In-patient, out-patient stroke rehab might benefit from yoga

Researchers looking into the value of adapted yoga for stroke rehabilitation report that after an eight-week program, study participants demonstrated improved balance and flexibility, a stronger and faster gait, and increased strength and endurance.

The study, involving researchers from the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana University-Purdue University Indianapolis and IU Bloomington, exposed older veterans recovering from stroke to yoga. The men and women had completed their post-stroke occupational and physical therapy before the study but continued to have impairments.

The findings from two new analyses of the study will be presented on Wednesday during the annual meeting of the American College of Sports Medicine in San Francisco.

Arlene Schmid, rehabilitation research scientist at the Roudebush VA Medical Center and principle investigator of the VA-funded study, said loss of functional strength, flexibility and endurance is common after a stroke, which can lead to long-term disability. She said 5 million Americans are living with the consequences of stroke, which can alter patients' lifestyles through decreased independence in activities of daily living, limited mobility and reduced participation in society.

"Clinicians need methods to manage and improve these post-stroke physical impairments," said Schmid, also an assistant professor of occupational therapy in the School of Health and Rehabilitation Sciences at IUPUI.

Her analysis, "Physical Improvements After Yoga for People With Chronic Stroke," examined gains in functional strength, flexibility and endurance as a result of the yoga and found significant improvements in all areas. The yoga activities, she said in her report, might have "improved neuromuscular control, likely allowing for strength improvements in affected limbs, sides or areas of disuse."

Tracy Dierks, associate professor of physical therapy in the School of Health and Rehabilitation Sciences, focused his analysis of study findings on how well study participants could walk after the program.

In "The Effect of Balance Exercise Therapy on Gait Parameters in Individuals With Chronic Stroke," he reports that after the yoga program, the study participants showed improved balance and faster gait speeds with longer steps or strides. But, while the veterans could walk faster, they were unable to sustain this faster speed for the duration of the six-minute test.

"The gait findings from our study have the potential to greatly impact clinical practice for gait recovery," Dierks said. "The yoga intervention was designed to improve balance, not gait; we did not focus on improving gait at all. Yet we saw major improvements in most clinical gait measurements. But one often overlooked deficit remained: the inability to sustain gait speed for endurance."

Schmid concluded in her presentation that it might be appropriate to include yoga in the in-patient or out-patient rehabilitation people receive after a stroke. Such a class should be taught by a yoga therapist who has had additional training in anatomy and physiology and how to work with people with disabilities

Early Treatment by a Physical Therapist Associated with Reduced Risk of Health Care Utilization and Reduced Overall Health Care Costs

A new study published in Spine shows that early treatment by a physical therapist for low back pain (LBP), as compared to delayed treatment, was associated with reduced risk of subsequent health care utilization and lower overall health care costs.

Using a national database of employer-sponsored health plans, researchers examined a sample of 32,070 patients who were newly consulting a primary care physician for low back pain. Patients were identified and categorized based on their use of physical therapist services within 90 days of the consultation. Those who were referred to a physical therapist early (within 14 days of the consultation) showed a reduced risk of subsequent health care utilization and experienced lower overall health care costs than did those patients with delayed treatment by a physical therapist (within 15-90 days of consultation).

During an 18-month follow-up period, researchers found that early treatment by a physical therapist was associated with reduced risk of subsequent surgery, injections, physician visits, opioid use, and advanced imaging, along with a corresponding reduction in overall LBP-related medical costs relative to delayed treatment by a physical therapist. Total health care costs for patients receiving early care from a physical therapist were an average of $2,736.23 lower.

According to the study's lead author, Julie M. Fritz, PT, PhD, ATC, associate professor in the Department of Physical Therapy at the University of Utah and clinical outcomes research scientist at Intermountain Health care in Salt Lake City, "The value of referring patients to physical therapy who are newly consulting primary care physicians for low back pain likely depends on the timing of the referral and how patients adhere to physical therapy guidelines that recommend maintaining and improving activity levels." She added, "Despite the fact that primary care practice guidelines generally recommend delaying referral to a physical therapist for several weeks, we found that about half the patients receiving treatment from a physical therapist did so within two weeks, which is a practice that may be justified by emerging evidence."

Fritz explained that one possible reason for the link between early care by a physical therapist and positive outcomes may be that physical therapists can contribute to promoting a greater sense of self-reliance in managing LBP and confidence in a positive outcome. "If a physical therapist's treatment assists in developing self-efficacy, it is reasonable to expect it would have greater impact when implemented very early, before negative expectations have become reinforced and entrenched." Fritz added that early care administered by a physical therapist may offer an alternative to management strategies that can foster a sense of dependency in the patient, such as use of MRI or opioids.

The study found that patients using a PPO plan were more likely to receive early treatment from a physical therapist (53.4%) as compared with those using an HMO plan (44.7%). Also, the highest rates of physical therapist utilization were found in the Northeast and West. Patients in the Midwest were more likely to seek early treatment from a physical therapist (58.7%).

An April 20 study in Spine also supports the benefits of early physical therapy for low back pain. In this study, researchers found that patients who received physical therapy early (within 30 days) after an episode of acute low back pain had a lower risk of subsequent medical service usage (surgery or epidural steroid injections) than patients who received physical therapy later. In this study, authors analyzed a national sample of the Centers for Medicare and Medicaid Services' physician outpatient billing claims.

Currently 47 states and the District of Columbia allow some form of direct access to physical therapists for treatment/intervention, although some states impose restrictions if patients have not been referred by a physician.

Coauthors of the study were John D. Childs, PT, PhD, associate professor and director of research, US Army-Baylor University Doctoral Program in Physical Therapy, Ft Sam Houston, San Antonio, TX; Robert S. Wainner, PT, PhD, associate professor, Texas State University - San Marcos, San Marcos, TX, and Timothy W. Flynn, PT, PhD, distinguished professor, Rocky Mountain University of Health Professions.

The study was funded by grants from the Orthopedic and Private Practice Sections of the American Physical Therapy Association (APTA) and the American Academy of Orthopaedic and Manual Physical Therapists. Funds were also provided by a faculty grant from Texas State University.

The American Physical Therapy Association (APTA) represents more than 80,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Learn more about conditions physical therapists can treat and find a physical therapist in your area at www.moveforwardpt.com. Consumers are encouraged to follow us on Twitter (@moveforwardpt) and Facebook.

A quick fix is possible for sacroiliac joint pain in many children and adolescents

Investigators report that a simple bedside manual therapy to correct a painful misaligned sacroiliac joint was highly successful in a group of 45 patients 10 to 20 years of age. Thirty-six patients (80 percent) obtained significant pain relief, whereas nine patients (20 percent) experienced minimal to no relief. In 24 patients (53 percent) complete resolution of pain was experienced immediately upon treatment. Only two patients required a second treatment because of symptom recurrence. These findings are reported in a new article, "Sacroiliac joint pain in the pediatric population. Clinical article," by Stoev and colleagues, published in the June 2012 issue of the Journal of Neurosurgery: Pediatrics, scheduled to appear online today.

Investigators at Washington University in St. Louis and St. Louis Children's Hospital conducted a retrospective analysis of patient records in children and adolescents with low back pain who had been referred to a single neurosurgeon, Jeffrey R. Leonard, M.D., between 2005 and 2011. At the initial consultation, the patients performed a variety of physical maneuvers designed to evaluate whether their pain stemmed from misalignment of the sacroiliac joint. In 48 patients pain was attributed to this misalignment. There were 37 female and 11 male patients with a mean age of 15.7 years (range 10 to 20.6 years). The average duration of symptoms was 7 months (range 0.25 to 48 months). Before treatment the patients' mean pain score was 5.7 (range 3 to 9.5) on a 10-point visual analog scale ranging from 0 = no pain to 10 = most extreme pain. Three patient files were incomplete, and therefore the investigators could only report results on pain relief in the 45 pediatric patients in whom complete follow-up data were accessible.

Treatment consisted of sacroiliac joint manipulation accomplished by performing isometric hip contraction and extension. Physical therapists call this procedure the "muscle energy technique." The patient flexes and extends the hip while the physical therapist provides resistance to the move. This forces the sacroiliac joint back into proper alignment. Most patients experienced improvement in their symptoms, and more than half of the patients had immediate pain relief following treatment.

When asked whether the investigators were surprised to find that such a simple technique could bring about pain relief in so many patients, Dr. Leonard said, "No we were not surprised. We were surprised by the number of patients who actually presented with this problem. These children have had prior imaging studies, procedures, or been in back pain for over a year."

Following treatment, patients were given instructions for at-home exercises to strengthen muscles in the region to ensure that sacroiliac joint alignment would be maintained. Dr. Leonard believes that patients were compliant with these exercises "because a large number of patients were in significant debilitating pain which kept them out of activities. This simple manipulation allowed them to potentially leave clinic pain free." In this study only two patients needed repeated treatment.

The authors state that there are no clear estimates on how many children and adolescents suffer pain from misaligned sacroiliac joints, but low back pain is fairly common. Unlike adults whose sacroiliac joint–related pain is usually related to disc deterioration or joint disease, children and adolescents are more likely to experience pain due to repeated stress from athletic activities. Girls are more susceptible (77% in this study) because of the laxity of the female developing pelvic girdle.

As the authors point out, the source of low back pain is often difficult to identify, which can make patients face long periods of painful symptoms, drug dependency, and/or unnecessary surgical procedures. The take-away message from this study is that simple manual manipulation should be tried in children and adolescents whose low back pain is suspected to be caused by a misaligned sacroiliac joint. The therapy described in this paper is cost-effective, takes little time, and poses no negative consequences to the patient. The authors found that this simple manipulation procedure can provide sustained relief in most patients.

COPD: Acupuncture appears linked with improvement in patients with chronic obstructive pulmonary disease

According to a small clinical trial reported by investigators from Japan, acupuncture appears to be associated with improvement of dyspnea (labored breathing) on exertion, in patients with chronic obstructive pulmonary disease (COPD), according to a study published Online First by Archives of Internal Medicine, a JAMA Network publication.

The management of dyspnea is an important target in the treatment of COPD, a common respiratory disease characterized by irreversible airflow limitation. COPD is predicted to be the third leading cause of death worldwide by 2020, according to the study background.

Masao Suzuki, L.Ac., Ph.D., of Kyoto University and Meiji University of Integrative Medicine, Kyoto, Japan, and colleagues conducted a randomized controlled trial from July 2006 through March 2009. A total of 68 patients diagnosed with COPD participated, and 34 were assigned to a real acupuncture group for 12 weeks, plus daily medication. The other 34 were assigned to a placebo acupuncture group in which the needles were blunt (and appeared to, but did not enter the skin). The primary measure was the evaluation of a six-minute walk test on a Borg scale where 0 meant "breathing very well, barely breathless" and 10 signified "severely breathless."

"We demonstrated clinically relevant improvements in DOE [dyspnea on exertion] (Borg scale), nutrition status (including BMI), airflow obstruction, exercise capacity and health-related quality of life after three months of acupuncture treatment," the authors note.

After 12 weeks of treatment, the Borg scale score after the six-minute walk test improved from 5.5 to 1.9 in the real acupuncture group. No improvement was seen in the Borg scale score in the placebo acupuncture group before and after treatment (4.2 and 4.6, respectively), according to the study results.

"Randomized trials with larger sample sizes and longer-term interventions with follow-up evaluations are necessary to confirm the usefulness of acupuncture in COPD treatment," the authors conclude.

Invited Commentary: Reevaluating Acupuncture Research Methods

In an invited commentary, George T. Lewith, M.A., M.D., F.R.C.P., M.R.C.G.P, and Mike Thomas, Ph.D., F.R.C.P., of the University of Southampton, Hampshire, England, write: "Where does this study lead us? The authors note that acupuncture must be used in addition to conventional care, and although this is undoubtedly correct, it may have significant economic implications."

They continue: "Evaluating traditional interventions, such as acupuncture, that are widely available has many implications, including the fact that best practice and dose response have rarely been evaluated scientifically as would be the case for a new pharmaceutical agent."

"This study points to an important potential role for acupuncture in COPD management. These findings demand larger but equally methodologically rigorous confirmatory studies if we are to consider integrating this approach into our management strategy," they conclude.