application supported learning of psychomotor skills and improved clinical reasoning. This may lead to enhanced clinical decision making in pulmonary rehabilitation. The pattern recognition clinical reasoning strategy used by both participants demonstrates a high degree of knowledge organization that could have been facilitated by the knowledge support provided by the application. Further research should focus on a larger sample population to ensure that these findings are generalizable. CLINICAL RELEVANCE: Use of a mobile application may be effective in teaching pulmonary evaluation skills and may enhance clinical reasoning by increasing development of knowledge and psychomotor skills.
CRITICALLY ILL PATIENTS AT-RISK FOR SEDENTARY AND RELATIVELY SOLITARY EXISTENCES
Koermer B, Delmedico L, Southam L, Foley S, Hambrick K, Johnston L, Thompson J, Pastva A, Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, NC; Duke University School of Nursing, Durham, NC
PURPOSE/HYPOTHESIS: Critically ill patients, especially those on mechanical ventilation (MV), are at risk for short and long-term impairments in physical function. Increased levels of physical activity have been hypothesized to improve outcomes; however, there is only one report to-date describing physical activity patterns in this population (Berney, 2015). NUMBER OF SUBJECTS: This was a single center observational behavioral mapping study of 47 critically ill patients admitted to the medical (n = 18), surgical (n = 6) or cardiothoracic (n = 23) ICU who were 18 years or older and required MV for at least 48 hours. MATERIALS/METHODS: Patients were observed for 1 minute, every 10 minutes for 15 hours (6 am–9 pm). Patient location, persons present in room, and physical activity were recorded at each time point. Observations took place on 4 weekdays and 5 weekend days over 2 months. Activity was qualified using the ICU Mobility Scale (Hodgson, 2014) and was further classified into no/minimal, low, moderate, or high intensity categories. RESULTS: A total of 3463 observations were recorded; 3302 (95.35%) on patients with MV and 161 (4.65%) on patients who no longer required MV. Mean age was 54.57 ± 13.88 years; mean observation day severity of illness scores were APACHE II 18.60 ± 5.74 and SOFA 7.55 ± 3.11; and median (IQR) MV days and ICU length of stay (LOS) were 7 (3–12) and 7 (4–11.5) days, respectively. In 98.9% of all observations, patients were in bed, participating in no or minimal activity (nothing more than sitting in bed). Those eligible for mobility (not on activity restriction/not sedated) (36.2%) were 30 times more likely (OR = 30.49) to participate in low intensity activity (sitting edge or out of bed), however, this accounted for only 1% of total observations. Physical Therapists were present for 0.32% of observations and the only recorded instance of moderate intensity activity (standing). Patients in surgical ICU spent a higher percentage of time (5%) participating in low intensity activity than those in other units. Age, sedation level, illness severity, and LOS did not impact activity levels. Patients spent a median of 29% (15%–28%) of time alone, and those who were sedated (RASS −2 to −5) were 55% more likely to be observed alone. CONCLUSIONS: Like the previous report, patients who are critically ill were a minimally active and relatively solitary population. Characteristics such as age, sedation level, illness severity, and LOS had limited utility in predicting activity levels. CLINICAL RELEVANCE: Although optimal levels of physical activity for ICU patients have not yet been established, limited amounts of either incidental or structured activity, even in those eligible for mobility, places patients at risk for short and long-term impairments in physical function. In addition, patients, especially those who are sedated, are vulnerable to social isolation. To address these disparities, further evaluation of administrative and cultural barriers at the institutional level and strategies that foster a culture of physical activity and social interaction in critical care settings should be explored.
MOTOR VEHICLE DRIVING AFTER CARDIAC SURGERY VIA A MEDIAN STERNOTOMY: MECHANICAL AND COGNITIVE CONSIDERATIONS
El-Ansary D, Physiotherapy, University of Melbourne, Melbourne, VIC, Australia
PURPOSE/HYPOTHESIS: Over 1 million cardiac surgery operations are performed worldwide annually. The demands of surgery include anesthesia, incision and rewiring of the sternum and mechanical heart-lung perfusion. Individuals are required to restrict the use of their arms and cease driving from 4 weeks up to 3 months post-operatively in order to prevent wound and bone breakdown; ensure road safety and prevent road trauma. However these restrictions have no evidence, are marked by discrepancy and are not consistent. Controlling a motor vehicle is a complex task that requires advanced psychomotor skills, neuromotor co-ordination and motion of the arms and trunk. The purpose of this study was to evaluate the effects of cardiac surgery on driving performance; psychomotor vigilance; and neurocognitive function. NUMBER OF SUBJECTS: Twenty-seven patients. MATERIALS/METHODS: A prospective, longitudinal, observational study was conducted at 2 cardiac centres. Twenty-seven individuals who had elective cardiac surgery participated in the study. Measures were taken pre-operatively, pre-hospital discharge; 4 weeks and 3 months post-operatively. Outcome measures were sternal micromotion (Real-time Ultrasound); and driving performance (lane and speed variability, braking reaction time) using a driving simulator (AusEd software). The Neurocognitive tests included were: Psychomotor Vigilance; PostopQRS (Quality of Recovery Scale); and the Digit Symbol Substitution Test (DSST). RESULTS: Sternal micromotion decreased significantly for all driving tasks overtime (P < .05) with bone consolidation evident at 4 weeks in 15% and at 3 months in 55% of participants. Driving performance was not significantly impaired at any time-point and improved overtime after surgery. Neurocognitive measures examining executive functioning were significantly reduced prior to hospital discharge and returned to or exceeded baseline at 4 or 12 week (P < .05). CONCLUSIONS: It may be warranted to apply a reduced timeline of 4 weeks from the time of surgery to the resumption of driving following cardiac surgery. A larger trial is needed to determine if a battery of cognitive tests are reflective of driving performance and safety. CLINICAL RELEVANCE: A battery of neurocognitive tests (PVT; PostopQRS; DSST) may be an accurate reflection of driving performance in the absence of a driving test. Cognitive training tasks initiated immediately after surgery may play a role in facilitating recovery of executive function at hospital discharge. The outcomes of this research may inform health professionals and driving authorities in developing guidelines to ensure an optimal return to community role that involves safe driving and prevention of road trauma.
STERNAL MICROMOTION DURING UPPER LIMB MOVEMENTS: IS IT TIME FOR A CHANGE TO STERNAL PRECAUTIONS FOLLOWING CARDIAC SURGERY VIA A MEDIAN STERNOTOMY?
El-Ansary D, Physiotherapy, University of Melbourne, Melbourne, VIC, Australia
PURPOSE/HYPOTHESIS: Despite the advantages of a median sternotomy for cardiac surgery a small but significant number of patients experience sternal complications that impact on recovery and return to optimal function. To prevent these complications Sternal precautions that restrict upper limb and trunk movements are uniformly prescribed worldwide. There is no evidence to support this clinical practice, excepting limited cadaver studies. The purpose of this study was to measure sternal micromotion during dynamic tasks of the upper limbs and trunk. NUMBER OF SUBJECTS: Seventy-five patients. MATERIALS/METHODS: This was a prospective, observational study. The primary outcome measure was ultrasound measures of sternal micromotion at rest and during 5 dynamic tasks (deep inspiration, cough, unilateral and bilateral upper limb elevation, and sit to stand) at 3 postoperative time points (T1: 3–5 days, T2: 6 weeks and T3: 3 months), using the device proprietary software. Secondary outcomes measures included pain and function (Functional Difficulty Questionnaire). RESULTS: The intra and inter-observer reliability of the mean ultrasound measures for all tasks ranged from ICC (3,1) 0.990 to 0.997 and ICC (2,1) 0.994 to 0.998, respectively. There was a significant decrease in both the separation (T1–T3: 0.110 mm mean decrease) and overlap of the sternal edges (T1–T3: 0.080 mm mean decrease) over time, in the vertical and horizontal directions respectively. This correlated with a decrease in sternal pain and an increase in postoperative function over time. Cough produced the greatest increase in sternal pain and micromotion. Five participants demonstrated sternal union at 3 months. CONCLUSIONS: The results suggest that sternal precautions may be overly restrictive and not warranted in all patients. Further investigation of the factors that affect sternal healing is warranted. CLINICAL RELEVANCE: Patient-specific sternal care that focuses on movement within comfort, and function that is informed by the assessment of risk for sternal complications may be more appropriate to facilitate recovery and return to optimal function.
DISCHARGE LOCATION AND FUNCTIONAL MOBILITY FOLLOWING MEDIAN STERNOTOMY
Hiser S, Ricard P, Brown C, Physical Medicine and Rehabilitation, The Johns Hopkins Hospital, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
PURPOSE/HYPOTHESIS: Sternal precautions (SP) are considered standard of care for patients post Coronary Artery Bypass Graft (CABG) and/or Aortic Valve Replacement (AVR) via median sternotomy, yet no evidence supports these precautions. As a result there is considerable variance across institutions. Literature exists studying specific forces on the sternum during various loads; however, these studies are limited to healthy subjects, chronic sternal instability or patients that are >6 weeks post-operation. It has been suggested that SP limit mobility resulting in difficulty with home re-integration. At this facility SP included: No lifting/pushing >10 pounds and maintaining arms down by torso. The purpose of this study was 2 fold: (1) Identify percentage of patients going to rehabilitation facilities that may benefit from liberalization of SP; (2) Develop a revised SP protocol. NUMBER OF SUBJECTS: Fifty patients. MATERIALS/METHODS: A retrospective chart review of patients' inpatient medical record and physical therapy (PT) documentation post CABG/AVR during January to February 2016. Inclusion criteria: Median sternotomy and inpatient PT consultation. Exclusion: Greater than 1 day on mechanical ventilation or re-admission to the intensive care unit. The following data was extracted from the chart review: demographic information, Activity Mobility Post-Acute Care (AMPAC) score documented by PT upon evaluation and last inpatient session, average John Hopkins-Highest Level of Mobility (JH-HLM) documented by nurses, JH-HLM documented by PT, length of stay, and discharge location. A literature review was performed for current studies or recommendations for sternal precautions. Compilation of these liberal, evidence-based precautions were presented to and agreed upon by all cardiac surgeons at this facility. Materials were developed to educate all clinical staff for implementation June 13, 2016. RESULTS: Patients discharged to rehabilitation facilities versus home was 1:5 with 3 of the 10 discharged to rehabilitation meeting a JH-HLM of 8 (ambulating 250 ft) upon final PT treatment. The following SP were agreed upon: No lifting/pushing greater than 20 pounds and may use upper extremities for functional mobility/activities of daily living. Data collection is ongoing post-implementation for further data analysis. CONCLUSIONS: The findings support the hypothesis that some ambulatory patients' following CABG/AVR procedures may benefit from liberalization of sternal precautions to facilitate discharge home. Following implementation of the revised protocol, we are collecting outcome data to determine if the changes improve mobility and discharge to home. CLINICAL RELEVANCE: Historically, facilities have adhered to strict SP, which has often presented problems with discharge planning. Liberalizing SP may improve functional mobility, thus discharge home versus rehabilitation facilities. No study to date has published data illustrating this clinical theory.
COMPARISON OF SUPINE LEGS ELEVATED TO SEATED ANKLE PUMPS FOR PROMOTING VENOUS RETURN FOLLOWING MODERATE AMBULATION
Shaw D, Bierscheid CJ, Bodenbender E, Schursky B, Toves K, Physical Therapy, Franklin Pierce University, Googyear, AZ
PURPOSE/HYPOTHESIS: To facilitate venous return following ambulation, clinicians often employ one of 2 recovery methods: lying supine with legs elevated (SLE) or performing seated ankle pumps (SAP). The purpose of this study was to determine if venous return, as measured by arterial blood pressure (ABP), differed as a function of the post-exercise recovery method employed. NUMBER OF SUBJECTS: A convenience sample of 10 healthy physical therapy students (25.3 ± 2.0 years) participated in the study. MATERIALS/METHODS: Following acquisition of informed consent, subjects were screened for participation via PAR-Q. A resting heart rate (HR) and blood pressure (BP) were then obtained using a Polar HR monitor and automated WelchAllyn Connex 6000 BP unit. A Nordic Track Commercial 1750 treadmill was used in conjunction with a modified Balke-Ware protocol to attain an 80% HRmax response with HR continuously monitored during the exercise. At exercise termination, an initial BP and HR were obtained while subjects remained standing on the treadmill. Treatment order was randomly assigned for either seated ankle pumps at a set metronome cadence of 80 beats per minute or lying supine with legs elevated to 30° for 5 minutes. During the recovery period, HR and BP were obtained each minute. Subjects were given a 30-minute break and were then exercised again using the same protocol but with the alternate recovery position assumed. Data were analyzed using one-way and repeated measures ANOVA with Bonferroni adjustment. Alpha level was set at P ≤ .05; SPSS Version 23 software was utilized for all calculations. RESULTS: Mean ± SD values for systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR for SLE and SAP at rest and at 5 minutes were: SBP: 138.9 ± 14.75 versus 138 ± 20.33 and 125.4 ± 16.67 versus 139.9 ± 18.79; DBP: 82.3 ± 12.61 versus 84.7 ± 8.84 and 71.3 ± 6.13 versus 85.3 ± 10.21; and HR: 90.6 ± 15.44 versus 92.1 ± 13.49 and 84.6 ± 6.88 versus 97.2 ± 9.66. No significant difference was found for any variable either within or between the 2 venous return positions. This was true for all recovery intervals following treadmill ambulation. Although not significant, comparison of SLE and SAP relative to speed of recovery revealed SLE generated a slightly more rapid return to initial ABP than SAP. Specifically, SLE and SAP returned SBP to resting levels at 2 and 3 minutes of recovery; DBP levels returned immediately for both; and HR levels returned at 2 and 3 minutes of recovery, respectively. CONCLUSIONS: Both interventions appear efficacious in facilitating ABP reduction over 5 minutes. Although not significant, study of ABP trends during recovery revealed SLE promotes a more rapid ABP normalization than SAP. CLINICAL RELEVANCE: While the SLE group was superior to the SAP group with regard to venous return normalization, our results support the use of either SLE or SAP following ambulation to reduce the possibility of a hypotensive event.
EXAMINING THE UNDERUTILIZATION OF OUTPATIENT CARDIAC REHABILITATION IN PHYSICAL THERAPY
Marks T, Henry A, Protopopas T, Quan E, Garcia RK, Physical therapy, Touro college, New York, NY
PURPOSE/HYPOTHESIS: The purpose of this study was to assess the level of Physical Therapist (PT) awareness of Outpatient Cardiac Rehabilitation as a resource and what factors may inhibit those who are aware of Outpatient Cardiac Rehabilitation from recommending it to eligible patients. NUMBER OF SUBJECTS: Three hundred nine. MATERIALS/METHODS: Research design was a descriptive survey; 309 surveys were returned from a paper survey mailed to a list of 1000 randomized PTs obtained from the American Physical Therapy Association. RESULTS: Fifty-four percent of respondents reported that they have not educated or encouraged a patient to attend Outpatient Cardiac Rehabilitation. 29.1% report believing they are unable recognize a patient who would benefit from Outpatient Cardiac Rehabilitation. 68.9% of respondents reported they are not familiar with insurance guidelines for Outpatient Cardiac Rehabilitation. 12.9% of respondents stated they were not educated about Outpatient Cardiac Rehabilitation in their PT curriculum, and 13.6% reported they believe there is no scientific evidence supporting Outpatient Cardiac Rehabilitation. CONCLUSIONS: There is a large gap in the knowledge-base of practicing PTs with regard to cardiac rehabilitation. CLINICAL RELEVANCE: Physical therapists who are unaware of or uneducated about the benefits of Outpatient Cardiac Rehabilitation and ill equipped to recognize those who qualify for and would benefit from attending Outpatient Cardiac Rehabilitation are unlikely to recommend Outpatient Cardiac Rehabilitation to appropriate candidates placing these patients at increased risk for secondary sequelae.
STATIC AND DYNAMIC BALANCE IN INDIVIDUALS WITH CARDIOVASCULAR DISEASE: A PILOT STUDY
Pathare N, Plowinske T, Ragonese G, Silvestri L, Woitkoski S, Physical Therapy, The Sage Colleges, Troy, NY
PURPOSE/HYPOTHESIS: There is emerging evidence that individuals with cardiovascular diseases (CVD) have impaired balance which may predispose them to falls.1,2 The death rate resulting from falls in individuals >65 years has increased from 29.6% to 56.7% between the years 2000 and 2013.3 This underscores the importance to identify patient populations with decreased balance. To date, data on balance and falls in individuals with CVD is limited. Therefore, the main objective of this study was to evaluate the static and dynamic balance in community dwelling individuals with CVD. Secondarily, we examined the falls risk in these individuals. NUMBER OF SUBJECTS: Nineteen. MATERIALS/METHODS: This was a cross-sectional study with 2 groups: CVD group (n = 10, 61.5 ± 3.6 years, 3 females and 7 males), and an age/gender matched control group (n = 9; 60.4 ± 3.3 years, 3 females and 6 males). The CVD group inclusion criteria were: 40 to 75 years, history of cardiac surgery (>3 months prior to the study), currently on cardiac medication/s, at least one cardiologist visit annually and no orthopedic or neurological impairments. The control group included individuals without a history of CVD or other co-morbidities. Static balance was measured using the Short Form of Berg Balance Scale (SFBB),4 the Sharpened Romberg (SR) for 60 seconds with eyes open/closed and the 5 times sit to stand test (STS).5 Dynamic balance was evaluated with the 4 step square test (4SQT), and the 4 meter walk test (4MWT).6 Data between the 2 groups were compared with a Mann Whitney U test (P ≤ .05). For SFBB, SR, and STS, based on the age appropriate cut off scores for falls, participants were categorized as “no risk” and “at risk.” A chi square test was conducted to compare the falls risk in both groups (P ≤ .05). RESULTS: The CVD group showed significant impaired performance compared with the control group for the SFBB (CVD: 25.9 ± 0.7 vs control: 27.8 ± 0.1; P = .017) and the STS (CVD: 10.7 ± 0.6 seconds vs control: 7.9 ± 0.4 seconds, P = .004). The CVD group performed the SR eyes open (CVD: 39.5 ± 8.0 seconds vs control: 60.0 ± 0 seconds, P = .15) and closed (CVD: 15.5 ± 5.7 seconds vs control: 31.5 ± 7.6 seconds, P = .18) for a shorter time compared to the control group with no significant differences. There were no significant differences in the 4SQT (CVD: 8.9 ± 0.3 seconds vs control: 7.3 ± 0.7 seconds, P = .053) or the 4MWT (CVD: 1.4 ± 0.13 m/s vs control: 1.4 ± 0.0 m/s, P = 1.00) between both the groups. The chi square test for STS indicated there was a significant association between falls risk and group assignment, χ2 (1) = 6.107, P = .013. CONCLUSIONS: Our preliminary findings suggest that significant differences existed in the SFBB and the STS scores in individuals with CVD compared to the control group. Individuals with CVD had significant greater falls risk than control participants only for the STS test. CLINICAL RELEVANCE: These findings are important to understand balance impairments and falls risk in community dwelling patients with CVD. Such data is crucial to design effective interventions to prevent falls and improve physical activity in individuals with CVD.
THE USE OF PHYSICAL THERAPY FOR THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE
Yelvington CJ, Rehab, Mayo Clinic Jacksonville, St. Johns, FL
Reflux or gastroesophageal reflux disease (GERD) is controlled by a high pressure zone (HPZ) at the gastroesophageal junction (GEJ). The HPZ is created by both the lower esophageal sphincter (LES) and the diaphragmatic crura. The crura is a striated muscle and is under voluntary control. Contraction of this muscle increases pressure in the HPZ. Training individuals to use specific exercises, as with Kegel's for pelvic floor dysfunction, can help reduce not just symptoms associated with reflux but also the frequency of reflux events that lead to symptoms. Acid reflux is the most common reason individuals seek treatment from gastroenterologists.1 According to Kahrilas et al, GERD is “likely the most prevalent condition afflicting the gastrointestinal tract in the United States” with 14% to 20% of the population reporting weekly symptoms.2 Treatment, including proton pump inhibitors (PPIs), typically involves controlling the acid rather than controlling the reflux: symptom reduction being the end point. PPIs, a first line treatment, reached $13.6 billion in prescriptions in 2009 alone.3 Reflux is controlled by the “2 sphincter” mechanism.1 The crural portion is embedded in the costal diaphragm and envelopes the lower esophagus, normally at the level of the LES. Contraction of the crura during deep breathing can increase esophageal pressure by 4.5 to 6 times.4,5 Crural EMG output increases 20 fold over tidal breathing.6 Studies have shown that generalized deep breathing exercises have reduced both symptoms after reflux and PPI usage.7−10 Pandolfino concluded “the strongest association and the only independent predictor of GERD as a categorical outcome in a logistical regression analysis was impaired crural diaphragm function as indicated by reduced inspiratory augmentation of EGJ pressure.”11 Bitnar found that weakness in the crurae was more evident in individuals with GERD.12 GERD is a disease of dysfunction. Like pelvic floor muscle dysfunction diaphragm dysfunction is described in the practice patterns for physical therapy. Practice pattern 4C (impaired muscle performance), includes muscular dysfunction including incontinence. GERD can be considered a form from sphincter incompetence. Also the patterns of practice include ICD 9 CM code 564 for functional digestive disorders.13 Considering these practice patterns the treatment of this gastrointestinal disorder could easily be included in the realm of present physical therapy practice. Physical therapy, as a profession, has the skills to lead in rehabilitation of this muscular dysfunction in a revolutionary way. Rehabilitation of the crura through assessment and retraining of the diaphragm appears to be able to control the reflux event by increasing dynamic esophagogastric junction pressure. Controlling the reflux event, not just the pH of the refluxed material, should be the end point of intervention. Physical therapy has a unique opportunity, a potential to add to the treatment algorithm, and change the cycle of GERD.
EARLY MOBILITY FOR CRITICALLY ILL PATIENTS IN THE CARDIOVASCULAR INTENSIVE CARE UNIT DECREASES ACUTE LENGTH OF STAY
Lohse BD, Johnson JK, Yolken HA, Noren CS, Marcus RL, Tonna JE, Acute Rehab, University of Utah Hospital, Salt Lake City, UT; Division of Cardiothoracic Surgery, Critical Care, University of Utah SOM, Salt Lake City, UT; Department of Physical Therapy, University of Utah, Salt Lake City, UT
PURPOSE/HYPOTHESIS: Early mobility in the intensive care unit (ICU) has been shown to be feasible, but challenges to implementation exist for critically ill patients where medical stability has been the priority and safety is a concern. Additionally, resources to provide physical therapy (PT) treatment are often limited. Recognizing these challenges, we instituted a quality improvement (QI) project on the cardiovascular intensive care unit (CVICU) to increase therapy dosing for appropriate patients. The purpose of this report is to describe the process and effect of increasing early mobility interventions for critically ill patients in the CVICU. NUMBER OF SUBJECTS: The QI period (September 2015 to March 2016) included 27 patients with 26 patients in the season-matched baseline period one year prior. MATERIALS/METHODS: With multidisciplinary support, PT staff developed and implemented patient-specific treatment approaches and increased its number of dedicated PTs on the CVICU from 2 to 4. For the purpose of this research, critically ill patients were defined as those with a CVICU length of stay (LOS) ≥10 days. Treatment time and billed units were reviewed retrospectively. Additionally, LOS and mobility outcomes using the Activity Measure for Post-Acute Care “6-Clicks” (AM-PAC) were analyzed. All variables were analyzed for a 6-month period and compared to the baseline period using t tests. RESULTS: Mean daily PT treatment per patient increased from 3.2 to 3.6 units in the QI period (P = .11) with the ratio of treatment units to LOS increasing from 2.2 to 2.8 (P = .02). Mean CVICU LOS did not change during the QI period (20.3 days) compared to baseline (19.3 days; P = .76), but mean post-ICU LOS was reduced from 7.3 to 3.9 days in the QI period (P = .03). Patient mobility improvement (raw AM-PAC score) was greater in the QI period (1.4 points) compared to baseline (0.7), but did not achieve statistical significance. CONCLUSIONS: The QI project was successful as the emphasis on early mobility resulted in an increased duration of PT treatment per patient, and an overall decrease in LOS. Furthermore, a non-significant improvement in mobility for patients in this QI process was also observed. Considering the complex medical status of the patients studied (CVICU LOS >10 days), this finding is not surprising as mobility changes in this population are expected to be highly variable. These results warrant further investigation. CLINICAL RELEVANCE: In a healthcare system focused on value, this data shows more PT treatment time, rather than less, leads to improved patient outcomes. This data shows that the critically ill population can tolerate increased therapy dosing and suggests a relationship with functional outcomes. Future research should determine the financial impact of this care model and further examine the relationship between increased therapy and functional outcomes in this population.
EXPIRATORY AIRFLOW LIMITATIONS ON LUNG FLUTE EFFECTIVENESS IN SECRETION CLEARANCE
Da Silva FC, Physical Therapy, NYU Langone Medical Center—Rusk Institute, Bridgeport, CT
PURPOSE/HYPOTHESIS: The Lung Flute (LF), manufactured by Medical Acoustics, is new a small, self-powered Positve Expiratory Pressure (PEP) audio device. It produces low frequency sound waves in the lungs by having the patient vibrate a reed inside the device promoting secretion clearance (SC). Manufacturer guidelines suggest the minimal expiratory flow rate needed to oscillate the reed is 128.4 L/min which resembles the peak expiratory flow rate (PEF). In clinical practice some patients were observed unable to properly use the device, and it was suspected these patients had PEF above the manufacture's guidelines (at least 128.4 L/min). It was determined that there was a need to investigate the proper PEF range for effective use of the LF and create a protocol for future use. The purpose of this study was to investigate if subjects who achieve a PEF of ≥128 L/min experienced proper use of LF, and identify the best PEF range for optimal clinical outcomes. NUMBER OF SUBJECTS: The study included 50 adult subjects ranging in age from 33 to 89 years-old with a pulmonary diagnosis or co-morbidities necessitating SC. MATERIALS/METHODS: The PEF of each subject was assessed using a portable pulmonary function spirometer. Subjects were then provided with verbal education about the LF and attempted its use according to the instructions provided in the manufacture's manual. The subjects who were able to oscillate the reed for at least 2 seconds or at least twice during expiration were labeled as “capable” and the ones who could not were labeled as “non-capable” of using the LF device. Subjects were given up to 10 trials. RESULTS: Of the 50 patients included in the study, 11 subjects had PEF <128 L/min of which none were able to use the LF as expected. However, of the 39 remaining patients with PEF ≥128 L/min, 23% (n = 8; 95% CI 14%–35%) were unable to use the LF effectively. The median PEF values with 95% confidence intervals were 153 L/min (135–162 L/min) for “non-capable” patients and 264.5 L/min (232–289 L/min) for “capable” patients. CONCLUSIONS: This study demonstrates the manufacturer guidelines regarding the minimum requirement to use the LF effectively is not accurate. Data showed the minimum PEF exhibited by a patient able to consistently use the LF successfully was 232 L/min (higher than the 128.4 L/min). We are aware that this information is a pilot study and refers solely to our group of subjects. Based on statistical analysis the results described and clinical experience we strongly believe that the cut-off point of PEF 172 L/min, the least PEF value deemed as capable, can be considered capable to use the LF, the indeterminate group between PEF 164 and 172 L/min should be determined capable only following clinical examination, and PEF ≤163 L/min should be considered non-capable of using the LF. CLINICAL RELEVANCE: We believe that the use of the values found in the study will help clinicians to have a more accurate parameter before ordering the LF for their patients, thus avoiding unnecessary medical expenses and ensuring that patients will be able to use the device effectively.
BLOOD PRESSURE ATTITUDES, PRACTICE BEHAVIORS AND KNOWLEDGE AMONG OUTPATIENT PHYSICAL THERAPISTS
Arena S, Ratza A, Rolf M, Schlagel N, Physical Therapy, Oakland University, Rochester, MI
PURPOSE/HYPOTHESIS: Negative health related sequelae of elevated blood pressure (BP) are well established in the literature; however, prior reports suggest physical therapists (PTs) practicing in an outpatient practice (OP) setting are measuring this vital sign infrequently. Therefore, the purpose of this study is to describe BP attitudes, practice behaviors, and knowledge and determine correlations between these variables among PTs practicing in OP settings. NUMBER OF SUBJECTS: Three hundred thirteen surveys. MATERIALS/METHODS: After obtaining IRB approval, a prospective descriptive survey, was mailed to 1440 OP PTs in 6 states. Assuming a 20% response rate, a sample size of 288 would result in 95% confidence interval in the survey findings. Recipients were randomly selected from the American Physical Therapy Association Listserv if: (1) a physical therapist (PT), (2) a member of the orthopedic special interest section and (3) practicing in a health system, hospital based or private practice OP setting. The 28 question survey tool, previously tested for validity and reliability, included PTs self-reported demographics, attitudes, practice behaviors and knowledge regarding BP measures. Descriptive statistics provided data on demographics and responses to each question; whereas a nonparametric Spearman version of the correlation coefficient was used to analyze correlations between attitudes, behavior and knowledge category responses. RESULTS: Three hundred thirteen surveys (21.9% response rate) were received from 58.7% female and 41.3% male PTs with 57.8% reporting greater than 10 years of experience. While 51.8% of respondents did not feel it is important to take a BP measurement during an evaluation, 94.2% felt confident in their ability to do so. Additionally, 85.0% of respondents reported not routinely measuring BP during evaluations. Knowledge of systolic and diastolic BP pre-hypertensive (PHTN) classification were correct at rates of 29.3% and 35.4%, respectively; whereas, systolic and diastolic BP hypertensive (HTN) classifications were correct at rates of 60.9% and 61.3%, respectively. Furthermore, a significant positive correlation (r = 0.84, P < .001) was identified between attitude and practice behaviors; however, no significant correlations were found between attitude or practice behavior and knowledge. CONCLUSIONS: Initiatives to address misinformed attitudes and behaviors as well as gaps in knowledge of BP related measures may optimize the health and wellness of individuals under the care of a PT providing care in the OP setting. CLINICAL RELEVANCE: The clinical practice culture among OP PTs suggest attitudes, behaviors and knowledge of BP related examination are not in line with the Guide to Physical Therapist Practice suggestion of vital sign assessment as an important component of a physical therapy examination for individuals with and without cardiopulmonary disease. Despite well-established clinical BP definitions for PHTN and HTN classifications, the frequency of incorrect responses suggest divergences in knowledge among OP PTs.
IS AEROBIC EXERCISE EFFECTIVE FOR MANAGEMENT OF RESTLESS LEG SYNDROME? A SYSTEMATIC REVIEW
Buttadauro M, Evans CC, Physical Therapy, Midwestern University, Downers Grove, IL
PURPOSE/HYPOTHESIS: To determine the effectiveness of aerobic exercise in management of restless leg syndrome (RLS) compared to no treatment or to pharmacological treatment. NUMBER OF SUBJECTS: Six studies were included in this systematic review with a total of 142 subjects. MATERIALS/METHODS: Pub Med, EbscoHost, and the PEDro databases were searched from 1995 to 2016. Studies that reported the effectiveness of exercise as a treatment for RLS were included. Inclusion criteria were: systemtic reviews, randomized or non-randomized control trial with a comparison or control group, compared exercise to another intervention that was not exercise or to no treatment, intervention was some form of aerobic exercise, outcome measures included self report or objective measure of RLS symptoms, published between 1995 and 2016, included subjects with a diagnosis of RLS (with uremic and non-uremic RLS) based on physician or self report. Exclusion criteria were: lack of a comparison or control group, did not include exercise as an intervention, case reports or non-systematic reviews, studies that only used subjective outcome measures for RLS, studies limited to only subjects with spinal cord injury, and studies published before 1995. The PEDro scale was used to determine methodological quality and studies were stratified as high, moderate, or low quality for comparison. RESULTS: Six studies met all criteria and included a total of 142 subjects. Four studies compared the effectiveness of aerobic exercise training with no treatment. One study compared the effectiveness of aerobic exercise training with the use of dopamine agonists and another compared differing intensities of exercise between patients with and without RLS. All 6 studies shared the same overall result: Aerobic exercise was found to be an effective non-pharmacological approach to improve symptoms of RLS in patients with chronic renal disease. Cycling at an intensity of 10 to 13 on the Borg Scale and/or at 60% to 65% of the patients' maximum power were most effective. The most effective duration and frequency of exercise were 30 to 45 minutes of continuous cycling or walking 3 times per week. Overall, long term interventions had the greatest effectiveness. CONCLUSIONS: There is moderate support for the effectiveness of aerobic exercise in treatment for RLS, but additional randomized clinical trials are needed comparing various modes and volumes of exericse to determine the optimal protocol. CLINICAL RELEVANCE: Aerobic exercise provides an alternative to the medical management of RLS, one that can have a positive effect on a patient's overall well being. Particularly in patients with uremic RLS, aerobic exercise may offer the additional benefit of reducing complications such as hypertension and cardiovascular disease.
PRESSOR AND PULSE RESPONSE TO MUSIC PLAYED DURING FORMAL NEUROMUSCULAR RELAXATION SESSIONS
Dyakiv W, Meconi C, Simon B, Steffen C, Shaw D, Physical Therapy, Franklin Pierce University, Googyear, AZ
PURPOSE/HYPOTHESIS: Music is often played during the formal neuromuscular relaxation period that follows structured group exercise sessions. Studies addressing the influence of various music forms on a patient's ability to relax have rendered mix results. The purpose of this study was to examine select vital sign responses under 3 relaxation conditions: no music, melodic music, and non-melodic music. NUMBER OF SUBJECTS: A convenience sample of 10 health professions students (5 females, 5 males; mean ± SD, 26.7 ± 4.9 years of age) volunteered for study participation. MATERIALS/METHODS: Subjects were randomly assigned to the 3 supine relaxation conditions following acquisition of informed consent. Arterial blood pressures (ABP) and pulse rates (PR) were obtained both at the beginning and at the end of each relaxation session performed in a non-distractive laboratory setting. Duration of each relaxation trial was 10 minutes with subjects measured under all conditions. A 5 minute break was interposed between each separate trial. Subjects were permitted to set music volumes according to preference. All ABP and PR were obtained using an automated Welch Allyn Connex 6000 vital signs monitor. Bonferroni-adjusted repeated measures ANOVA employing SPSS Version 23 software was used for all data analyses. An α level of 0.05 was selected for significance determination. RESULTS: End of relaxation systolic blood pressure (SBP), diastolic blood pressure (DBP), and PR comparisons were all non-significant. Mean ± SD for SBP, DBP, and PR specific to no music, melodic music, and non-melodic music were as follow: 117.6 ± 8.9 mm Hg, 70.5 ± 5.7 mm Hg, and 61.2 ± 8.6 b·min−1; 117.8 ± 8.9 mm Hg, 70.1 ± 6.4 mm Hg, and 66.4 ± 9.1 b·min−1; 117.6 ± 11.3 mm Hg, 69.6 ± 5.9 mm Hg, and 62.1 ± 9.6 b·min−1, respectively. CONCLUSIONS: Despite a number of studies supporting the hypothesis that music played during formal relaxation sessions has a tendency to produce ABP and PR reduction, the present study is in contrast to these findings. We conclude no music, or any music, played at a reasonable sound level and in an otherwise low sensory stimulation environment will have no discernable effect on either ABP or PR. CLINICAL RELEVANCE: It appears clinicians utilizing music as an adjunct to neuromuscular relaxation may do so without altering the desired calming effect. However, this study was limited by sample size and subject composition negatively affecting external validity.
WHITE COAT SYNDROME: EFFECT ON ARTERIAL BLOOD PRESSURE IN A CONTROLLED ENVIRONMENT
Hefferon T, Arave K, Mitchell S, Peters AM, Sibbett S, Franklin Pierce University, Goodyear, AZ
PURPOSE/HYPOTHESIS: “White Coat Syndrome” is a syndrome characterized by a patient's feeling of anxiety in a medical environment resulting in abnormally high arterial blood pressure (ABP) readings. Approximately 20% of the adult population is thought to be so affected. Although well researched in clinical settings, there is a paucity of research performed in laboratory settings where extraneous stimuli are controlled. Purpose of the present study was to determine if in ABP obtained by a faculty member, presenting as a “white coat” clinician (WCC), is significantly different than ABP obtained by a familiar student peer evaluator (PE). NUMBER OF SUBJECTS: A convenience sample of 20 healthy physical therapy students participated in this study (27.1 ± 5.7 years; 11 males, 9 females). MATERIALS/METHODS: Prior to the session, randomization was used to determine blood pressure testing order (WCC or PE). A Welch Allyn Connex 6000 Vital Signs Monitor was used to obtain all measurements: diastolic blood pressure (DBP), systolic blood pressure (SBP), and pulse rate (PR). Once informed consent was secured, a 5 minute rest period was imposed with ABP then acquired by the first evaluator. Repeating the same rest protocol, an ABP measurement from the alternate evaluator was acquired. All measurements were taken in a quiet university laboratory area. Paired t tests were used to assess differences in SBP, DBP, and PR between values obtained by WCC and FE. Version 23 SPSS software was employed for all statistical analyses. Alpha level P ≤ .05 was selected for significance determination. RESULTS: Measurements of SBP, DBP, and PR were significantly lower when taken by FE than by WCS: SBP: 124.7 ± 13.0 versus 130.6 ± 11.4; DBP: 76.7 ± 6.1 versus 81.2 ± 6.1, PR: 66.6 ± 9.9 versus 71.6 ± 13.0. For all comparisons of these variables, P values were 0.005, 0.001, and 0.019, respectively. CONCLUSIONS: We conclude the elevations observed in ABP and P as obtained by WCC manifested independent of ambient environmental conditions. We further posit that a sympathetic nervous system response generated by past experiences with WCC's is a probable mechanism for ABP change. CLINICAL RELEVANCE: Physical therapists need to be aware of the “White Coat Syndrome” and the possible influence this has on vital sign measurement. Further study is indicated examining the WCC effect on patients in physical therapy settings concomitant with discussion of referrals to higher level of care based on abnormal vital signs.
USE OF TELEHEALTH FOR PATIENTS WITH CONGESTIVE HEART FAILURE UNDERGOING PHYSICAL REHABILITATION: A SYSTEMATIC REVIEW
Anderson AE, Hernandez C, Calvin S, Royer J, Padilla J, Shaw D, Physical Therapy, Franklin Pierce University, Goodyear, AZ
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to discuss telehealth as viable adjunct for improving physical outcomes in patients with congestive heart failure (CHF) as compared to patients receiving cardiac rehabilitation in traditional hospital settings. NUMBER OF SUBJECTS: Not Applicable. MATERIALS/METHODS: A comprehensive literature search was completed using PubMed, CINAHL, PEDro, Cochrane Central Register of Control Trials, and Google Scholar. Grey literature and reference lists from relevant publications were also reviewed to identify additional articles. Inclusion criteria included relevance to CHF, telemedicine as an intervention, reports of at least one physical outcome measure, studies published after 1990, English language only, randomized control trials including patients with NYHA heart failure classifications, and patient follow-up lasting between 8 and 52 weeks. Exclusion criteria included duplicates, books, texts, patents, controlled clinical trials, cluster trials, retrospective studies, pilot studies, cross sectional studies, case series, case reports, studies with outcomes of cost or economic-based only, and studies relating only to self-care. Articles were assessed by 3 reviewers for quality using the PEDro scale. RESULTS: Five randomized controlled trials were selected and analyzed. Results focused on the affect telemonitored home programs (THP) had on select physical outcome measures (ie, V̇o2peak, 6 Minute Walk Test, and ECG monitoring). All articles characterized THP as a safe alternative to usual hospital-based cardiac rehabilitation in patients with CHF. Four of the studies revealed significantly greater improvements in V̇o2peak for THP groups when compared to hospital-based rehabilitation groups. There were no untoward ECG-related events reported in patients participating in cardiac rehabilitation either at home or at a hospital. CONCLUSIONS: Results of this review are consistent with other systematic reviews focusing on telehealth applications for patients with CHF. All studies further establish THP to be as safe as, and sometimes superior to, hospital-based cardiac rehabilitation programs. Improvements in physical outcome measures for aerobic power and functional mobility were consistent throughout. In addition, THP had a positive effect on post-treatment measures of self-care while also contributing to enhanced quality of life. The opportunity for telemonitored patients to receive direct feedback from healthcare professionals regarding physical responses to exercise added to patient confidence. We conclude THP is an efficacious rehabilitation adjunct for improving physical outcomes in patients with CHF when compared to cardiac rehabilitation received in traditional hospital settings. CLINICAL RELEVANCE: The present systematic review builds on the growing evidence that telehealth is a promising treatment alternative for patients with CHF.
PHYSICAL ACTIVITY, BALANCE PERFORMANCE AND K-LEVELS IN INDIVIDUALS WITH BELOW KNEE AMPUTATIONS
Devour A, Coolsaet R, Galen S, Reid K, Burzynski E, Filippis R, Eick K, Pepin ME, Physical Therapy Program, Wayne State University, Detroit, MI; Wright and Filippis, Detroit, MI
PURPOSE/HYPOTHESIS: The association between K-level and objective measures of physical activity, balance and balance confidence has not been studied extensively. Therefore the aim of this study was to investigate the association between K-levels, balance performance/confidence and physical activity. We hypothesized the K-levels would be correlated with balance, balance confidence and physical activity measures and that physical activity would be correlated with balance and balance confidence. NUMBER OF SUBJECTS: Twenty subjects (age = 59.6 ± 10.8 years, time since amputation = 6.1 ± 7.2 years) with a unilateral below knee amputation were recruited from outpatient prosthetic fitting clinics. MATERIALS/METHODS: The subjects completed the Activity-specific Balance Confidence (ABC) scale, the Amputee Mobility Predictor (AMP) and instrumented balance assessments using the NeuroCom Balance Master. The order of tests was randomized. The K-level and type of prosthesis used by each patient was provided by the prosthetists. The subject's physical activity was monitored continuously 24 hr/d over 7 days using an ActivPAL body worn sensor. The ActivPAL sensors recorded the subject's steps/day as well as the duration in sitting/lying, standing and walking. Both descriptive statistics and correlation analyses using Spearman's rank were performed with significance set at P < .05. RESULTS: Twenty subjects completed the study. Descriptive analysis indicated that the participants spent on average 19.7 ± 0.5 hr/d laying/sitting, 3.5 ± 0.4 hours standing, 0.77 ± 0.07 hours stepping, and walked an average of 3145 ± 378 steps/day. The correlation analysis revealed a positive and strong association between the K-levels and AMP score (r = 0.758, P < .001), moderate associations between the AMP and time spent sitting/lying (−0.430, P < .05), stepping (0.476, P < .05) and the average steps/day (0.535, P < .01). The ABC was correlated with time spent sitting/lying (−0.528, P < .05), standing (0.493, P < .05) and average steps/day (0.412, P < .05). Movement velocity towards the amputated side, measured by the Balance Master, was moderately correlated with time spent stepping (R: 0.579, P < .05; L: 0.810, P < .01) and average steps/day (R: 0.597, P < .05; L: 0.833, P < .01). CONCLUSIONS: The individuals with transtibial amputations in this study took an average of 3145 ± 378 steps/day, placing them in the sedentary category. Balance performance and confidence measures were moderately correlated with physical activity. Participants in the K3/4 groups performed better on the AMP than those in the K2 group but there were no significant differences in physical activity levels between the 2 groups. CLINICAL RELEVANCE: Physical Therapists need to consider that some of their clients with transtibial amputations may not be physically active and may wish to assess physical activity. More research is needed to determine if perhaps improving balance performance and balance confidence may increase physical activity.
ARTERIAL BLOOD PRESSURE RESPONSE TO REPEATED CUFF RE-INFLATIONS WITHOUT INTERPOSED RESTS
Shaw D, Johnson S, Hefferon T, Physical Therapy, Franklin Pierce University, Goodyear, AZ
PURPOSE/HYPOTHESIS: The purpose of the study was to determine if 5 rapid blood pressure cuff re-inflations obtained without interposed rests progressively alter individual arterial blood pressure (ABP) values. NUMBER OF SUBJECTS: Twenty (10 males, 24.8 ± 2.5; 10 females, 23.5 ± 1.6 years) students volunteered to participate in the study. MATERIALS/METHODS: Following receipt of informed consent, subjects were moved to a separate room for 5 minutes of quiet rest. Upon return to the testing area, each subject was seated comfortably with a blood pressure cuff affixed to the left arm following standard protocol. A Welch Allyn Connex 6000 Series Vital Signs Monitor was used to obtain all ABPs. No rest interval was provided between successive ABP measurements with cuff re-inflated immediately following deflation. Investigators did not engage subjects in conversation once the cuff inflation protocol was initiated. A total of 5 ABP trials (T) were administered utilizing this rapid re-inflation procedure. Alpha level was set at P ≤ .05; data were analyzed using SPSS Version 23 software. Bonferroni adjustment was provided for all repeated measure comparisons. RESULTS: Mean ± SD mm Hg for systolic (SBP) and diastolic (DBP) pressures over the 5 trials were: T1: 125.6 ± 16, 75.8 ± 5.7; T2: 120.5 ± 16.1, 74.3 ± 6.7; T3: 120 ± 15.4, 75.4 ± 6.8; T4: 118.8 ± 15.4, 73.9 ± 6.5; and T5: 119.8 ± 14.7, 73.8 ± 6.9. Pairwise comparisons revealed significant differences between SBPs T1 versus T2 − T5 (P ≤ .015) only. Significant differences between DBPs over 5 trials were: T1 versus T2, T4, T5 (P ≤ .041); and T3 versus T4, T5 (P ≤ .021). Pulse rates appeared to vary independent of the changes observed in ABP. CONCLUSIONS: All SBPs were lower after T1. This same trend was observed for all DBPs except for T3. The T3 DBP approximated that observed at T1 (ie, 75.8 vs 75.4 mm Hg). Given the range of change for both SBPs (6.8 mm Hg) and DBPs (2.0 mm Hg) was quite small, it appears no mechanism is at play to alter ABPs when obtained sequentially without interposed rests. The higher ABPs observed at T1 are likely a sympathetic response to initial study participation. We conclude the time interval of cuff re-inflation has a negligible effect on ABP measurement. CLINICAL RELEVANCE: This study further supports evidence now emerging that ABP measurement guidelines specific to cuff re-inflation need to be revisited and amended as necessary.
IMPROVED DIAPHRAGM DESCENT IN CHILDREN WITH POMPE DISEASE FOLLOWING INTRAMUSCULAR GENE THERAPY
Smith BK, Marcus J, Lawson LA, Islam S, Corti M, Collins S, Byrne BJ, Physical Therapy, University of Florida, Gainesville, FL; University of Florida, Gainesville, FL
PURPOSE/HYPOTHESIS: Pompe disease is a neuromuscular disorder resulting from a gene mutation in the enzyme that degrades lysosomal glycogen. Children with infantile onset Pompe disease develop progressive weakness and cardiopulmonary insufficiency that often requires early mechanical ventilator (MV) support. Our team conducted a first-in-human clinical trial of gene therapy (AAV1-GAA) to the diaphragm, in attempt to treat ventilatory insufficiency. We hypothesized that AAV1-GAA would stabilize or improve diaphragmatic function in the recipients. NUMBER OF SUBJECTS: Nine children with Pompe disease (aged 2–15 years, full time MV: n = 5, partial/no MV: n = 4) were studied 3-months before and 1 year after receiving AAV1-GAA. Institutional IRB approval was obtained. Parents signed informed consent on behalf of their children, and older children gave their assent. MATERIALS/METHODS: Children completed customized inspiratory muscle conditioning exercises both before and after a single thorascopic adminstration of AAV1-GAA. Dosing was 1–5 × 1012 vector genomes, distrubuted via 6 separate injections to the bilateral ventral, lateral, and dorsal costal regions. Changes in respiratory function after exercise alone were compared to changes in function after intramuscular delivery of AAV1-GAA to the diaphragm. Every 90 days, tidal breathing assessments, maximal inspiratory pressure and maximal voluntary ventilation were completed. At baseline and 180 days after dosing, physical evidence of diaphragm activity was evaluated with kinematic evaluation via dynamic thoracic magnetic resonance imaging (MRI, 1.5 tesla, T2-weighted gradient echo sequences). Two independent observers compared diaphragm descent in the right sagittal plane, during tidal breathing without MV. Mann-Whitney U tests were used to compare diaphragm movement, and significance was P < .05. RESULTS: At 6 months following the AAV1-GAA dosing, 4 subjects had evidence of diaphragm descent. Subjects with diaphragmatic motion tended to be younger, have a greater maximal inspiratory pressure, and have less reliance on MV. Maximal ventilatory ventilation was significantly larger in subjects with diaphragm motion (P < .05). CONCLUSIONS: Changes in diaphragm descent visualized with MRI corresponded to ventilatory functional gains in the subjects. The results suggest a potential AAV1-GAA therapeutic benefit in dynamic respiratory muscle function, among some children with impaired ventilation at baseline. However, further study of the potential AAV-GAA benefit is needed with systemic administration of AAV-GAA. CLINICAL RELEVANCE: Children with higher baseline function may have a greater potential for functional gains in dynamic respiratory muscle function.
