Merrill R. Landers

External Focus Instructions Reduce Postural Instability in Individuals With Parkinson Disease

Background: Postural instability while standing, walking, and interacting with objects or the environment places individuals with Parkinson disease (PD) at risk for falls, injuries, and self-imposed restrictions in activity. Recent research with motor skills, including those demanding postural stability, has demonstrated performance and learning advantages when performers are instructed to adopt an external rather than an internal focus of attention. Despite the potential benefits in stability-related risk reduction and enhanced movement effectiveness, attentional focus research in individuals challenged with postural instability is limited. Objective: The present translational research study examined the generalizability of the attentional focus effect to balance in older adults with PD. Design: A within-participant design was used to account for potentially substantial individual variations in balancing capabilities. Methods: Fourteen participants diagnosed with idiopathic PD (Hoehn and Yahr stages II and III) participated in the experiment. They were asked to balance on an unstable surface (inflated rubber disk). In counterbalanced orders, they were instructed to focus on reducing movements of their feet (internal focus) or the disk (external focus), or they were not given attentional focus instructions (control). Results: The adoption of an external focus resulted in less postural sway relative to both internal focus and control conditions. There was no difference between the internal focus and control conditions. Limitations: Mental functioning was not formally assessed, and comprehensive clinical profiles of participants were not obtained. Conclusions: The results are consistent with previous findings on attentional focus in samples of patients and people without disabilities. Subtle wording distinctions that direct attention to movement effects external to the mover reduce postural instability during standing for individuals with PD relative to an internal focus. The findings have potentially important implications for instructions given by clinicians and the reduction of fall risk.

Postural instability in idiopathic Parkinson's disease: Discriminating fallers from nonfallers based on standardized clinical measures

Background: Parkinson’s disease (PD) predisposes one to falls, which in turn may lead to serious injury and decreased quality of life. Therefore, it is critical to accurately identify those at risk of falling so that preventive measures may be properly applied. Methods: Forty-nine participants (25 retrospectively identified fallers and 24 nonfallers) with a diagnosis of idiopathic PD were included in this study. Each was assessed using three categories of measurement tools: PD-specific scales (modified Hoehn and Yahr [HY] and Unified Parkinson’s Disease Rating Scale [UPDRS]), balance-specific scales (Berg Balance Scale [BBS], Sensory Organization Test [SOT], and Activities-Specific Balance Confidence Scale [ABC]), and functional gait scales (Self-Selected Gait Velocity [SSGV], Dynamic Gait Index [DGI]), and a standardized obstacle course. Results: Using discriminant function analysis, the BBS, HY, and UPDRS-Activities of Daily Living subscale (UPDRS-ADL) were found to be the best discriminators of faller or nonfaller group membership. Receiver operating characteristic (ROC) curves were employed to suggest cutoff scores and to determine overall predictability. The area under the ROC curves, and the corresponding cutoff scores were as follows for the highest three clinical tests: UPDRS-ADL (0.888/12.5), UPDRS-Overall (0.879/36.5), and the BBS (0.851/43.5). The odds ratios for the UPDRS-ADL, UPDRS-Overall, and the BBS were 32.8, 26.7, and 48.9, respectively. Using positive likelihood ratios and a pretest probability of 51.0%, the changes in posttest probability were UPDRS-ADL (85.9%), UPDRS-Overall (89.9%), and BBS (94.4%). Conclusion: Results from this study suggest that the UPDRS-ADL, UPDRS-Overall, and the BBS are the best clinical tests for discriminating falls in persons with PD.

Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients With Acute Neck Pain : A Randomized Clinical Trial

STUDY DESIGN Randomized clinical trial. OBJECTIVE To determine if patients who met the clinical prediction rule (CPR) criteria for the success of thoracic spine thrust joint manipulation (TJM) for the treatment of neck pain would have a different outcome if they were treated with a cervical spine TJM. BACKGROUND A CPR had been proposed to identify patients with neck pain who would likely respond favorably to thoracic spine TJM. Research on validation of that CPR had not been completed when this trial was initiated. In our clinical experience, though many patients with neck pain responded favorably to thoracic spine TJM, they often reported that their symptomatic cervical spine area had not been adequately addressed. METHODS Twenty-four consecutive patients, who presented to physical therapy with a primary complaint of neck pain and met 4 out of 6 of the CPR criteria for thoracic TJM, were randomly assigned to 1 of 2 treatment groups. The thoracic group received thoracic TJM and a cervical range-of-motion (ROM) exercise for the first 2 sessions, followed by a standardized exercise program for an additional 3 sessions. The cervical group received cervical TJM and the same cervical ROM exercise for the first 2 sessions, and the same exercise program given to the thoracic group for the next 3 sessions. Outcome measures collected at 1 week, 4 weeks, and 6 months from start of treatment included the Neck Disability Index, numeric pain rating scale, and Fear-Avoidance Beliefs Questionnaire. RESULTS Patients who received cervical TJM demonstrated greater improvements in Neck Disability Index (P ≤.001) and numeric pain rating scale (P ≤.003) scores at all follow-up times. There was also a statistically significant improvement in the Fear-Avoidance Beliefs Questionnaire physical activity subscale score at all follow-up times for the cervical group (P ≤.004). The number needed to treat to avoid an unsuccessful overall outcome was 1.8 at 1 week, 1.6 at 4 weeks, and 1.6 at 6 months. CONCLUSION Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine TJM demonstrated a more favorable response when the TJM was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical TJM also demonstrated fewer transient side-effects. LEVEL OF EVIDENCE Therapy, level 1b.

Preoperative Pain Neuroscience Education for Lumbar Radiculopathy A Multicenter Randomized Controlled Trial With 1-Year Follow-up

Study Design. Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy. Objective. To determine if the addition of NE to usual preoperative education would result in superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery. Summary of Background Data. One in 4 patients after lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is nonresponsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in populations with chronic low back pain. Methods. Eligible patients scheduled for LS for radiculopathy were randomized to receive either preoperative usual care (UC) or a combination of UC plus 1 session of NE delivered by a physical therapist (verbal one-on-one format) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and 1, 3, 6, and 12 months after LS: low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire). Results. At 1-year follow-up, there were no statistical differences between the experimental and control groups with regard to primary outcome measure of low back pain (P = 0.183), leg pain (P = 0.075), and function (P = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (P = 0.001); preoperative session preparing them for LS (P < 0.001) and LS meeting their expectations (P = 0.021). Health care utilization post-LS also favored the NE group (P = 0.007) resulting in 45% less health care expenditure compared with the control group in the 1-year follow-up period. Conclusion. NE resulted in significant behavior change. Despite a similar pain and functional trajectory during the 1-year trial, patients with LS who received NE viewed their surgical experience more favorably and used less health care facility in the form of medical tests and treatments. Level of Evidence: 2

Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports

Abstract Background Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial. Purpose To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician. Data sources PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM. Study selection Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE. Data synthesis Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0·05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/preventable, inappropriate/unpreventable, and inappropriate/unknown. Results One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P = .46. Of the 134 cases, 60 (44·8%) were categorized as preventable, 14 (10·4%) were unpreventable and 60 (44·8%) were categorized as ‘unknown’. CSM was performed appropriately in 80·6% of cases. Death resulted in 5·2% (n = 7) of the cases, mostly caused by arterial dissection. Limitations There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases. Conclusions This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44·8% of AEs associated with CSM. Additionally, 10·4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.

Surface Electromyographic Assessment of the Effect of Dynamic Activity and Dynamic Activity with Static Stretching of the Gastrocnemius on Vertical Jump Performance

The purpose of this study was to investigate the effects of dynamic activity and dynamic activity/static stretching of the gastrocnemius muscle on vertical jump (VJ) performance. Additionally, muscle activity was recorded using electromyography. Thirteen healthy adults (7 men and 6 women) with a mean age of 26 ± 4 years served as subjects. The average jump height and muscle activity from 3 separate maximal VJ attempts were performed at the start of each session to be used as baseline measures using the Kistler force plate and the Noraxon telemetry EMG unit. Subjects then performed 1 of 2 protocols: dynamic activity only or dynamic activity with static stretching. Each protocol was followed by 3 maximal VJ trials. Average VJ height was analyzed using a 2 (time: pre, post) × 2 (prejump protocol: dynamic activity, dynamic activity + stretching) analysis of variance with repeated measures on both factors. A paired-samples t-test was used to compare the intraday difference scores for EMG activity between the 2 conditions. Jump height was not influenced by the interaction of pre-post and protocol (p = 0.0146. There was no difference for the main effects of time (p = 0.274) and pre-jump protocol (p = 0.595). Gastrocnemius muscle activity was likewise not different for the 2 prejump protocols (p = 0.413). The results from this study imply that the use of static stretching in combination with dynamic activity of the gastrocnemius muscle does not appear to have an adverse affect on VJ height performance. The practical importance concerns the warm-up routine that coaches and athletes employ; that is, they may want to consider including an aerobic component when statically stretching the gastrocnemius immediately prior to a vertical jumping event.

Development of a Scale to Assess Avoidance Behavior Due to a Fear of Falling: The Fear of Falling Avoidance Behavior Questionnaire

Background A history of falls or imbalance may lead to a fear of falling, which may lead to self-imposed avoidance of activity; this avoidance may stimulate a vicious cycle of deconditioning and subsequent falls. Objective The purpose of this study was to develop a questionnaire that would quantify avoidance behavior due to a fear of falling. Design This study consisted of 2 parts: questionnaire development and psychometric testing. Questionnaire development involved an expert panel and 39 residents of an assisted living facility. Sixty-three community-dwelling individuals with various health conditions participated in psychometric testing. Method Questionnaire development included the evaluation of face and content validity and factor analysis of the initial questionnaire. The final result of questionnaire development was the Fear of Falling Avoidance Behavior Questionnaire (FFABQ). In order to determine its psychometric properties, reliability and construct validity were assessed through administration of the FFABQ to participants twice, 1 week apart, and comparison of the FFABQ with other questionnaires related to fear of falling, functional measures of balance and mobility, and daily activity levels using an activity monitor. Results The FFABQ had good overall test-retest reliability (intraclass correlation coefficient=.812) and was found to differentiate between participants who were considered “fallers” (ie, at least one fall in the previous year) and those who were considered “nonfallers.” The FFABQ predicted time spent sitting or lying and endurance. Limitations A relatively small number of people with a fear of falling were willing to participate. Conclusion Results from this study offer evidence for the reliability and validity of the FFABQ and support the notion that the FFABQ measures avoidance behavior rather than balance confidence, self-efficacy, or fear.

Balance Confidence and Fear of Falling Avoidance Behavior Are Most Predictive of Falling in Older Adults: Prospective Analysis

Background Evidence suggests that there are several fall predictors in the elderly population, including previous fall history and balance impairment. To date, however, the role of psychological factors has not yet been thoroughly vetted in conjunction with physical factors as predictors of future falls. Objective The purpose of this study was to determine which measures, physical and psychological, are most predictive of falling in older adults. Design This was a prospective cohort study. Methods Sixty-four participants (mean age=72.2 years, SD=7.2; 40 women, 24 men) with and without pathology (25 healthy, 17 with Parkinson disease, 11 with cerebrovascular accident, 6 with diabetes, and 5 with a cardiovascular diagnosis) participated. Participants reported fall history and completed physical-based measures (ie, Berg Balance Scale, Dynamic Gait Index, self-selected gait speed, Timed “Up & Go” Test, Sensory Organization Test) and psychological-based measures (ie, Fear of Falling Avoidance Behavior Questionnaire, Falls Efficacy Scale, Activities-specific Balance Confidence Scale). Contact was made 1 year later to determine falls during the subsequent year (8 participants lost at follow-up). Results Using multiple regression, fall history, pathology, and all measures were entered as predictor candidates. Three variables were included in the final model, explaining 49.2% of the variance: Activities-specific Balance Confidence Scale (38.7% of the variance), Fear of Falling Avoidance Behavior Questionnaire (5.6% additional variance), and Timed “Up & Go” Test (4.9% additional variance). Limitations Falls were based on participant recall rather than a diary. Conclusions Balance confidence was the best predictor of falling, followed by fear of falling avoidance behavior, and the Timed “Up & Go” Test. Fall history, presence of pathology, and physical tests did not predict falling. These findings suggest that participants may have had a better sense of their fall risk than with a test that provides a snapshot of their balance.

Rehabilitation Following Lumbosacral Percutaneous Nucleoplasty: A Case Report

STUDY DESIGN Case report. BACKGROUND Lumbar spine nucleoplasty is a new surgical option for patients with disc pathology. There are no reports in the literature describing the role of physical therapy in postoperative lumbar nucleoplasty management. The purpose of this case is to describe the postoperative physical therapy management of a patient who underwent this procedure. CASE DESCRIPTION A 50-year-old male, 7 weeks following a L5/S1 lumbar nucleus replacement, completed 6 weeks of rehabilitation. The focus of the treatment was controlled reloading of the spine through a spinal stabilization progression in weight-bearing and non-weight-bearing activities. In addition, education, spinal manual therapy techniques, and a home exercise program were also incorporated. OUTCOMES The patients Oswestry Disability Index decreased from 56% to 4% over 6 weeks of treatment. When contacted at 6, 12, 18, and 24 months posttherapy, his Oswestry Disability Index was 2%, 2%, 0%, and 0%, respectively, and he had returned to all previous activities without recurrence of symptoms. DISCUSSION This case report outlines the clinical decision-making process during the postoperative management of an individual who had undergone a single-level lumbar nucleoplasty. A postoperative regimen of education, segmental spinal stabilization, and a home exercise program might have contributed to the observed improvement in pain and disability levels in this patient. The role of these postoperative interventions warrants further research. LEVEL OF EVIDENCE Therapy, level 4.

Immediate Effects of Lumbar Spine Manipulation on the Resting and Contraction Thickness of Transversus Abdominis in Asymptomatic Individuals

STUDY DESIGN Randomized, blinded, controlled crossover trial. OBJECTIVE To determine if thrust joint manipulation (TJM) to the lumbar spine would result in changes to the resting and contraction thickness of transversus abdominis (TrA) in healthy individuals. BACKGROUND Recent studies have demonstrated an immediate decrease in resting thickness and an increase in contraction thickness in TrA following lumbar TJM in patients with low back pain (LBP) who met a clinical prediction rule (CPR) for spinal manipulation. This observed phenomenon has not been investigated in healthy individuals. METHODS Thirty-five healthy participants were randomly assigned to receive a TJM or sham manipulation treatment. All participants received instruction on how to produce an isolated concentric contraction of the TrA that involved visual ultrasound imaging biofeedback. Data were analyzed using ultrasound imaging to measure changes in thickness of the TrA at rest and during contraction, following the administration of each treatment. RESULTS There were no interactions observed between treatment and time for TrA muscle thickness at rest (P = .351) and during the contracted state (P = .761). CONCLUSION Our results indicate that TJM to the lumbar spine does not appear to affect the resting or contraction thickness of TrA in healthy individuals. These findings are in contrast to previous research in which patients with LBP who met a CPR demonstrated an immediate decrease in resting thickness and an increase in contraction thickness in TrA following lumbar TJM.