• News New Blog Banner

  • From PTJ: Group-Based Physical Therapy No More Effective Than 1-on-1 Care for Knee OA

    In a recent clinical trial published in the May issue of Physical Therapy (PTJ), APTA's science journal, group physical therapy for individuals with knee osteoarthritis (OA) was found to be no more effective in reducing pain and improving functional outcomes than 1-on-1 sessions—contrary to researchers' expectations.

    Researchers randomly assigned 320 patients with pain, aching, stiffness, or swelling associated with knee OA at a Veterans Administration (VA) medical center to either group or individual physical therapy. Most (88%) were male. Authors hypothesized that group-based physical therapy would lead to superior outcomes, citing several advantages of this setting, including the potential for more visits per patient, better ways to deliver education and support for chronic conditions, and stronger peer support that could lead to greater adherence to exercise-based interventions.

    Most aspects of care were the same for both groups. All patients were instructed in a home exercise program, educated on joint protection and activity pacing, and screened to determine if they required braces, assistive devices, or shoe lifts. To start, they all were instructed to perform the same 4 stretching exercises daily and 6 strengthening exercises 3 times a week. As they progressed, they were given opportunities to increase the difficulty of their exercises.

    The physical therapists (PTs) gave all participants written and illustrated instructions, exercise logs, and therapy bands, as well as reminder calls before each therapy session.

    The only difference between the groups was the greater number of sessions for patients in the group-based program compared with patients in the individual program. Because of this, the PTs in the group setting were able to follow up more on educational components and exercise progression. Patients in the group setting also had more time to ask questions and experienced greater peer support.

    Here is what researchers found:

    WOMAC scores were no different for each group.
    At the 12-week and 24-week follow-up assessments, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were slightly lower for patients who received group-based sessions, but with no meaningful difference. On average, patients in both groups improved from baseline, even at 24 weeks.

    Satisfaction with physical function didn’t improve much for either group.
    Both groups self-reported similar levels of satisfaction with physical function on the SPPB at 12 weeks. There was also no significant change over time for either group.

    Frequency and duration of exercise increased for both groups.
    There was no significant difference between the groups at any point, as measured by the Community Health Activities Model Program for Seniors. At 12 weeks, patients in both settings had improved frequency of exercise by 24% and duration by 12%. But while the overall frequency of moderate or greater intensity exercise improved by 31%, there was no noticeable difference in duration of moderate or greater intensity exercise.

    6-Minute Walk Test distances improved for patients in groups, decreased for individual settings.
    The only significant difference was change from baseline for the 6-Minute Walk Test at 12 weeks. Group physical therapy participants improved by 14.3 meters, while the individual program patients actually had a mean decrease of 3.2 meters.

    Staffing costs may or may not be optimal.
    When staff costs per patient were estimated based on the expected number of patients, it was more cost-effective to deliver group care. However, when cost was calculated based on the actual number of patients who showed up, 1-on-1 care turned out to be cheaper.

    While these outcomes contradicted researchers’ expectations, authors note that “the results suggest that there may have been different advantages of each approach that ultimately resulted in similar changes for most outcomes. Although the group physical therapy approach allowed more contact and group support, the individual physical therapy visits allowed greater one-on-one time with a physical therapist.”

    Authors noted several limitations of the study. For example, all outcome measures were self-reported, and actual strength and range of motion were not objectively measured. And, while the researchers “assessed adherence” to physical therapy sessions, they did not measure performance of home exercises.

    Even though results of both approaches were nearly equivalent, authors of the study believe that group-based treatment for knee OA may be worth a closer look.

    "Given the expected rise in prevalence of knee OA and the general need to provide efficient health care,” authors note, “a physical therapist–led, group-based approach to delivering nonpharmacological treatment of knee OA could be a useful approach in many health care settings.”

    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 Offers Online Viewing for First-Ever Conference on PT Health Services Research

    A first-of-its-kind gathering to explore physical therapy health services research with some of the profession's top researchers is nearly at capacity, but you still have a chance to tune in remotely.

    The Center on Health Services Training and Research (CoHSTAR) is offering a 2-day Summer Institute on Health Services Research June 28-29 at Boston University. Specifically targeted toward training physical therapists in health policy and health services, the institute is CoHSTAR’s first national conference since its inception in 2015.

    Events during the institute will include presentations on integrated health care systems, pragmatic trials, health care industry collaboration, hospital and academic collaboration, as well as discussions of ongoing CoHSTAR research projects.

    The list of presenters reads like a who's who of physical therapy research: Kristin Archer, PhD, DPT, Katherine Berg, PT, PhD, Gerard Brennan, PT, PhD, Tony Delitto, PT, PhD, FAPTA, Pamela Duncan, PT, PhD, FAPTA, Kelley Fitzgerald, PT, PhD, Michael Friedman, PT, MBA, Julie Fritz, PT, PhD, ATC, FAPTA, James Irrgang, PT, PhD, ATC, FAPTA, Alan Jette, PT, PhD, FAPTA, Diane Jette, PT, DSc, FAPTA, Michael Johnson, PT, PhD, OCS, Vincent Mor, PhD, Ken Ottenbacher, PhD, OTR, Linda Resnik, PT, PhD, and Mary Stilphen, PT, DPT.

    In-person attendance has reached capacity, but CoHSTAR will offer live online access to the conference on June 29—though this option also has limits on the number of attendees it can accommodate. Bottom line: if you want to get in on this, do it now.

    CoHSTAR was created through a $2.5 million grant awarded by the Foundation for Physical Therapy, a grant that received $1 million in support from APTA. In addition to the summer institute, CoHSTAR sponsors visiting scientists, offers fellowships, and provides other training sessions.

    County-by-County Analysis Finds Pockets of High Arthritis Prevalence

    As if the prevalence of arthritis in more than 1 and 5 Americans isn't challenging enough, now comes information that breaks down statistics at the county level to find that prevalence is very uneven across the US, with rates as low as 15.8% in some counties and more than 33% in others.

    The new statistics are part of the US Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report set for release on May 20. That report describes the results of a detailed study of the 2014 Behavioral Risk Factor Surveillance System (BRFSS), a survey of 464,444 noninstitutionalized adults across the 50 states, the District of Columbia, and US territories.

    Researchers analyzed the prevalence rates for respondents who answered "yes" to the question "have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" and found that the overall prevalence rate for US adults is 22.7%.

    But that's not all they found. Because data were broken down by county, researchers were able to create a more granular view of just where arthritis was taking a toll. The worst areas: counties along the Appalachian Mountains, the Mississippi River, and the Ohio River. The majority of counties in Alabama, Kentucky, Michigan, Tennessee, and West Virginia registered in the highest quintile for prevalence (27.5%-38.6%).

    At the state level, West Virginia registered the highest overall incidence rate at 35.5% of residents, followed by Kentucky (31.4%), Alabama (31.1%), Michigan (28.7%), and Mississippi (27.1%). The lowest-prevalence state was Hawaii at 18.8%, with Texas not far behind at 19.3%, and California at 19.7%.

    Authors of the study write that the new state and county-level information should help guide health care decisions at the local level.

    "The high prevalence of arthritis in all counties, and the high frequency of arthritis-attributable limitations among adults with arthritis, suggests that states and counties might benefit from expanding underused, evidence-based interventions for arthritis that can reduce arthritis symptoms and improve self-management," authors write. "Few [adults] are aware of interventions that have been shown to reduce their joint pain (eg, physical activity) and help them better manage their arthritis (ie, self-management education)."

    APTA offers multiple resources on arthritis management through community-based programs, including an overview of evidence-based programs, and a decision aid to help physical therapists choose an appropriate program for the patient. Additionally, the US Bone and Joint Initiative (USBJI) offers a series of free public education programs aimed at helping providers increase community awareness of osteoarthritis treatment. APTA is a founding member of USBJI.

    Don't miss the NEXT Conference and Exposition for even more on the subject. Be sure to attend "New Arthritis Foundation Resources for Individuals With Arthritis," presented by Cindy McDaniel, senior vice president of consumer health at the Arthritis Foundation, and Lori Schrodt, PT, PhD, chair of the Health Promotion and Wellness Special Interest Group of the APTA Academy of Geriatric Physical Therapy.

    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.

    New Study Links Leisure-Time Physical Activity to Reduced Risk for 13 Types of Cancer

    Ties between moderate-to-vigorous physical activity and cancer prevention may be much stronger than previously thought: according to a new large-scale study, physically active individuals drop their risk of developing 13 different types of cancer by as much as 20%, including risk reduction for 3 of the 4 most-commonly diagnosed cancers worldwide. Additionally, that preventive tie isn't significantly lessened by a higher Body Mass Index (BMI) or smoking.

    The study, published in the May 16 issue of JAMA Internal Medicine (abstract only available for free), used pooled data from 8 studies in the United States and 4 in Europe to look at the relationship between physical activity (PA) and development of 26 types of cancer among 1.44 million participants who had no cancer at baseline. Individuals tracked in the studies ranged in age from 18 to 98 (average age, 59), with 57% female. A total of 186,932 cancers were included.

    For their analysis, authors of the JAMA study defined moderate-intensity PA as activity with an intensity of 3 or more metabolic equivalents (METs), and vigorous-intensity PA as 6 or more METs. Because the individual studies varied somewhat in the ways they obtained information on PA, researchers for the current study translated PA rates into percentiles, and focused on differences between individuals in the 10th and 90th percentiles.

    Here's what they found:

    Higher levels of leisure-time PA reduced cancer risk in 13 of 26 types of cancer.
    For individuals in the 90th (or higher) percentile of PA rates, researchers reported a greater than 20% drop in risk for esophageal, liver, lung, and kidney cancers, as well as cancers of the gastric cardia and endometrium. Risk of myeloma, as well as breast, colon, rectal, and bladder cancer dropped by 10%-20%. Overall, higher levels of PA were associated with a 7% lower risk for total cancer.

    Cancer risk reduction through PA was generally independent of BMI.
    For the most part, individuals with a higher BMI (25 or greater) who engaged in significant amounts of moderate-to-vigorous PA also saw a reduction in risk similar to their lower-BMI counterparts—including lung and endometrial cancers.

    The protective effects of PA also worked for current and former smokers—with exceptions.
    Other than rates of lung cancer and myeloma, researchers found little evidence that smoking (or having smoked) affected the ability of PA to reduce risk among the 13 types of cancers that registered reductions.

    Risk of melanoma and prostate cancer increased slightly for the more active, but probably not because of the PA itself.
    Researchers recorded upticks in risk for melanoma and prostate cancer among the high-PA groups, but they believe the reasons behind those differences may be due to factors outside the PA itself. Authors theorize that individuals with high PA rates are more likely to be screened for prostate cancer, and many individuals with high rates of PA engage in outdoor activities that increase exposure to the sun (and risk of sunburn). They think these factors may account for the associated risk.

    A JAMA Internal Medicine editorial that accompanies the research article describes the study as "innovative" and one that "provides clarity to the potentially important role of leisure-time activity in cancer prevention." The editorial states that "these exciting findings … underscore the importance of leisure-time physical activity as a potential risk reduction strategy to decrease the cancer burden in the United States and abroad."

    Editorial authors also call for more studies of the PA-cancer prevention relationship, including whether the positive effects are only realized when individuals have been physically active throughout their lives, or if they can be achieved by beginning a higher level of PA later in life.

    Researchers believe their work is the largest-ever study on the relationship between PA and cancer risk, and the findings expand on previous evidence of a relationship between increased PA and reduced risk for colon, breast, and endometrial cancers.

    The researchers are also encouraged by the overall reach of the reductions. "Our results support that these associations are broadly generalizable to different populations, including overweight or obese individuals, or those with a history of smoking," authors write. "These findings support promoting physical activity as a key component of population-wide cancer prevention and control efforts."

    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.

    From PTJ: Could Genomic Awareness Transform the Profession?

    As researchers continue to put together the pieces of the genetic puzzle, physical therapists (PT) can use this knowledge to better assess, treat, and refer patients according to their unique family histories, according to an article in the April issue of Physical Therapy(PTJ), APTA's science journal.

    The “Perspectives” article points out how the instance and progression of chronic disease, including osteoarthritis (OA) and cardiovascular disease (CVD), are affected not only by a patient’s lifestyle and environment, but by their genetics.

    Authors explain how, over the past decade, genome-wide association studies have provided insight into the potential for personalized medicine, in which providers can use genetic markers to identify risk factors for certain health conditions. The eventual goal is to offer individualized therapies or preventive strategies.

    But researchers are looking even beyond disease predictors to identify genetic influences on a patient’s response to treatment, according to the article. One emerging area, “exercise genomics,” holds the promise of individualized exercise prescription for chronic disease prevention.

    There are hereditary factors, authors write, that may predict an individual’s response to a variety of exercise interventions, from muscle fitness to maximum oxygen consumption to lumbar range of motion. Even our tendency to participate in physical activity at all is partially inherited—up to 57%, according to 1 study of twins.

    In a clinical setting, genomics could “help clinicians understand the variability in patient presentation.” The authors cite the example of hand OA, which has been linked with increased risk for knee OA “requiring meniscectomy after injury.” Armed with this knowledge, combined with a patient’s family history, a PT could design a rehab program to minimize adverse outcomes.

    While full-genome sequencing and accurate gene identification won’t be widely available for quite some time, the field holds promise for PTs as part of an interdisciplinary team. Genomics, authors assert, presents “a key leadership opportunity for physical therapists in prevention, health, and wellness” to transform the health of society.

    "It is essential that clinicians reconsider the role of genetics in the preservation of wellness and risk for disease to identify ways to best optimize fitness, health, or recovery," authors write. "Clinicians with knowledge of the influence of genetic variants on health and disease will be uniquely positioned to institute individualized lifestyle interventions, thereby fulfilling roles in prevention and wellness."

    Study: Could Reducing Smoking, Drinking, Physical Inactivity Affect Prevalence of LBP?

    Authors of a new study say that public health efforts to reduce smoking, alcohol use, obesity, physical inactivity, and irregular sleep may also pay off in reducing the prevalence of low back pain (LBP).

    In an article e-published ahead of print in Spine (abstract only available for free), researchers shared findings from what they believe is the first study to document the association between behavior-related factors and LBP in US adults. Authors gathered data from a series of cross-sectional surveys pulled from the National Health Interview Survey (NHIS), a population that featured adults between the ages of 18 and 85, with a population size totaling 122,337.

    When authors cross-referenced individuals with LBP with various behaviors, they found some telling connections. Among them:

    • The prevalence of LBP was highest in those who were inactive.
    • Among tobacco users, current regular smokers experienced the most frequent rate of LBP.
    • For alcohol consumers, former regular drinkers had the highest rate of LBP.
    • In terms of sleep patterns, females who slept 3 to 4 hours per night had the highest prevalence of LBP.
    • In regard to weight, females who were obese experienced increased prevalence of LBP.

    Because the behavior-related factors in this study are considered critical not only for LBP, but for health problems such as heart disease, stroke, and cancer, the authors recommend that clinicians consider the findings of this study when counseling patients on an array of issues. And from a public health perspective, authors believe that attempts to reduce unhealthy behaviors such as smoking and inactivity "hold the potential to reduce the burden of [LBP]."

    Although they write that it is still unclear whether the behaviors they studied are risk factors, comorbidities, or "prognostic factors," for LBP, they characterize their study results "far reaching" and call for more research on possible connections.

    Authors estimate that in the US, 28.6% (66 million) of the total adult population suffers from LBP.

    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.

    First-Ever AHA/ASA Stroke Rehab Guidelines Support IRFs, Interprofessional Approaches

    The American Heart Association (AHA)/American Stroke Association (ASA) first-ever guidelines on stroke rehabilitation not only cover many of the details of care for patients poststroke, but they also contain 2 big-picture ideas: namely, that effective rehabilitation requires a sustained, coordinated, multidisciplinary effort; and that rehabilitation should not be eyed as an area for belt-tightening, but as an investment in reducing downstream morbidity and associated costs.

    The new guidelines, published in Stroke with the complete guideline available through PTNow (sign-in required), are the result of an extensive review of evidence surrounding the rehabilitation setting, prevention and management of comorbidities, assessment, sensoriomotor impairments and activities, and transition in care and community rehabilitation. According to guidelines authors, gathering evidence was no easy task, given the "unique and somewhat idiosyncratic nature of the stroke rehabilitation system in the United States."

    In terms of setting, authors found that inpatient rehabilitation facilities (IRFs) were associated with higher rates of return to community living than skilled nursing facilities (SNFs) or nursing homes, though they acknowledge that "the decision to refer a stroke patient to a particular setting after discharge is dictated by a complex set of demographic, clinical, and nonclinical factors that are also inevitably related to patient outcomes."

    Still, they write, "the consistency of the findings in favor of IRF referral suggests that stroke survivors who quality for IRF services should receive this care in preference to SNF-based care."

    The guidelines contain recommendations in multiple areas, accompanied by ratings for the class and level of evidence supporting the recommendations. In an interview with Medscape(free registration may be required), lead author Carolee Winstein, PT, PhD, FAPTA, says that while many of the recommendations "make sense intuitively," the guidelines establish a strong objective evidence base that in turn can make these interventions more common.

    Among the recommendations with the highest (IA) ratings:

    • "Organized, coordinated, interprofessional care" during rehabilitation
    • "Organized, interprofessional stroke care" focused on early rehabilitation in the inpatient setting
    • Formal falls-prevention programs during hospitalization
    • Evaluation for calcium and vitamin D supplementation among individuals poststroke residing in long-term care facilities
    • "Enriched environments to increase engagement with cognitive activities" for individuals poststroke with cognitive impairments
    • Speech and language therapy for individuals with aphasia
    • Targeted injections of botulinum toxin to reduce upper- and lower-limb spasticity
    • Balance-training programs for individuals poststroke
    • Assistive devices as appropriate
    • Ankle-foot orthoses for individuals with remediable gait impairment
    • Repeated practice in functional tasks
    • Activities of daily living training
    • Individually tailored exercise program to enhance cardiorespiratory fitness
    • Participation in a community or at-home physical activity

    The guidelines include other recommendations that, though not the most highly rated, are still considered reasonable and possibly useful.

    If nothing else, the range of the recommendations demonstrates the fact that all the best evidence points to a rehabilitation program that is anything but piecemeal.

    "Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers … physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others," authors write. "Without communication and coordination [among these team members] isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential."

    And achieving that full potential is also important in terms of how the health care system views rehabilitation. Authors write that while rehabilitation and postacute care are often considered areas ripe for cuts in spending, those cuts are made "without recognition of their clinical impact and their ability to reduce the risk of downstream medical morbidity caused by immobility, depression, loss of autonomy, and reduced functional independence."

    "The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in [health care] redesign efforts," authors write.

    In addition to Winstein, APTA-member authors of the guidelines include Ross Arena, PT, PhD, FHAH; Beth Fisher PT, PhD, FAPTA; and Catherine Lang PT, PhD.

    Foundation Accepting 2016 Grant and Scholarship Applications, Letters of Intent

    The Foundation for Physical Therapy (Foundation) now is accepting applications for the 2016 Florence P. Kendall Doctoral Scholarships and the 2016 Research Grants.

    The Kendall Post-Professional Doctoral Scholarships assist physical therapists and physical therapist assistants with outstanding potential who are in their first year of postprofessional doctoral degree studies. The $5,000 awards are given to meet tuition expenses or academic fees associated with a doctoral program. Application deadline is Wednesday, August 3, at noon EDT.

    Grant opportunities include:

    • Magistro Family Foundation Research Grant: $80,000 for a research project investigating physical therapist interventions. A letter of intent is required; applicants will be invited to submit full applications based on content. Letter of intent is due June 1, 2016 at noon, EDT; full application is due Wednesday, August 3, at noon.
    • Foundation Research Grant: $40,000 for an investigator-initiated research project by an emerging investigator. Full application due Wednesday, August 3, at noon.
    • Geriatric Research Grant: $40,000 for a single project investigating methods to facilitate the aging-in-place of older adults in a supportive community setting. Full application is due Wednesday, August 3, at noon.
    • Moffat Geriatric Research Grant (new for 2016): $40,000 awarded to an emerging investigator to evaluate the effectiveness of physical therapist examinations or interventions in geriatric populations. Full application is due Wednesday, August 3, at noon.
    • Orthopaedic Research Grant: $40,000 to explore clinical outcomes of physical therapist practice for patients with musculoskeletal conditions. Full application is due Wednesday, Aubust 3, at noon.
    • Pediatric Research Grant: $40,000 for a research project examining 1 or more elements in physical therapist patient or client management for children with developmental disabilities. Full application is due Wednesday, August 3, at noon.

    Questions? Email the Foundation, or call 800/875-1378.

    Note: Eligibility guidelines for several of the grants have changed (and in some instances, expanded), so please review the criteria. Before starting your funding application, be sure to carefully read all instructions and funding mechanism deadlines. Also, it's a good idea to start the submission process early to allow for potential questions to be answered.

    Study: High School Football Players Experience More Concussion Symptoms, Longer Return-to-Play Times Than Youth League or College Counterparts

    Researchers have found that high school and college football players report more concussion symptoms than youth league players, and that youth league players tend to return to play within 24 hours of injury at a higher rate than their older counterparts. What they haven't figured out is what accounts for the differences, although they have a few ideas.

    Authors of a study e-published ahead of print in JAMA Pediatrics tracked athletic trainer-reported diagnoses, symptoms, and return-to-play rates of 1,429 sports-related concussions among the 3 levels of football during the 2012-2014 seasons. The concussion data were drawn from 310 youth football team seasons, 184 high school team seasons, and 71 college team seasons.

    Researchers used a symptom cluster system to organize 17 concussion-related symptoms into 4 groups—cognitive, migraine, neuropsychiatric, and sleep—and tallied up all symptoms reported from initial injury to return to play, not just those reported at the time of the concussion.

    Here's what they found:

    • Across all concussions at all levels of play, an average of 5.48 symptoms were reported, with headache (94.3%), dizziness (75%), and difficulty concentrating (60.5%) being most common.
    • The average number of symptoms reported trended higher for high school players (5.6) and college players (5.56) than for youth sports players (4.76).
    • Within the symptom clusters, cognitive symptoms were experienced more frequently among high school and college players than among the youth league players. High school athletes reported higher rates of neurocognitive symptoms than the other groups, while college players reported a higher rate of sleep symptoms.
    • High school players were more likely to have a return-to-play wait of at least 30 days (19.5%), followed by youth (16.3%) and college players (7%).
    • Just over 10% of youth players returned to play within 24 hours of the injury, a rate more than twice that of college athletes (4.7% returned within 24 hours), and more than 10 times more than high school players (.8% returned within 24 hours).
    • Very few concussions resulted in loss of consciousness, a finding that authors believe "further [highlights] the limited utility of that symptom in diagnosing concussion."

    Researchers speculated on a number of possible reasons for the various differences among player groups. For example, the higher rate of cognitive symptoms experienced by high school players may be related to the fact that growth in brain gray matter peaks in adolescence, they write, and longer return to play times among this group could have something to do with "longer durations of class without breaks, which prolong symptom recovery."

    When it comes to the number of players who return to play within 24 hours, authors believe those rates might be partly accounted for by athletes presenting with delayed concussion symptoms, as well as "disagreement between athletic trainers and physicians" over a concussion assessment.

    The much higher rates of return to play within 24 hours for youth players may be explained by that age group's "struggle" to identify and describe their symptoms to athletic trainers, which authors believe presents a challenge of its own. "It is imperative to educate athletic trainers, parents, coaches, and officials on recognition and management of concussions in youth," they write. "This should include strategies on how to effectively elicit symptoms in this younger age group because they may be at greater risk for second impact syndrome."

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage, and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Continuing education offerings from APTA include the prerecorded webinar "Managing Concussions With an Interprofessional Team" available through the APTA Learning Center.

    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.

    Even more information on concussion and youth sports injuries is available at the NEXT Conference and Exposition, June 8-11 in Nashville. Related sessions include "Concussion: Evidence-Informed Rehabilitation" and "The Young Athlete: Injury Prevention, Training, and Exercise Prescription for Performance Enhancement." Advance registration discounts end May 4.

    From PTJ: Electrodiagnostic Testing Sheds Light on 'Bioscaffolding' Procedure for VML

    Researchers believe electrodiagnostic testing may be a useful way to predict just what kind of improvement to expect from an experimental approach that uses material from pig bladders and intestines to grow new muscle in patients with severe muscle loss.

    According to an April 2016 article in Physical Therapy (PTJ), APTA's science journal, presurgical electrodiagnostic testing may help predict increase in muscle strength after a process known as extracellular matrix (ECM) implantation, a procedure that uses pig tissue cells to act as "scaffolding" that draws a patient's own stem cells to the site of volumetric muscle loss (VML). The procedure has been successful in regrowing tissue in preclinical testing, but research has been lacking on patient functional outcomes.

    In the longitudinal case series, authors wanted to find out how the surgery would change preoperative and postoperative electromyography (EMG) and nerve conduction study (NCS) results, as well as whether these tools could identify the best candidates for ECM implantation. They hypothesized that both electrophysiologic activity and muscle strength would improve.

    Researchers implanted 8 patients with severe muscle loss due to trauma. Three of the patients had VML in the anterior tibial compartment, 4 in the quadriceps compartment, and 1 in the biceps brachii. The average percentage of muscle loss was 66.1%.

    All participants completed a preoperative physical therapy program until they reached what authors describe as "a plateau in strength and function." One day prior to surgery, researchers performed needle EMG and NCS testing, and a physical therapist (PT) measured muscle strength using a handheld dynamometer. EMG testing measured muscle recruitment and abnormal spontaneous activity; the latter can indicate instability of muscle fibers.

    Within 48 hours after surgery, each patient began a 6-month physical therapy regimen, after which the same testing was performed. Four had significant improvement in strength (20% or more), 2 had minor improvement, and 2 experienced no increase in strength.

    Authors concluded that electrodiagnostic testing could be beneficial in predicting suboptimal outcomes. Five of the participants had improvements in either NCS or EMG results while also showing clinical improvements in muscle strength. Two participants showed no EMG activity or strength at baseline; they had no improvement in strength.

    "These findings suggest that muscles judged to have no electrical activity at baseline are unlikely to display improved strength following ECM implantation," authors note.

    The researchers attribute the wide variability in response to ECM implantation in part to degree and type of initial injury causing the muscle loss. For example, 1 participant showed increased compound muscle action potential (CMAP) amplitude of 80% but no increase in strength. Another had a 33.3% improvement in strength but no electrophysiologic improvement. Two others showed a "dramatic increase" in strength but decreased CMAP amplitude.

    Authors suggest the possibility "that the increased strength was a result of a restoration of mechanical integrity, rather than electrical conductance, of the muscle." However, the improvement in CMAP amplitude in 4 of the participants "is encouraging," they write, because it indicates an increased number of muscle fibers after implantation. These findings, the researchers contend, could not only inform surgical decisions in the future but also help PTs in designing regenerative rehabilitation protocols.

    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.