CPS II Presentation Alyssa Campbell

Purpose

• To investigate the relationship between a given intervention and patient outcome using the best evidence available

Demographics and Patient Diagnosis • Patient was a 56 year old African American

female

• Initially admitted to outside hospital for embolization of L subclavian artery and thoracic aortic aneurysm via L brachial artery approach

• Patient presented to outside hospital ICU with facial droop and L sided weakness and diagnosed with acute CVA (location of stroke occurrence unknown)

Patient Information from Current Visit • Patient re-admitted to hospital approximately

one month following CVA (from inpatient rehab) with lower GI bleed and colonoscopy performed

Past Medical History

• Anemia, aneurysm, anxiety disorder, aortic valve defect, arthritis of R knee, coronary artery disease, cancer of R breast, chronic kidney disease, heart murmur, hypertension, and depression

• Surgical History: aortic valve replacement, breast biopsy (2012), colonoscopy (2014), coronary stent placement (2014), heart catheterization, and hysterectomy (2014)

Social History

• Lives in a one story private residence with fiancé and 27 year old son

• Has 2 steps to enter home with bilateral hand rails available

• Only DME available is a blood pressure cuff

• Was independent in functional mobility prior to initial admittance

PT Exam and Eval Findings • Orientation- alert and oriented x4, able to follow

commands

• Skin Integrity- skin intact

• ROM- AROM and PROM generally decreased but functional

• Strength- generally decreased with at least 3+/5 on R side and 2/5 on L side (no synergy patterns noted)

• Sensation- Intact to light touch

• Coordination- generally decreased but functional

• Bed mobility- rolling with modA to R side and minA to L, supine to sit with modA and use of UEs, sit to supine with modA x2, and scooting with maxA

• Balance- static sitting balance fair with us of RUE to maintain and dynamic sitting balance poor at this time

Vital Signs

• Taken at start of session and remained stable throughout

• BP: 136/52

• HR: 70

• Respiratory Rate: 28

• SpO2: 100%

• Pain: 4/10 with pain mainly located in buttocks

• Patient Height and Weight: 5’6” and 176 lbs

• BMI of 28 kg/m2

Prognosis

• Strong family support available

• Deficits in several areas (ROM, strength, balance, endurance, functional mobility)

• Complicated medical history

• Overall, fair prognosis for this patient

Patient Goals

• 1) Patient will perform a supine to sit transfer with minA in 7 days

• 2) Patient will transfer from bed to chair with maxA in 7 days

• 3) Patient will perform sit to stand transfer with modA x2 in 7 days

• 4) Patient will sit unsupported for two minutes with minA to maintain balance for dynamic tasks in 7 days

• 5) Patient will maintain midline EOB sitting for 2 minutes with only verbal cues in 7 days

PT Interventions

• Bed mobility- rolling to both sides, supine to sit transfers

• Sitting balance- provided cuing to avoid posterior lean, modA-minA needed to maintain

• Dynamic sitting balance- reaching for objects outside BOS and across midline, poor to fair

• Trunk rotations- performed to L side with modA to maintain sitting balance, attempted weight-bearing on L side but unable at this time due to pain

• Posterior leans- leaned patient posteriorly and asked patient to pull self forward using trunk musculature, maxA needed

• Bridging- patient able to contract trunk musculature but unable to clear self off bed

Outcomes of Treatment

• Patient demonstrated small gains in functional mobility, strength, and balance following treatment sessions

• This was evidenced by improvements in bed mobility, transfers, static sitting balance, and dynamic sitting balance

Clinical Intervention Question

• In my 56 year old female patient with a history of a recent stroke, does trunk training exercises improve balance and increase functional recovery?

Article #1

Purpose

• Following a stroke, patients can experience difficulties with trunk performance, including impairments of selective muscle activation, inter-segmental coordination, and functional trunk performance. These impairments can decrease balance, gait, and function (Verheyden et al., 2007).

• This review wanted to assess how adding trunk exercises to a treatment program affects functional outcomes in stroke patients.

Methods • Completed a systematic review of articles

published until July 2012 that evaluated the effect of trunk exercises on functional outcomes in stroke patients.

• They searched 7 different databases using the search terms stroke, stroke patient, trunk exercise, truncal exercise, sitting balance, dynamic reaching, trunk control, ADLs, balance, and function.

• They summarized the collective data using mean differences or standardized mean differences with 95% confidence intervals.

Inclusion Criteria

• Inclusion Criteria:

• RCT published in English

• Involving adult survivors of ischemic or hemorrhagic stroke (within first three months following the stroke)

• Include specific trunk exercises in lying and sitting or other specific interventions (sitting balance, weight shifts in sitting, arm reaching in sitting) in addition to conventional rehab program

• Included a control group of conventional rehab

• Used at least one valid outcome measure

Results

• Six RCTs were included in the study with 155 participants and a mean PEDro score of 6.5 (ranged from 6-8)

• Found a moderate (SMD=.5) but not statistically significant effect of additional trunk exercises on trunk performance (P=.19)

• Found large effects (SMD=.72) on standing balance (P=.05)

• Large effect (SMD=.81) was also found on walking ability (P=.002)

• However, there was a small that was not statistically significant on functional independence (P=.44)

Conclusion

• There is evidence that the addition of trunk exercises to a treatment program significantly improves standing balance and walking ability in stroke patients

• However, the evidence did not support an effect of trunk exercises on functional independence

Strengths

• Large effects found for balance and walking ability despite differences in trunk exercises used in experimental groups and outcome measures reported

• Average PEDro score of 6.5 (all studies scored either 6 or 7)

Limitations

• Relatively small sample size (155 patients across all studies)

• One study included was at high risk of bias (due to lack of accessor blinding)

• Dosage had high variability (5 hours to 20 hours)

Clinical Implications (Relating Back to Patient Case) • Patient experienced several of the expected impairments

that occur with stroke (decreased strength, balance, trunk function, coordination, ect.)

• Patient met the inclusion criteria for this study (adult, within first three months of stroke, participated in specific trunk exercises during treatment) • Performed many of the same exercises used in the

included studies (sitting balance, weight shifts in sitting, reaching outside BOS, trunk rotations, trunk flexion/extension)

• Studies showed significant improvements in standing balance and walking ability (patient eventually hopes to get close to PLOF where she was independent in functional mobility)

• Therefore, including trunk exercises in the patient treatment program can be beneficial in several ways

Article #2

Purpose

• It has been asserted that trunk function can help predict functional outcomes of patients at discharge (Duerte et al., 2002)

• Sitting balance is crucial to functional tasks such as reaching and sit to stand transfers (Feigin et al., 1996)

• This study looked to assess the available literature to see if trunk training exercises can improve trunk performance and sitting balance in stroke patients

Methods

• Searched 12 different databases for RCTs assessing trunk training exercises in stroke survivors

• “TTE was pragmatically defined as exercise training on trunk, performed in sitting or supine, specifically aimed at improving trunk performance and functional sitting balance under the supervision of a physiotherapist”

• Primary outcomes used were trunk performance and sitting balance

• Secondary outcomes were standing balance and walking ability

Inclusion Criteria

• Inclusion Criteria:

• Had to be a RCT

• Studies involving adult patients suffering from sub-acute (0-3 months) or chronic (>3 months) strokes

• Patients had to have the ability to follow instructions

• Had to assess trunk training exercises on either a stable or unstable surface

• Compared to a control group

• Needed to use an outcome measure that was valid to assess the primary or secondary outcomes the study was addressing

Exclusion Criteria

• Exclusion Criteria:

• Patients with neurological diseases affecting balance

• Patients with orthopedic problems impacting their ability to sit

• Patients with visual impairments affecting their ability to pick up objects

• Trunk training exercise programs that used electromechanical devices

• Studies with bias due to not being randomized

Results • 11 studies included with a total of 317 subjects (mean age of 64.1

years with a range of 45-86)

• PEDro scores for the articles ranged from 3-8 with a mean of 6.3 (could only be assessed on an 8 point scale due to inability to blind participants and physiotherapists)

• No difference in static sitting balance, LE muscle activation, sway in standing, or symmetry in standing found between groups

• Moderate evidence was found showing trunk training exercises improved trunk performance and dynamic sitting balance

• Improved maximum distance in modified reach test in forward, ipsilateral, and across body directions

• Increased weight-bearing seen on affected side in first 6 months (no difference after that)

• Improvements in gait as seen by DGI and Tinetti sub-scale scores

• Quicker return to ambulation

Conclusion

• Trunk training exercises utilizing stable or unstable surfaces help improve trunk function and dynamic sitting balance in stroke patients

• These types of exercises should be considered when working with both sub-acute and chronic stroke patients

Strengths/Limitations

• Strengths:

• Improvements were seen consistently in both sub-acute and chronic stroke patients

• Most studies were deemed good to very good on PEDro scale

• Limitations:

• Inability to blind therapists and patients

• Small sample size (317 subjects among 11 studies)

• Wide variety in stroke characteristics experienced by patients

Clinical Implications (Relating Back to Patient Case) • Patient met the inclusion criteria of the studies included

(adult stroke survivor in sub-acute phase, able to follow directions, participated in trunk exercises, used both stable and unstable surfaces for exercises)

• Patient performed several of the exercises used in the different studies (sitting balance, reaching outside BOS, movements of upper an lower trunk, use of unstable surfaces)

• Patient was within the age range of those included in the studies

• Studies showed improvement in dynamic balance, trunk performance, and gait which are areas patient has deficits

• Trunk training could benefit patient

Analysis of Case and Lessons Learned • Trunk exercises appear to be an effective and useful

treatment strategy for stroke patients, including the treated patient

• This treatment strategy can be safely incorporated early on during the treatment process (first three months) and also impact those further out from their stroke

• Specific patient impairments and deficits need to be considered when choosing which trunk exercises are best to include in a given treatment plan

• However, trunk exercises were not shown to improve all areas of impairment (ex. no change in static sitting balance, LE muscle activation, functional independence, ect.)

• Therefore, trunk exercises should function as part of a treatment plan in addition to other treatment ideas

Sources • http://www.hopkinsmedicine.org/sebin/p/s/nelson_harvey_room.jpg • https://3.imimg.com/data3/OD/OT/MY-11760474/bp-cuff-250x250.jpg • http://www.intrepidtravel.com/sites/intrepid/files/teal/intrepid_marketing/families2.

jpg.pagespeed.ce.iBDNdd4L_Q.jpg • https://www.samuelmerritt.edu/images/physical_therapy/fist/pt_quiz_question5.jpg • http://bethparmar.co.uk/wp-content/uploads/2015/07/question-marks.jpg • http://images.clipartpanda.com/hospital-clipart-hospital.png • http://www.activemindsglobal.com/wp-content/uploads/Cardio-Heart.jpg • Sorinola, I. O., Powis, I., & White, C. M. (2014). Does additional exercise improve trunk

function recovery in stroke patients? A meta-analysis. NeuroRehabilitation, 35(2), 205-213.

• Cabanas-Valdés, R., Cuchi, G. U., & Bagur-Calafat, C. (2013). Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. NeuroRehabilitation, 33(4), 575-592.

• Feigin, L., Sharon, B., Czaczkes, B., & Rosin, A. J. (1996). Sitting equilibrium 2 weeks after a stroke can predict the walking ability after 6 months.Gerontology,42(6), 348-353.

• Duarte, E., Marco, E., Muniesa, J., Belmonte, R., Diaz, P., Tejero, M.,& Escalada, F. (2002). Trunk control test as a functional predictorin stroke patients.Journal of Rehabilitation Medicine,34(6), 267-272.Duncan, P., Studenski, S., Ric