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  • Pilot Study Indicates Yoga Improves Quality-of-Life for Pediatric Cancer Patients and Their Parents

    With childhood cancer mortality rates falling over the past 4 decades, some researchers say it's time to take a closer look at better ways of supporting the psychosocial and quality-of-life needs of patients and their families during treatment—including making yoga a part of the mix.

    That's the premise of a preliminary feasibility study that looked at parent and patient receptivity to the idea of including yoga as an adjunct to cancer treatment, and tracked changes to quality of life after an 8-week yoga program. Results were published in Rehabilitation Oncology, the science journal of the APTA Oncology Section.

    The research was conducted in 2 parts: first, researchers administered surveys to patients and their parents that aimed to assess willingness and barriers to participate in a yoga program that would take place during treatment visits; in the second phase of the project, patients and their parents participated in an 8-week yoga program, and were asked about quality-of-life issues at baseline and after the program's completion. To qualify for the studies, patients had to be 8-18 years old, possess a cognitive ability of at least an 8-year-old, and be undergoing cancer treatment during the study period. In addition, parents were required to be able to physically participate in yoga with their children. The first phase of the study involved 20 patients and 20 parents or guardians; the second part of the study included 12 patient-parent pairs.

    Researchers found that even though patients and parents recognized potential barriers to participating in yoga—most frequently, concerns about side-effects of cancer treatments, and potential pain and discomfort—just over half were interested in participating in a program, and 80% believed "participating in a program that would help you relax" would be helpful. Researchers used the results to help yoga instructors create interventions that would accommodate side effects such as fatigue and discomfort to help reduce those perceived barriers.

    Volunteer patient-parent dyads were then enrolled in the 8-week yoga intervention, a program held weekly by a certified yoga instructor with special training in providing instruction to the pediatric cancer population. Sessions were designed to last for an hour each; however, patient symptoms prevented sessions from going longer than 30 minutes in 30% of the sessions. Delivery methods varied by patient status, and included bed and chair-based yoga.

    Researchers found that the program resulted in significant changes among patient perceptions of quality-of-life related to emotional and social wellbeing, measured on a 100-point scale. Patients who participated in the program saw an average uptick of 11.5 points on the emotional scale, from 62.5 to 74. Average gains in the social scale jumped by just over 10 points, from 76.1 to 86.5. For parents, the biggest gains were made in the "mental health composite scale" assessment, which revealed an average increase of 8 points, from 39.1 to 47.

    Authors of the study acknowledge that their research is preliminary, and that several limitations—including lack of a control group, small sample size, and relatively low dose of intervention—make it difficult to draw definitive conclusions about effectiveness.

    Researchers also found implementation to be problematic, given their attempts to coordinate the sessions with inpatient or outpatient treatment. "We found that the patients' treatment appointments were somewhat erratic, making scheduling difficult," authors write. "We only had a few specific times available for offering the yoga, and often these times did not fit patients' schedules."

    Still, they believe, it's time for health care to more carefully consider integrating a broad range of interventions, such as yoga, to help patients and parents stay as physically and emotionally healthy as possible during cancer treatment.

    "Given advances in pediatric cancer survival rates, the importance of support for the wide range of treatment-related challenges incurred by children and their families has increased. As a result, integrative medicine has received an increasing amount of attention in hopes of promoting holistic health and wellness for this growing group of survivors," authors write, concluding that "our findings support the notion that yoga for pediatric cancer patients during active treatment is feasible and potentially helpful in improving both patients' and parents' well-being."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Early Physical Activity After Concussion May Reduce Risk of Persistent Symptoms, Researchers Say

    A Canadian study published in JAMA turns the current thinking on postconcussion physical activity on its head. According to researchers, early return to physical activity within 1 week of concussion may actually decrease the likelihood of persistent symptoms in the pediatric population.

    The prospective cohort study included 2,413 children and adolescents between the ages of 5 and 18 years. At 7 days and at 28 days postinjury, participants filled out questionnaires about their physical activity and rated their postconcussion symptoms using the Post-Concussion Symptom Inventory. Of the respondents, 30.5% rested for the first 7 days, and 69.5% participated in some sort of physical activity, including light aerobic exercise, sport-specific exercise, noncontact drills, full-contact practice, or full competition.

    According to researchers, those who participated in early physical activity had a significantly lower risk of persistent postconcussion symptoms (PPCS) at day 28. Only 28.7% of those patients were still experiencing PPCS, compared with 40.1% of those who rested.

    Among the patients who were experiencing symptoms only at day 7, the rate of PPCS was lower for those who participated in light aerobic activity, moderate activity, and full-contact activity, compared with those who rested.

    Existing concussion guidelines recommend a period of physical and cognitive rest, while some have found “limited” or “preliminary” evidence supporting return to moderate or graded physical activity to aid in recovery. This study takes a step forward in the direction of activity, though authors recommend randomized controlled trials to explore the subject more objectively.

    The JAMA article received attention from several media outlets including CNN.com, which interviewed study co-author Roger Zemek, MD. Zemek told CNN that that earlier physical activity could play a psychologically important role in recovery, but he warned that return to activity should be approached with caution.

    Still, Zemek told CNN, the findings make a case for the importance of physical activity in recovery. “I think there are many different ways in which exercise may be beneficial," Zemek said. "Exercise itself can be a great medicine."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Physical therapists are well-qualified to assess and treat concussions. Read more about our advocacy efforts toward safe concussion management, sign up for related courses, and visit MoveForwardPT.com to see what APTA tells consumers about the PTs’ role in concussion management.

    Sports and Recreation-Related Injuries Top 8.6 Million Annually

    A growing number of Americans may be engaging in physical activity, but that also means a growing number of Americans are getting injured while doing so—to the tune of about 8.6 million episodes in 2014, according to a recent study from the US Department of Health and Human Services. The analysis, based on National Health Interview Survey data from 2011 to 2014, also sheds light on where injuries are taking place, what activities were involved, and what areas of the body are most often affected.

    Authors of the study claim their analysis is the first to take a broad look at recreation-related injuries by using data that reflects, among other things, all medically attended injuries, not just emergency department (ED) visits. They write that focusing solely on ED data "may underestimate the overall burden of injury from sports and recreation activities."

    Among the findings in the study:

    • The average annual injury estimate of 8.6 million per year represents an age-adjusted rate of 34.1 per 1,000 population.
    • About half of all injuries were treated in a setting other than an ED, and even fewer required hospitalization—about 2.7%, or 230,000 individuals.
    • Most of the injury episodes (65%) involved individuals aged 5-24 years, with the highest rate registered by children 5-14, at 76.6 per 1,000 (86 per 1,000 for boys, 66.8 for girls).
    • An estimated 2.9 million injuries annually—just over a third of all injuries—occurred at a "sports facility, athletic field, or playground."
    • The most prevalent activity related to injury varied by age group. For children aged 5-14, and adults 25 and older, "general exercise" topped the list, at 10.1 per 1,000 for the younger group, and 3.2 per 1,000 for the adults. Among individuals aged 15-24, basketball edged out general exercise for the top spot, at 7.9 per 1,000 (general exercise was close behind at 7.5). After that, activities began to vary by age group, with football, "playground," gymnastics/cheerleading, and pedal cycling rounding out the top 5 for the 5- 14-year-olds; soccer, football, and gymnastics/cheerleading taking the third, fourth, and fifth positions, respectively, for the 15- 24-year-old group; and "recreational sport’ (racquet sports, golf, bowling, hunting, fishing, hiking, and other leisure sports), basketball, pedal cycling, and water sports completing the top 5 list for the group aged 25 and older.
    • The highest percentage of injuries reported—about 27.9 per 1,000—were related to a fall, followed by overexertion (16.8), "struck by or against" (15.4), "transportation" (15.4), and "cut or pierce" (12.3).
    • Sprains and strains accounted for the largest portion of injury types, at 41.4 per 1,000. Fractures, at 20 per 1,000, were next, followed by contusions (19), open wound (10), traumatic brain injury (4.5), and dislocation (2.9).
    • The most frequently injured area of the body was the lower extremities, at 42 per 1,000 individuals, followed by upper extremities (30), head/neck (16), and trunk (10).

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: Virtual Reality Systems Could Enhance Intermanual Transfer

    It's well-known that physical training in 1 hand can result in performance gains in the opposite, untrained hand—a phenomenon known as intermanual transfer—and that using a mirror to make it look as if the untrained hand is moving can speed up the process. But now researchers claim that allowing a subject to "see" the untrained hand move by way of virtual reality (VR) can further enhance the gains, and light up the neural networks that make it possible.

    In a series of experiments conducted on a total of 53 participants, researchers hooked up subjects to a VR system that used a headset and a pair of gloves that tracked finger movements and translated them into a visual representation of the participant's hands. Researchers could then make it seem as if, when the subject moved fingers on his or her right hand, the left hand was moving. Results were published in Cell Reports.

    The experiments themselves involved participants learning and then performing a set of rapid finger movement sequences in their right hands. During the learning stage, the visual images of their moving fingers were manipulated in 3 ways: as movement of the right-hand fingers (what authors call "congruent feedback"), as movement of the left-hand fingers even though the right-hand fingers were moving ("incongruent feedback"), and no feedback. Finally, participants were shown images of the left hand performing the movements while both hands remained immobile.

    Researchers found that while left-hand performance improved in all 3 scenarios that involved actual movement of the subject's right-hand fingers (not true of simply watching the movements while immobile), the most significant gains in left-hand performance were achieved when subjects received incongruent feedback—that is, when it looked like a participant's left-hand fingers were moving as they moved the fingers on the right.

    In the second experiment, researchers coupled the VR system with a device that passively moved the left-hand fingers in conjunction with images sent to the headset. Again, they applied the 3 basic visual elements—congruent, incongruent, and no image—employing the passive movement device along the way. Their findings: when participants weren't supplied with the visual representation of left-finger movements, the passive movement system didn't improve performance over what was observed the first experiment. However, when researchers coupled the visual element with the passive movements, participants experience the highest performance gains of all, "significantly higher than all other training types." Authors assert that the "gains across training conditions cannot be explained by differences in the number of self-paced movements or subliminal movement of the untrained hand."

    Finally, researchers used whole-brain functional magnetic resonance imaging (fMRI) to get a better idea of just how functional connectivity worked in the training scenarios from the first experiment (without the passive movement system). Focusing on the left and right superior parietal lobules (L-SPL and R-SPL, respectively), and the bilateral occipito-temporal visual regions (R-Visual and L-Visual), they found that only activity in the left and right SPL was correlated with performance gains, and that, somehow, the "incongruent" visual training created stronger activity in the SPLs. "This suggests an SPL-based mechanism that plays a significant role in the integration of input received from both the visual and motor cortex during training with incongruent visual feedback," authors write.

    Researchers believe that "exploiting the current novel approach has the potential for enhancing motor acquisition in clinical patients who exhibit mild to moderate upper extremity hemiparesis," asserting that, while direct training of the affected hand has "well-established" effects, it can be a very challenging approach, "especially in cases where…basic movement capability…is limited." Authors believe that the VR approach is a way to "bypass this challenge by combining the VR setup…with physical training of the nonaffected hand."

    "Our results suggest that, at least when motor skills are concerned, contrary to the popular idiom, my left hand actually does know what my right hand is doing, and this knowledge is likely medicated through information conveyed by the SPL," authors write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    APTA Offers Fellowship Opportunities

    APTA has announced the creation of 2 new fellowships within the association: a visiting scholar postdoctoral fellowship set to begin in 2017, and a 2018 visiting scholar early-investigator fellowship. Both positions seek a physical therapist "who will be able to add to or refine the body of knowledge on which physical therapy is based."

    A complete description of the fellowships, including responsibilities, requirements, terms, and application instructions, can be found on the APTA website (postdoctoral fellowship here, early-investigator fellowship here). The deadline for submission of applications is February 28, 2017, by midnight, ET. In-person and virtual interviews will be conducted beginning at the APTA Combined Sections Meeting in February, 2017, in San Antonio, Texas, and continue as needed.

    Questions about the fellowship should be directed to the APTA research department.

    From PTJ: High-Intensity Locomotor Exercise Improves Ability to Walk After Incomplete SCI

    The conventional approach to rehabilitation for patients with incomplete spinal cord injury (iSCI) is being turned on its head: according to researchers, high-intensity locomotor exercise does not “degrade gait performance” but actually improves an individual’s locomotor function and quality.

    It wasn't exactly what the researchers were expecting. They had a 2-part hypothesis: first they hypothesized that short-term exposure to higher walking speeds and higher-intensity stepping would cause a decline in gait quality in people with iSCI. The second part of their hypothesis was that once achieved, repeated high-intensity walking would then improve gait quality. Findings were published in Physical Therapy (PTJ), the scientific journal of APTA.

    To assess short-term effects, authors used a graded-intensity treadmill test on 19 individuals with iSCI. While the participants increased walking speed by 0.1 m/s every 2 minutes, researchers gathered kinematic data using a motion capture system, as well as electromyographic data. Participants continued walking until they needed support from a safety harness to stand upright. Researchers also evaluated intensity using the Rate of Perceived Exertion (RPE) scale.

    Authors were surprised to find that the first part of their hypothesis was off the mark: short-term increases in intensity of treadmill walking did, in fact, significantly improve muscle activity, joint excursions, spatiotemporal parameters, and some kinematic metrics, such as total ROM of the hip and ankle. They then moved on to test the second part of their hypothesis—that repeated high-intensity practice would improve gait quality.

    To do this, researchers worked with a 9-person subset of participants who had completed the first phase, putting them through a 12-week high-intensity locomotor training program consisting of 3 1-hour sessions each week. Each individual attempted to walk for 45 minutes continuously, with body-weight support only if needed. A physical therapist provided limb swing assistance using elastic bands attached to the front of the treadmill and to the knee, ankle, or both. Authors attempted to achieve RPE ratings of higher than 14. All 9 participants walked at least 25 minutes per session, with the exception of a few with limited tolerance due to “unrelated illness.”

    Researchers found only partial support for their hypothesis that the repeated high-intensity practice would lead to improvements. At the end of the 12-week program, the high-intensity training had not led to much change in gait parameters, nor did it result in large or consistent change in joint kinematics or muscle timing. However, the individuals did significantly improve peak gait speed and stride length and cadence.

    Overall, these findings “highlight the need for this proposed link between increases in exercise intensity and impaired gait quality to be reevaluated,” authors write. More rigorous research needs to examine this interaction, they note, “given the pervasive influence of these and similar theories on current standard clinical practice.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    PT Locum Tenens, Rehab Research Among Victories in New Health Care Legislation

    The 21st Century Cures Act—sweeping health care legislation touches on everything from mental health coverage to the regulatory approval process for new drugs—also contains some good news specifically for physical therapists (PTs) and supporters of rehabilitation research.

    The bill, passed by both the US House of Representatives and the Senate, contains 2 provisions that have been high on APTA's advocacy list: the inclusion of PTs among the health professionals permitted to enter into locum tenens arrangements, and language that will increase that stature of—and funding for—rehabilitation research at the National Institutes of Health (NIH). President Barack Obama is expected to sign the legislation into law before leaving office.

    The locum tenens portion of the legislation would allow a PT to bring in another licensed physical therapist to treat Medicare patients and bill Medicare through the practice provider number during temporary absences for illness, pregnancy, vacation, or continuing medical education. Only PTs in non-Metropolitan Statistical Areas, Medically Underserved Areas, and Health Professions Shortage Areas as defined by the US Department of Health and Human Services would qualify for the program.

    The Cures Act also includes legislation that will improve coordination of rehabilitation research throughout NIH, and require the development of a comprehensive rehabilitation research plan, updated every 5 years. The first version of that 5-year plan was unveiled in September, with APTA Chief Executive officer Justin Moore, PT, DPT, calling the roadmap "a long awaited and significant step forward" for research efforts.

    "The inclusion of PTs in locum tenens arrangements and the recognition of the importance of rehabilitation research are big wins for the physical therapy profession but, more important, for patients," said Justin Elliott, APTA vice president of governmental affairs. "APTA and other stakeholders worked hard to make the case for both of these issues, and we're pleased to see that legislators are showing increased understanding of the important role physical therapy and PTs can play in the future of health care."

    Other provisions in the act that could also affect PTs: a requirement that the Centers for Medicare and Medicaid Services (CMS) take a closer look at expanding the range of telehealth services under Medicare (including an expansion of originating sites of these services), and a delay in the implementation of Medicare fee schedule adjustments for wheelchair accessories and seating systems when used with complex rehabilitation technology wheelchairs. Under the Cures Act, the adjustments would begin in July 1, 2017, instead of January 1 of 2017.

    The more wide-ranging provisions of the legislation also include $1 billion in state grants to help fund efforts to battle the opioid epidemic.

    Researchers Find 'Unsettling' Uptick in Stroke Rates in Adults Under 55

    A recent study of stroke rates has found that while rates have declined in patients older than age 55, there has been an uptick among younger populations—and the potential underlying factors are “unsettling.”

    Authors of the study, published in theJournal of the American Heart Association, write that over the past 20 years, the incidence of stroke has decreased in many countries, but that trend may now be reversing itself. Researchers applied an “age-period-cohort” analysis to data from the Myocardial Infarction Data Acquisition System in New Jersey in an attempt to “unravel the separate effects due to aging, secular changes, and life course experience” on incidence of ischemic stroke and ST-elevated myocardial infarction (STEMI). The time periods considered were 1995-1999 (period 1), 2000-2004 (period 2), 2005-2009 (period 3), and 2010-2014 (period 4).

    Researchers found that overall, the stroke rate for individuals aged 35 to 84 decreased from 314.1 strokes per 100,000 “person-years” (PY) in period 1 to 271 in period 4. The overall rate for STEMI decreased by 60% in the same time period.

    However, the stroke rate among patients 35-39 more than doubled over that same 20-year period, from 9.5 to 23.6 per 100,000 PY. The rate also doubled for those in the age 40-44 cohort, from 22.9 to 46.0 strokes per 100,000 PY between periods 1 and 4. There also were smaller yet still significant increases for individuals aged 45-49 and 50-54. For groups older than 55, rates declined.

    These findings echo results of similar studies in the United States, as well as Taiwan, France, and Denmark, authors noted, writing that, in their study, “the downward trend in the oldest age groups, the flattening trend in the middle age groups, and the upward trend in the youngest groups suggest a birth cohort effect.” Authors suspect that higher prevalence of obesity and diabetes among younger cohorts, in addition to lack of treatment for high blood pressure and lower likelihood of having health insurance, may be contributing to this disturbing trend in the US. The rise in obesity among younger populations has also led to an increase in atrial fibrillation, a risk factor for stroke.

    Interestingly, the STEMI rate decreased for all groups. Authors suggest this could be due to the fact that STEMI is more closely associated with lipid levels than with high blood pressure, and “the increasing prevalence of atrial fibrillation in the young would have a greater impact on rates of stroke than those of STEMI.”

    Taken together, researchers assert, “these trends may have significant implications for health outcomes and the overall healthcare burden in the future.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    CoHSTAR Research Center Accepting Postdoctoral and Faculty Fellowship Applications

    Physical therapists (PTs) who are interested in playing a transformative role in physical therapy health services research now have a big chance to do just that.

    The Center on Health Services Training and Research (CoHSTAR) is seeking candidates for fellowships at either a full-time postdoctoral level or a part-time faculty level. Fellowships are available at the 3 institutions participating in CoHSTAR: Brown University, Boston University, and the University of Pittsburgh.

    For the full-time fellowships, applications are being sought from PTs with a PhD, ScD, or DrPH, or from PTs with a DPT and research training, experience, and publication history. Part-time faculty fellow applicants must be licensed PTs and full-time faculty members with a doctoral degree or equivalent research experience. Faculty fellows must devote the bulk of their time to research activities, and be able to participate in CoHSTAR activities and regularly visit the CoHSTAR site.

    Application instructions are available at the CoHSTAR webpage.

    CoHSTAR was created through a $2.5 million grant awarded by the Foundation for Physical Therapy through its "Center of Excellence" initiative. In addition to the fellowships, CoHSTAR sponsors visiting scientists and provides special summer training sessions. The center also funds several pilot studies each year from investigators inside and outside the program.

    For more information about the CoHSTAR fellowships, email Audrey Kidd.

    Researchers: A City's 'Stress Level' Could Affect Local Hospital Ratings

    Could it be that when it comes to the Centers for Medicare and Medicaid's (CMS) star rating system, no hospital is an island? Some researchers are wondering just that, after finding a high correlation between a city's level of "stress" among residents and lower overall ratings for local hospitals.

    The report, published as a research letter in the November 28 edition of JAMA Internal Medicine (abstract only available for free), compares CMS hospital ratings with the results of a recent study that compiled demographic, health, and financial data on residents of 150 cities across the US. The CMS star system, posted at its Hospital Compare website, bases its ratings on factors such as readmission rates, surgical mortality, and hospital-acquired infection. The stress study, sponsored by WalletHub, looked at 5 categories of stress: work, money, family, health/safety, and coping mechanisms. Using data that touched on a range of issues including, among others, poverty levels, divorce rates, suicide rates, average hours of sleep per night, binge drinking, and number of psychologists per capita, WalletHub researchers assigned an overall "stress level" score to each city.

    Authors of the JAMA letter compared the star ratings of 657 hospitals with the stress ratings of the 150 cities in which they were located. They found that the less stressed a city is, the more likely it would be to contain hospitals with higher overall star ratings. For example, 2 of the most highly stressed cities in the US—Detroit, Michigan, and Newark, New Jersey—also contained hospitals with relatively lower star ratings. The same was true at the other end of the spectrum: low-stress cities such as Madison, Wisconsin, and Sioux Falls, South Dakota, tended to have hospitals with higher star ratings.

    Researchers for the JAMA article estimate that "around 20% of the variance in the star ratings can be explained by community characteristics such as poverty or unemployment rate."

    The correlation may cast the CMS rating system in a somewhat different light, say researchers—one that isn't entirely related to factors within the hospital's control.

    "On one hand, hospitals in stressed cities might provide care of lower quality on average, perhaps because of inability to invest in needed clinical or technological infrastructure or staff shortage," authors write. "On the other hand, the star rating component measures may be affected by community factors such as poor public transportation or limited social support services through causal pathways other than hospital quality."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.