David G. Embrey

Functional Electrical Stimulation to Dorsiflexors and Plantar Flexors During Gait to Improve Walking in Adults With Chronic Hemiplegia

OBJECTIVEnTo determine whether functional electrical stimulation (FES) timed to activate the dorsiflexors and plantar flexors during gait improves the walking of adults with hemiplegia.nnnDESIGNnRandomized crossover trial.nnnSETTINGnOutpatient rehabilitation clinic.nnnPARTICIPANTSnAdults with hemiplegia (N=28) with a mean age +/- SD of 60+/-10.9 years and 4.9+/-3.8 years postincident.nnnINTERVENTIONSnIntervention A included 3 months of wearing the FES system, which activated automatically during walking for 6 to 8h/d, 7d/wk, plus walking 1h/d, 6d/wk. Intervention B included 3 months of walking 1h/d, 6d/wk without FES. Of the 28 patients who completed the study, 15 were randomly assigned to group A-B, 13 to group B-A. Crossover occurred at 3 months.nnnMAIN OUTCOME MEASURESnVariables were measured at pretreatment, 3 months, and 6 months. Three primary outcomes were selected a priori and included 2 functional variables, the 6-minute walk test and the Emory Functional Ambulatory Profile, and 1 participation variable, the Stroke Impact Scale. Secondary impairment measures included muscle strength and spasticity. Assessments were done without electrical stimulation.nnnRESULTSnIn phase 1, patients who received treatment A (A-B group) showed improvement compared with patients who received treatment B (B-A group) on the 6-minute walk test (P=.02), Emory Functional Ambulatory Profile (P=.08), and Stroke Impact Scale (P=.03). In phase 2, the A-B group maintained improvement in all 3 primary outcomes even without FES. Both groups improved significantly on all primary outcome measures, comparing 6-month to initial measures (P</=.05).nnnCONCLUSIONSnAn FES system that stimulates dorsiflexors and plantar flexors similar to the timing of typical adult gait, combined with daily walking, can improve the walking ability of adults with hemiplegia.

Foot and ankle joint movements inside orthoses for children with spastic CP

We compared the ankle joint and foot segment kinematics of pediatric cerebral palsy (CP) participants walking with and without orthoses. A six segment foot model (6SF) was used to track foot motion. Holes were cut in the study orthoses so that electromagnetic markers could be directly placed on the skin. The Hinged Ankle Foot Orthoses (HAFO) allowed a significant increase in ankle dorsiflexion as compared to the barefoot condition during gait, but significantly constrained sagittal forefoot motion and forefoot sagittal range of motion (ROM) (pu2009<u20090.01), which may be detrimental. The Solid Ankle Foot Orthoses (SAFO) constrained forefoot ROM as compared to barefoot gait (pu2009<u20090.01). The 6SF model did not confirm that the SAFO can control excessive plantarflexion for those with severe plantarflexor spasticity. The supramalleolar orthosis (SMO) significantly (pu2009<u20090.01) constrained forefoot ROM as compared to barefoot gait at the beginning and end of the stance phase, which could be detrimental. The SMO had no effects observed in the coronal plane.

Clinical Applications of Procedural Changes by Experienced and Novice Pediatric Physical Therapists

Some scholars propose that physical therapists use formal decision analyses in making clinical decisions, but these processes are time consuming. Other researchers suggest physical therapists make rapid, on the spot, clinical decisions based on improvisation and intuition. This study explores how frequently pediatric physical therapists change their therapy procedures within a therapy session. Procedural changes are illustrated and described using qualitative research methods to portray the practice of three experienced and three novice pediatric physical therapists. These clinicians were videotaped during 48 hourly sessions with 18 children who were diagnosed with diplegic cerebral palsy. Then, videotapes were used to elicit retrospective think-aloud dialogues, which were transcribed, coded, and analyzed to assess how frequently therapists verbalized changing their therapy procedures. Treatment videotapes of five sessions were further analyzed to highlight and illustrate how one experienced clinician applied procedural changes with one child. Findings revealed that experienced clinicians verbalized changing their procedures approximately every 46 seconds compared with a mean of every 86 seconds by novices. Six treatment activities accounted for 72% of the treatment time and illustrate how one experienced clinician applied procedural changes within sessions of therapy over four months of weekly treatment with one child. Generally, the rapid procedural changes found in this study suggest formal decision analyses are not practical for within-session decision making in pediatric physical therapy. Rapid procedural changes by experienced therapists seemed to be in “harmony” with the children, based on their large repertoire of clinical experience. In contrast, novices verbalized “abrupt” procedural changes based on lists of treatments activities. These results provide valuable insights into clinical practice and decision making in pediatric physical therapy.

Long-Term Effects of Orthoses Use on the Changes of Foot and Ankle Joint Motions of Children With Spastic Cerebral Palsy

Orthoses commonly are prescribed to children with cerebral palsy (CP) to provide foot correction and to improve ambulatory function. Immediate effects of ankle foot orthosis (AFOs) have been investigated, but long‐term kinematic effects are lacking clinical evidence.

Functional electrical stimulation improves quality of life by reducing intermittent claudication

OBJECTIVEnTo determine if Functional Electrical Stimulation (FES) would improve ischemic pain, walking distance, and quality of life of patients with intermittent claudication.nnnDESIGNnSingle blind, randomized block, two factorial design.nnnPATIENTSnPatients diagnosed with Peripheral Artery Disease (PAD) and intermittent claudication (IC). Ankle Brachial Index ranged 0.4-0.9 on at least one leg. Patients were randomly assigned to experimental (FES+Walk, N=13) or control (WALK, N=14) groups.nnnINTERVENTIONnExperimental group patients received FES to the dorsiflexor and plantarflexor muscles while walking for 1h/day, six days/week for eight weeks. Control group patients received similar intervention without FES. A Follow-up period of both groups lasted eight weeks.nnnOUTCOME MEASURESnOutcome measures were taken at baseline (T0), after intervention (T1), and after follow-up (T2). Primary measures included Perceived Pain Intensity (PPI), Six minute walk (6MW), and Peripheral Arterial Disease Quality of Life (PADQOL). Secondary measures included Intermittent Claudication Questionnaire (ICQ) and Timed Up and Go (TUG).nnnRESULTSnGroup by time interactions in PPI were significant (P<0.001) with differences of 27.9 points at T1 and 36.9 points at T2 favoring the FES+Walk group. Groups difference in Symptoms and Limitations in Physical Function of the PADQOL reached significance (T1=8.9, and T2=8.3 improvements; P=0.007). ICQ was significant (T1=9.3 and T2=13.1 improvements; P=0.003). Improvement in 6MW and TUG tests were similar between groups.nnnCONCLUSIONS AND RELEVANCEnWalking with FES markedly reduced ischemic pain and enhanced QOL compared to just walking. FES while walking may offer an effective treatment option for the elderly with PAD and Intermittent Claudication.nnnTRIAL REGISTRATIONnNIH-NIA 1R21AG048001 https://projectreporter.nih.gov/project_info_description.cfm?aid=8748641&icde=30695377&ddparam=&ddvalue=&ddsub=&cr=1&csb=default&cs=ASC. https://clinicaltrials.gov/ct2/show/NCT02384980?term=David+Embrey&rank=1.

Clinical Applications of Psychosocial Sensitivity by Experienced and Novice Pediatrie Physical Therapists

Pediatric physical therapists demonstrate psychosocial sensitivity when they recognize and respond to the emotional and social needs of children during clinical practice. This report describes and illustrates how experienced and novice pediatrie clinicians apply psychosocial sensitivity while working with children with diplegia. Three experienced and three novice pediatrie physical therapists were videotaped during 48 physical therapy sessions with 18 children with diplegic cerebral palsy. These videotapes were used to elicit retrospective think-aloud dialogues, which were transcribed, coded, and analyzed to identify and describe the characteristics of psychosocial sensitivity. Treatment videotapes were also analyzed to illustrate how treatment activities of one experienced clinician applied psychosocial sensitivity with one child representing four months of weekly treatment. The three experienced clinicians verbalized psychosocial sensitivity about every two minutes whereas the three novices verbalized these characteristics about every three minutes. Experienced clinicians verbalized positive psychosocial sensitivity twice as often as the novices. Four attributes of psychosocial sensitivity were found to shape the social interaction between the children and their therapists. These four attributes of psychosocial sensitivity have been illustrated using eight treatment activities over four months of treatment. These activities accounted for 77% of the total treatment time for one child treated by an experienced clinician. Applying these attributes may enable pediatrie physical therapists to demonstrate positive psychosocial sensitivity during long-term interventions often required for children with cerebral palsy.

Recommendations for Pediatrie Physical Therapists: Making Clinical Decisions for Children with Cerebral Palsy

Although we are beginning to explore and understand important characteristics of clinical decision making in physical therapy, a notable gap exists between the conceptual framework we have developed and clinical practice. In an effort to bridge this gap, we extend various recommendations that may assist clinicians to become more competent in making sound decisions. We propose conditions under which the conceptual framework may be generalized. Our recommendations are founded upon the examination of decision making processes of nine therapists representing male and female clinicians who worked at five different sites. In these studies therapists provided services for 18 children with diplegia and one with double hemiplegia. We propose decision-making strategies for inexperienced, experienced, and intermediate level therapists. A list of questions are provided to help therapists make clinical decisions in five areas: psychosocial sensitivity, movement scripts, treatment planning, procedural changes, and self-monitoring.