This case report describes a rehabilitation protocol using a video game-based exercise tool to improve dynamic short-sitting balance for three patients with chronic spinal cord injuries or traumatic brain injuries. The tool tracks the center of pressure to control games requiring weight shifting. All three patients showed increased motivation to exercise and dynamic balance control after using the game-based tool. The findings suggest game-based exercises can positively impact rehabilitation by enhancing patient engagement.
Spinal manipulation therapy (SMT) was more effective than medication for relieving acute or subacute neck pain in both the short and long term. Home exercise with advice (HEA) resulted in similar pain outcomes to SMT at most time points. For 272 participants with neck pain lasting 2-12 weeks, SMT had statistically significantly less pain than medication after 8 weeks and up to 1 year later. HEA was superior to medication for pain relief at 26 weeks. No important differences in pain were found between SMT and HEA. The trial demonstrated that SMT and HEA were both more effective than medication for acute or subacute neck pain.
Work related musculoskeletal disorders in physical therapistsTuğçehan Kara
This study examined work-related musculoskeletal disorders (WMSDs) in physical therapists through a prospective cohort study with 1-year follow up. The study found that 57.5% of physical therapists reported a WMSD in the follow up year, with a 1-year prevalence rate of 28% and incidence rate of 20.7%. Risk factors for low back WMSDs included patient transfers, repositioning, bent/twisted postures, and job strain. Risk factors for wrist/hand WMSDs included soft tissue work, joint mobilization, and manual therapy techniques. The study recommends safer patient handling policies and further research to examine the link between physical therapy exposures and WMSDs.
Subthalamic Deep Brain Stimulation in Patients with a Previous PallidotomyYavuz Silay
STN DBS patients with a previous unilateral pallidotomy had less improvement in motor function compared to other STN DBS patients, despite good outcomes after pallidotomy. Specifically, the post-pallidotomy STN DBS patients' mean "off" motor UPDRS scores improved by 16.6% compared to 40.2% for controls. Improvement in dyskinesia was similar. Adverse events like worse dysarthria and balance were reported. The authors hypothesize this may be due to patient selection bias or altered neurophysiology from the prior pallidotomy impacting DBS placement/outcomes. Overall results are mixed regarding efficacy of STN DBS after pallidotomy.
The document discusses chronic pain disorders, specifically chronic muscle pain. It provides epidemiological data showing chronic muscle pain is highly prevalent and costly. It discusses the importance of differential diagnosis to determine if pain has central or peripheral causes. Trigger points in muscles are identified as a key peripheral mechanism of chronic pain. The document also summarizes research supporting the role of sympathetic nervous system activation in triggering and maintaining trigger points. It concludes by outlining a treatment approach focused on education to change causal attributions of pain, in addition to physical therapies and cognitive interventions.
1. This document provides summaries of 4 recent studies related to chiropractic care, beginning with a major study published in Annals of Internal Medicine that found spinal manipulative therapy and home exercises were superior to medication for neck pain.
2. The second study summarized was the first randomized controlled trial to examine chiropractic management for patients with chest pain, finding that chiropractic patients improved significantly more than those receiving self-management.
3. References and appendices are provided for each study summarized. The document concludes by commenting on how chiropractic addresses the mechanical cause of problems rather than just symptoms.
Artigo - Acupuncture and physiotherapy for painful shoulderRenato Almeida
This randomized controlled trial evaluated the efficacy of single-point acupuncture combined with physiotherapy compared to physiotherapy alone for the treatment of painful shoulder. 425 patients with subacromial syndrome received 15 sessions of physiotherapy over 3 weeks along with either weekly acupuncture at point ST38 or sham TENS. Patients receiving acupuncture showed significantly greater improvement in shoulder function scores and reported less analgesic use compared to the control group receiving only physiotherapy. The study demonstrates that adding acupuncture to physiotherapy can more effectively treat painful shoulder conditions.
The article discusses the impacts of the COVID-19 pandemic on physiatry and rehabilitation medicine. It highlights how physiatrists played a vital role in the front lines during the pandemic by converting rehabilitation units and innovating care delivery. However, the pandemic has also caused significant disruptions and stress for medical practices through reduced patient volumes, higher costs, and threats of reimbursement cuts from insurers and governments. Moving forward, physicians are questioning the level of support they will receive from their employers and the government given the sacrifices many have made during the pandemic.
Spinal manipulation therapy (SMT) was more effective than medication for relieving acute or subacute neck pain in both the short and long term. Home exercise with advice (HEA) resulted in similar pain outcomes to SMT at most time points. For 272 participants with neck pain lasting 2-12 weeks, SMT had statistically significantly less pain than medication after 8 weeks and up to 1 year later. HEA was superior to medication for pain relief at 26 weeks. No important differences in pain were found between SMT and HEA. The trial demonstrated that SMT and HEA were both more effective than medication for acute or subacute neck pain.
Work related musculoskeletal disorders in physical therapistsTuğçehan Kara
This study examined work-related musculoskeletal disorders (WMSDs) in physical therapists through a prospective cohort study with 1-year follow up. The study found that 57.5% of physical therapists reported a WMSD in the follow up year, with a 1-year prevalence rate of 28% and incidence rate of 20.7%. Risk factors for low back WMSDs included patient transfers, repositioning, bent/twisted postures, and job strain. Risk factors for wrist/hand WMSDs included soft tissue work, joint mobilization, and manual therapy techniques. The study recommends safer patient handling policies and further research to examine the link between physical therapy exposures and WMSDs.
Subthalamic Deep Brain Stimulation in Patients with a Previous PallidotomyYavuz Silay
STN DBS patients with a previous unilateral pallidotomy had less improvement in motor function compared to other STN DBS patients, despite good outcomes after pallidotomy. Specifically, the post-pallidotomy STN DBS patients' mean "off" motor UPDRS scores improved by 16.6% compared to 40.2% for controls. Improvement in dyskinesia was similar. Adverse events like worse dysarthria and balance were reported. The authors hypothesize this may be due to patient selection bias or altered neurophysiology from the prior pallidotomy impacting DBS placement/outcomes. Overall results are mixed regarding efficacy of STN DBS after pallidotomy.
The document discusses chronic pain disorders, specifically chronic muscle pain. It provides epidemiological data showing chronic muscle pain is highly prevalent and costly. It discusses the importance of differential diagnosis to determine if pain has central or peripheral causes. Trigger points in muscles are identified as a key peripheral mechanism of chronic pain. The document also summarizes research supporting the role of sympathetic nervous system activation in triggering and maintaining trigger points. It concludes by outlining a treatment approach focused on education to change causal attributions of pain, in addition to physical therapies and cognitive interventions.
1. This document provides summaries of 4 recent studies related to chiropractic care, beginning with a major study published in Annals of Internal Medicine that found spinal manipulative therapy and home exercises were superior to medication for neck pain.
2. The second study summarized was the first randomized controlled trial to examine chiropractic management for patients with chest pain, finding that chiropractic patients improved significantly more than those receiving self-management.
3. References and appendices are provided for each study summarized. The document concludes by commenting on how chiropractic addresses the mechanical cause of problems rather than just symptoms.
Artigo - Acupuncture and physiotherapy for painful shoulderRenato Almeida
This randomized controlled trial evaluated the efficacy of single-point acupuncture combined with physiotherapy compared to physiotherapy alone for the treatment of painful shoulder. 425 patients with subacromial syndrome received 15 sessions of physiotherapy over 3 weeks along with either weekly acupuncture at point ST38 or sham TENS. Patients receiving acupuncture showed significantly greater improvement in shoulder function scores and reported less analgesic use compared to the control group receiving only physiotherapy. The study demonstrates that adding acupuncture to physiotherapy can more effectively treat painful shoulder conditions.
The article discusses the impacts of the COVID-19 pandemic on physiatry and rehabilitation medicine. It highlights how physiatrists played a vital role in the front lines during the pandemic by converting rehabilitation units and innovating care delivery. However, the pandemic has also caused significant disruptions and stress for medical practices through reduced patient volumes, higher costs, and threats of reimbursement cuts from insurers and governments. Moving forward, physicians are questioning the level of support they will receive from their employers and the government given the sacrifices many have made during the pandemic.
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
‘Neurodynamics as a therapeutic intervention; the effectiveness and scientifi...NVMT-symposium
This document discusses the evidence for neural mobilization as a treatment for nerve disorders. It begins by reviewing animal studies showing that movement such as exercise prevents neuropathic pain development, aids nerve recovery after injury, and reduces neuropathic pain. However, the evidence for neural mobilization and nerve gliding exercises in humans is limited. A systematic review found limited evidence that neural mobilization is more effective than minimal interventions for pain and disability in carpal tunnel syndrome, but not more effective than other treatments. Another review found limited evidence for the effectiveness of nerve gliding exercises in carpal tunnel syndrome. The document concludes that while movement may be beneficial, the evidence does not clearly support neural mobilization over other conservative treatments, and more high-quality research is
This document is the February/March 2008 issue of Connections, a bimonthly publication from Evanston Northwestern Healthcare. It features stories about innovative care provided by ENH physicians and its impact on patients' health. The issue highlights several ENH physicians who are leaders in their fields, including one who is researching a technique to detect colon cancer early using light scattering spectroscopy. It also profiles an interventional cardiologist who saved a woman's life after a massive heart attack and a physician team working to prevent a brain tumor from recurring in a patient.
The Injured Runner: An Evidence-Based Approach. Part Two: RunSmart ApproachAllan Besselink
1) The document discusses the RunSmart approach to injury prevention and recovery in runners based on evidence-based cellular physiology principles.
2) These principles include stimulus-response, specific adaptations to imposed demands, training principles, tissue repair processes, and developing competent self-care skills.
3) The RunSmart approach uses assessment and graded loading strategies tailored to the individual to foster normal tissue repair and development, with the goal of returning to running while avoiding reinjury.
Multimodal Behavioral Assessment After Experimental Brain TraumaInsideScientific
Corina Bondi, PhD discusses her research on experimental traumatic brain injury and the resulting cognitive deficits.
Traumatic brain injuries (TBIs) affect 2.8 million individuals in the United States each year. Moreover, 500,000 yearly emergency room visits are attributed to childhood-acquired brain trauma, while the elderly also constitute another high-risk population segment due to falls, with patients enduring long-lasting cognitive, physical, or behavioral effects. Impaired attention is central to the cognitive deficits associated with long-term sequelae for many TBI survivors. Considering that cognitive deficits are often assessed using multi-domain neuropsychological cognitive battery tests, Dr. Bondi’s group employed, for the first time, multimodal approaches to determine higher-order attentional capabilities after experimental TBI in rats. Their studies aimed to investigate complex cognitive deficits in adolescent and adult male and female rats subjected to frontal or parietal lobe injuries. Higher-order attentional testing will advance the understanding of long-term cognitive impairments in survivors of brain trauma and may provide reliable avenues towards developing more suitable therapeutic approaches.
Key Topics Include:
Cognitive functioning can be assessed via multiple test modalities in rodents, similar to the clinical setting.
Multiple domains of complex, higher-order cognitive functioning (sustained attention, behavioral flexibility, goal-directed behavior) are mediated by the frontal lobe in rodents in a similar fashion to the human brain, with long-lasting alterations after brain trauma occurring regardless of sex.
Differences between multiple classes of pharmacotherapies employed to restore neurobehavioral and cognitive performance after traumatic brain injury, such as antidepressants and cholinergic drugs.
1) Rats received a traumatic brain injury or sham injury and were then housed in either standard or abbreviated environmental enrichment conditions for varying time periods (2, 4, or 6 hours per day).
2) Rats housed in abbreviated environmental enrichment for 6 hours per day showed significantly better motor and cognitive recovery compared to standard housed rats, and performed similarly to rats in continuous environmental enrichment.
3) Abbreviated environmental enrichment for 6 hours per day may be a relevant rehabilitation model for traumatic brain injury, as it produces benefits similar to continuous enrichment but with a duration more comparable to clinical rehabilitation timeframes.
1) The document summarizes several journal articles related to physical medicine and rehabilitation (PMR). It includes abstracts on topics like cognitive communication skills after mild traumatic brain injury, seizure comorbidity and hospital readmissions after traumatic brain injury, effects of traumatic brain injury and spinal cord injury on sexual function, the relationship between white matter hyperintensities and response to language treatment in post-stroke aphasia, using mental imagery therapy to treat neuropathic pain in spinal cord injury patients, and impairments in spatial navigation during walking in younger patients with mild stroke.
2) The editor's preface welcomes readers to the first issue of 2021 and thanks contributors and the recognition from IAPMR. It encourages readers to keep learning with the
This document summarizes research on the effects of COX-2 inhibitors on fracture healing and implications for patient recovery. The main points are:
1) Past research has found that COX-2 inhibitors like celecoxib can impair fracture healing in animal models by reducing callus strength and increasing nonunion rates.
2) A recent study in rats found celecoxib administration was associated with weaker fracture calluses, more nonunions, and duration of inhibition correlated with decreased healing.
3) The investigators concluded NSAID use after fractures may negatively affect healing in humans, though more research is needed, and COX-2 drug use should be avoided in fusion patients for now.
Impairments In Prospective And Retrospective Memory Following StrokeJorge Barbosa
This document summarizes a study that examined prospective and retrospective memory impairments in community-dwelling stroke survivors compared to normal controls. Twelve stroke patients and twelve matched controls performed tests of executive function, prospective memory, and retrospective memory. The stroke patients performed worse than controls on laboratory tests of prospective and associative retrospective memory, as well as standard tests of retrospective memory and executive control. However, the groups did not differ on more structured clinical measures of these functions or on self-rated memory measures. The results suggest an impairment in stroke patients' ability to self-initiate effortful cognitive processes.
1. Patient Assessment
2. Formulation of treatment plan
3. Implementation of treatment plan
4. Follow up
5. Practice management
6. Promotion of Competency
Ct scan , self care, rehab after traumatic brain injuryConnie Dello Buono
This study examined the association between early CT scan findings and needs for assistance with ambulation, self-care, and supervision at rehabilitation discharge and 1 year after traumatic brain injury (TBI). The study analyzed CT scans from 1839 TBI patients taken during the first week after injury and recorded findings such as midline shift, subcortical contusions, and bilateral frontal or temporal contusions. It found that a midline shift greater than 5mm or subcortical contusions were associated with greater needs for assistance at discharge, and subcortical contusions were also associated with needs at 1 year. Bilateral frontal or temporal contusions were associated with needs for greater supervision at discharge but not for ambulation or self-care
This study evaluated patient controlled sedation (PCS) using propofol and alfentanil for dressing changes in 11 burn patients with over 10% total burn surface area. PCS was compared to sedation provided by an anesthesiologist. Patients preferred PCS due to greater control and less discomfort during recovery. No adverse respiratory or cardiovascular events occurred with PCS. Procedural pain was higher with PCS but lower after the procedure. The study concluded that PCS is an effective and safe alternative to anesthesiologist-provided sedation for burn dressing changes, but noted the small sample size limited the strength of this conclusion and further studies are warranted.
Hip arthritis, fatigue and brain injury and scale of pain intensity 3 articlesConnie Dello Buono
This document contains summaries of several poster presentations from an annual medical conference. It includes 3 posters on topics related to brain injury and rehabilitation:
1. A study examining factors that contribute to fatigue after traumatic brain injury, finding that depression, memory problems, pain, and abnormal hormone levels were significant predictors of fatigue.
2. A study validating a new pain assessment scale called the Scale of Pain Intensity for patients with cognitive and communication deficits after brain injury. It was found to accurately identify pain and track changes.
3. A study finding an increasing incidence of traumatic brain injury in the elderly using national hospitalization data, suggesting this may be an area for further research.
This document summarizes key findings from neuroimaging studies on pain processing in the brain. A meta-analysis of 122 pain studies found activation in brain regions involved in sensory and affective pain processing, including the thalamus, insula, and anterior cingulate cortex. Studies also show cortical thickness in pain regions correlates with pain modulation abilities and pain catastrophizing traits. Brain plasticity underlies changes from chronic pain, memory of pain, and phantom limb pain.
This systematic review evaluated the efficacy of various interventions for children with developmental coordination disorder (DCD) based on current research. The review found that task-oriented, functional interventions aimed at improving skills for daily living were most effective. Traditional physical therapy and cognitive approaches like CO-OP were also beneficial. Process-oriented interventions and perceptual-motor training were not recommended. The review identified a need for more rigorous study designs and consistent outcome measures to better understand best practices for treating DCD.
This document summarizes and compares different models of back schools for treating chronic low back pain. It discusses the original Swedish back school model and how various programs have modified the content, format, and length. Several recent randomized controlled trials that compared different back school models to other treatments are highlighted. The studies found that back schools based on biopsychosocial principles led to better long-term outcomes than traditional models. Spinal manipulation was also found to result in lower disability scores compared to back school or individual physiotherapy. Overall, back schools may be considered as part of multidisciplinary treatment, though more research is still needed.
Postmastectomy and Post Thoracotomy PainJason Attaman
This document discusses postmastectomy and postthoracotomy pain. It begins by describing the various mechanisms that can cause injury during breast and chest wall surgeries, including damage to muscles, nerves, and formation of scar tissue. It then discusses two specific pain syndromes - postmastectomy pain, which 4-14% of women experience after mastectomy surgery, and postthoracotomy pain, where 26-67% of patients report long-term pain after thoracic surgery. The causes of pain in both syndromes can include tissue injury from surgery or cancer, as well as nerve injury from surgical trauma, radiation, chemotherapy, fibrosis, or cancer metastasis.
Mx guideline for post stroke rehablitationNeurologyKota
This document provides guidelines for stroke rehabilitation. It discusses that stroke affects nearly 800,000 people in the US each year, with most receiving rehabilitation after hospitalization. The aim is to provide best practices for rehabilitative care. It recommends assessment by rehabilitation experts and discusses various levels of post-acute care like inpatient rehabilitation facilities and skilled nursing facilities. Effective rehabilitation requires a coordinated team and communication is paramount.
1. Cerebral palsy is caused by brain lesions early in life and results in non-progressive motor impairments. While it cannot be cured, interventions can improve function and quality of life.
2. Traditional physical therapy approaches for cerebral palsy focus on managing symptoms and limitations through stretching and assistive devices. However, evidence shows this provides only modest benefits and is highly painful.
3. There is a need for more effective, evidence-based therapies that strengthen muscles rather than just stretching them, and equip children's brains and bodies for independence rather than reliance on devices.
The document examines the feasibility of using the Sony PlayStation 2 gaming console for rehabilitation purposes for individuals with neurological impairments. It discusses how the PlayStation 2's game controllers can provide input to assess motor and cognitive functions. A pilot study was conducted with unimpaired individuals that demonstrated the PlayStation 2 is a low-cost and easily accessible option to evaluate motor and cognitive abilities through its games and controllers.
This document discusses evidence for the benefits and drawbacks of using computer and video games like the Wii for therapeutic purposes. It provides a table listing several benefits such as offering recreational opportunities, maintaining mobility, improving balance and coordination, and serving as a motivating and engaging framework. Another table lists some drawbacks, such as overuse can cause injuries and games may not be intense enough for exercise. The document concludes by questioning whether empirical evidence fully supports the proclaimed benefits.
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
‘Neurodynamics as a therapeutic intervention; the effectiveness and scientifi...NVMT-symposium
This document discusses the evidence for neural mobilization as a treatment for nerve disorders. It begins by reviewing animal studies showing that movement such as exercise prevents neuropathic pain development, aids nerve recovery after injury, and reduces neuropathic pain. However, the evidence for neural mobilization and nerve gliding exercises in humans is limited. A systematic review found limited evidence that neural mobilization is more effective than minimal interventions for pain and disability in carpal tunnel syndrome, but not more effective than other treatments. Another review found limited evidence for the effectiveness of nerve gliding exercises in carpal tunnel syndrome. The document concludes that while movement may be beneficial, the evidence does not clearly support neural mobilization over other conservative treatments, and more high-quality research is
This document is the February/March 2008 issue of Connections, a bimonthly publication from Evanston Northwestern Healthcare. It features stories about innovative care provided by ENH physicians and its impact on patients' health. The issue highlights several ENH physicians who are leaders in their fields, including one who is researching a technique to detect colon cancer early using light scattering spectroscopy. It also profiles an interventional cardiologist who saved a woman's life after a massive heart attack and a physician team working to prevent a brain tumor from recurring in a patient.
The Injured Runner: An Evidence-Based Approach. Part Two: RunSmart ApproachAllan Besselink
1) The document discusses the RunSmart approach to injury prevention and recovery in runners based on evidence-based cellular physiology principles.
2) These principles include stimulus-response, specific adaptations to imposed demands, training principles, tissue repair processes, and developing competent self-care skills.
3) The RunSmart approach uses assessment and graded loading strategies tailored to the individual to foster normal tissue repair and development, with the goal of returning to running while avoiding reinjury.
Multimodal Behavioral Assessment After Experimental Brain TraumaInsideScientific
Corina Bondi, PhD discusses her research on experimental traumatic brain injury and the resulting cognitive deficits.
Traumatic brain injuries (TBIs) affect 2.8 million individuals in the United States each year. Moreover, 500,000 yearly emergency room visits are attributed to childhood-acquired brain trauma, while the elderly also constitute another high-risk population segment due to falls, with patients enduring long-lasting cognitive, physical, or behavioral effects. Impaired attention is central to the cognitive deficits associated with long-term sequelae for many TBI survivors. Considering that cognitive deficits are often assessed using multi-domain neuropsychological cognitive battery tests, Dr. Bondi’s group employed, for the first time, multimodal approaches to determine higher-order attentional capabilities after experimental TBI in rats. Their studies aimed to investigate complex cognitive deficits in adolescent and adult male and female rats subjected to frontal or parietal lobe injuries. Higher-order attentional testing will advance the understanding of long-term cognitive impairments in survivors of brain trauma and may provide reliable avenues towards developing more suitable therapeutic approaches.
Key Topics Include:
Cognitive functioning can be assessed via multiple test modalities in rodents, similar to the clinical setting.
Multiple domains of complex, higher-order cognitive functioning (sustained attention, behavioral flexibility, goal-directed behavior) are mediated by the frontal lobe in rodents in a similar fashion to the human brain, with long-lasting alterations after brain trauma occurring regardless of sex.
Differences between multiple classes of pharmacotherapies employed to restore neurobehavioral and cognitive performance after traumatic brain injury, such as antidepressants and cholinergic drugs.
1) Rats received a traumatic brain injury or sham injury and were then housed in either standard or abbreviated environmental enrichment conditions for varying time periods (2, 4, or 6 hours per day).
2) Rats housed in abbreviated environmental enrichment for 6 hours per day showed significantly better motor and cognitive recovery compared to standard housed rats, and performed similarly to rats in continuous environmental enrichment.
3) Abbreviated environmental enrichment for 6 hours per day may be a relevant rehabilitation model for traumatic brain injury, as it produces benefits similar to continuous enrichment but with a duration more comparable to clinical rehabilitation timeframes.
1) The document summarizes several journal articles related to physical medicine and rehabilitation (PMR). It includes abstracts on topics like cognitive communication skills after mild traumatic brain injury, seizure comorbidity and hospital readmissions after traumatic brain injury, effects of traumatic brain injury and spinal cord injury on sexual function, the relationship between white matter hyperintensities and response to language treatment in post-stroke aphasia, using mental imagery therapy to treat neuropathic pain in spinal cord injury patients, and impairments in spatial navigation during walking in younger patients with mild stroke.
2) The editor's preface welcomes readers to the first issue of 2021 and thanks contributors and the recognition from IAPMR. It encourages readers to keep learning with the
This document summarizes research on the effects of COX-2 inhibitors on fracture healing and implications for patient recovery. The main points are:
1) Past research has found that COX-2 inhibitors like celecoxib can impair fracture healing in animal models by reducing callus strength and increasing nonunion rates.
2) A recent study in rats found celecoxib administration was associated with weaker fracture calluses, more nonunions, and duration of inhibition correlated with decreased healing.
3) The investigators concluded NSAID use after fractures may negatively affect healing in humans, though more research is needed, and COX-2 drug use should be avoided in fusion patients for now.
Impairments In Prospective And Retrospective Memory Following StrokeJorge Barbosa
This document summarizes a study that examined prospective and retrospective memory impairments in community-dwelling stroke survivors compared to normal controls. Twelve stroke patients and twelve matched controls performed tests of executive function, prospective memory, and retrospective memory. The stroke patients performed worse than controls on laboratory tests of prospective and associative retrospective memory, as well as standard tests of retrospective memory and executive control. However, the groups did not differ on more structured clinical measures of these functions or on self-rated memory measures. The results suggest an impairment in stroke patients' ability to self-initiate effortful cognitive processes.
1. Patient Assessment
2. Formulation of treatment plan
3. Implementation of treatment plan
4. Follow up
5. Practice management
6. Promotion of Competency
Ct scan , self care, rehab after traumatic brain injuryConnie Dello Buono
This study examined the association between early CT scan findings and needs for assistance with ambulation, self-care, and supervision at rehabilitation discharge and 1 year after traumatic brain injury (TBI). The study analyzed CT scans from 1839 TBI patients taken during the first week after injury and recorded findings such as midline shift, subcortical contusions, and bilateral frontal or temporal contusions. It found that a midline shift greater than 5mm or subcortical contusions were associated with greater needs for assistance at discharge, and subcortical contusions were also associated with needs at 1 year. Bilateral frontal or temporal contusions were associated with needs for greater supervision at discharge but not for ambulation or self-care
This study evaluated patient controlled sedation (PCS) using propofol and alfentanil for dressing changes in 11 burn patients with over 10% total burn surface area. PCS was compared to sedation provided by an anesthesiologist. Patients preferred PCS due to greater control and less discomfort during recovery. No adverse respiratory or cardiovascular events occurred with PCS. Procedural pain was higher with PCS but lower after the procedure. The study concluded that PCS is an effective and safe alternative to anesthesiologist-provided sedation for burn dressing changes, but noted the small sample size limited the strength of this conclusion and further studies are warranted.
Hip arthritis, fatigue and brain injury and scale of pain intensity 3 articlesConnie Dello Buono
This document contains summaries of several poster presentations from an annual medical conference. It includes 3 posters on topics related to brain injury and rehabilitation:
1. A study examining factors that contribute to fatigue after traumatic brain injury, finding that depression, memory problems, pain, and abnormal hormone levels were significant predictors of fatigue.
2. A study validating a new pain assessment scale called the Scale of Pain Intensity for patients with cognitive and communication deficits after brain injury. It was found to accurately identify pain and track changes.
3. A study finding an increasing incidence of traumatic brain injury in the elderly using national hospitalization data, suggesting this may be an area for further research.
This document summarizes key findings from neuroimaging studies on pain processing in the brain. A meta-analysis of 122 pain studies found activation in brain regions involved in sensory and affective pain processing, including the thalamus, insula, and anterior cingulate cortex. Studies also show cortical thickness in pain regions correlates with pain modulation abilities and pain catastrophizing traits. Brain plasticity underlies changes from chronic pain, memory of pain, and phantom limb pain.
This systematic review evaluated the efficacy of various interventions for children with developmental coordination disorder (DCD) based on current research. The review found that task-oriented, functional interventions aimed at improving skills for daily living were most effective. Traditional physical therapy and cognitive approaches like CO-OP were also beneficial. Process-oriented interventions and perceptual-motor training were not recommended. The review identified a need for more rigorous study designs and consistent outcome measures to better understand best practices for treating DCD.
This document summarizes and compares different models of back schools for treating chronic low back pain. It discusses the original Swedish back school model and how various programs have modified the content, format, and length. Several recent randomized controlled trials that compared different back school models to other treatments are highlighted. The studies found that back schools based on biopsychosocial principles led to better long-term outcomes than traditional models. Spinal manipulation was also found to result in lower disability scores compared to back school or individual physiotherapy. Overall, back schools may be considered as part of multidisciplinary treatment, though more research is still needed.
Postmastectomy and Post Thoracotomy PainJason Attaman
This document discusses postmastectomy and postthoracotomy pain. It begins by describing the various mechanisms that can cause injury during breast and chest wall surgeries, including damage to muscles, nerves, and formation of scar tissue. It then discusses two specific pain syndromes - postmastectomy pain, which 4-14% of women experience after mastectomy surgery, and postthoracotomy pain, where 26-67% of patients report long-term pain after thoracic surgery. The causes of pain in both syndromes can include tissue injury from surgery or cancer, as well as nerve injury from surgical trauma, radiation, chemotherapy, fibrosis, or cancer metastasis.
Mx guideline for post stroke rehablitationNeurologyKota
This document provides guidelines for stroke rehabilitation. It discusses that stroke affects nearly 800,000 people in the US each year, with most receiving rehabilitation after hospitalization. The aim is to provide best practices for rehabilitative care. It recommends assessment by rehabilitation experts and discusses various levels of post-acute care like inpatient rehabilitation facilities and skilled nursing facilities. Effective rehabilitation requires a coordinated team and communication is paramount.
1. Cerebral palsy is caused by brain lesions early in life and results in non-progressive motor impairments. While it cannot be cured, interventions can improve function and quality of life.
2. Traditional physical therapy approaches for cerebral palsy focus on managing symptoms and limitations through stretching and assistive devices. However, evidence shows this provides only modest benefits and is highly painful.
3. There is a need for more effective, evidence-based therapies that strengthen muscles rather than just stretching them, and equip children's brains and bodies for independence rather than reliance on devices.
The document examines the feasibility of using the Sony PlayStation 2 gaming console for rehabilitation purposes for individuals with neurological impairments. It discusses how the PlayStation 2's game controllers can provide input to assess motor and cognitive functions. A pilot study was conducted with unimpaired individuals that demonstrated the PlayStation 2 is a low-cost and easily accessible option to evaluate motor and cognitive abilities through its games and controllers.
This document discusses evidence for the benefits and drawbacks of using computer and video games like the Wii for therapeutic purposes. It provides a table listing several benefits such as offering recreational opportunities, maintaining mobility, improving balance and coordination, and serving as a motivating and engaging framework. Another table lists some drawbacks, such as overuse can cause injuries and games may not be intense enough for exercise. The document concludes by questioning whether empirical evidence fully supports the proclaimed benefits.
The article discusses how interactive video games can be used in physical education classes to encourage physical activity and exercise among students. It notes that video games appeal to many students and that digital games exist which require full-body movement and involve sports activities. The article argues these interactive games can help engage students and get them excited about being physically active if integrated into physical education curriculums.
This study compared the energy expenditure of adolescents when playing new generation active computer games (Wii Sports) versus traditional sedentary computer games (XBOX 360). The researchers found that playing bowling, tennis, and boxing on Wii Sports burned significantly more energy (average of around 190 kJ/kg/min) than playing games on XBOX 360 (around 125 kJ/kg/min). However, the energy expended when playing the active Wii Sports games was not high enough to contribute meaningfully to daily physical activity recommendations for children.
The document provides step-by-step instructions for setting up a Wii gaming console for use. It details how to connect the power cable and A/V cables to the Wii and television. The user is then instructed to set up the sensor bar below or above the TV, select options to configure the Wii system settings, and calibrate the controller. Finally, the user can insert a game disc and select start to begin playing.
Matinale eZ Publish : la personnalisation dynamiqueSofteam Agency
Présentation réalisée par François Sutter, directeur conseil chez Modedemploi, dans le cadre de la matinale eZpublish : 10 grandes typologies de personnalisation dynamique.
Stratégie de contenu, Brand content, content marketing : Une introductionLise Bissonnette Janody
Stratégie de contenu, brand content, content marketing : trois termes qui se ressemble, qu'on utilise souvent de manière interchangeable, qui sont effectivement liés...mais pas tout à fait les mêmes. Alors, de quoi parle-t-on quand on parle de stratégie de contenu? De content marketing ou de brand content? C'est le sujet de cette présentation, que j'ai préparée pour le premier Content Strategy Meetup à Toulouse.
The document introduces recent advances in rehabilitation technology and provides an overview of 11 devices. It discusses how these technologies can provide real-time feedback, objective measures of progress, and engaging rehabilitation. The technologies discussed include the Balancemaster and Biodex Balance System for balance training, Neuromove and Lokomat for gait rehabilitation, and Armeo for arm rehabilitation. Evidence is presented showing that these technologies have been effective for conditions like stroke and concussions when used as part of a comprehensive rehabilitation program.
This document discusses motor rehabilitation after acute stroke. It notes that the majority of neurological recovery occurs within the first 3 months after stroke, but can continue for up to 1 year. Motor rehabilitation aims to reacquire lost movement skills through meaningful, repetitive, intensive, task-specific practice in an enriched environment. Current treatment methods discussed include constraint-induced movement therapy, treadmill training, robotic training, electrical stimulation, noninvasive brain stimulation, mirror therapy, and selective serotonin reuptake inhibitors.
This document provides an overview of interventions to improve balance in children with cerebral palsy. It defines cerebral palsy and discusses its causes, classifications, common impairments, diagnosis and prognosis. It then summarizes several studies on interventions for improving balance, gait, upper extremity function, muscle strength, and postural control in children with cerebral palsy, including stretching, electrical stimulation, virtual reality, treadmill training, mirror therapy, and balance training. The studies examined the effects of these interventions on outcomes like gross motor function, muscle strength, and balance.
Preoperative physical therapy in primary total knee arthroplastyFUAD HAZIME
This study evaluated the effects of preoperative physical therapy in patients undergoing primary total knee arthroplasty. 10 patients completed 6 weeks of physical therapy before surgery while 10 control patients did not receive preoperative therapy. Both groups were tested before and after surgery and compared. The study found that preoperative physical therapy resulted in modest gains in knee flexion strength but no difference in extension strength or other short-term outcomes like function, range of motion, or muscle size. Therefore, the study did not support the routine use of preoperative physical therapy for knee replacement surgery.
This document summarizes evidence on the use of manual therapy and manipulation in the treatment of shoulder impingement syndrome (SIS). Several randomized controlled trials have found that combining manual therapy/manipulation with exercise therapy leads to better outcomes in pain, strength, and function compared to exercise therapy alone. While more research is still needed, the existing evidence supports the use of manipulation as a component of comprehensive treatment for SIS. Manipulation appears to be a safe intervention when applied properly to appropriate patients by a skilled provider.
This study evaluated the effects of aquatic strength training and the anabolic steroid oxandrolone on patients with neuromuscular diseases. 33 patients participated in a study with 4 phases: 1) aquatic exercises, 2) oxandrolone supplementation, 3) aquatic exercises with oxandrolone, and 4) conventional physiotherapy without loading. Muscle strength, quality of life, and mood were assessed at various timepoints. The results showed increased muscle strength in the elbows and knees at different phases, suggesting that oxandrolone combined with aquatic exercises may increase muscle strength in patients with progressive neuromuscular disorders.
Does a standard outpatient physiotherapy regime improve the range of knee mot...FUAD HAZIME
This study investigated whether a standard outpatient physiotherapy regime improved range of knee motion after primary total knee arthroplasty (TKA). 150 patients were randomly assigned to either receive 6 weeks of outpatient physiotherapy after TKA (Group A) or no outpatient physiotherapy (Group B). Range of motion measurements found that while Group A achieved greater flexion than Group B, the difference was not statistically significant. The study concluded that outpatient physiotherapy does not improve range of knee motion after primary TKA.
Artigo - Acupuncture on oxygen consumptionRenato Almeida
1) Auricular acupuncture had a significant effect on improving the oxygen consumption and recovery ability of boxing athletes.
2) The study found that VO2max, a key indicator of cardiovascular endurance, was significantly higher after auricular acupuncture stimulation compared to a control group.
3) Auricular acupuncture stimulation may enhance athletic performance by improving aerobic ability as shown by increased VO2max and VEmax, and faster recovery of heart rate and body temperature after exercise.
Concussions are a growing concern, especially in young athletes. Common symptoms include headaches, dizziness, and memory issues. While rest is usually recommended, longer periods of inactivity do not necessarily lead to faster recovery. Physical therapy can help address lingering symptoms through manual therapy, soft tissue work, vestibular rehabilitation, education, and light aerobic exercise. Further research is still needed to better understand and treat concussions.
This document describes a cross-cutting approach to improve symptom relief and enhance recovery for those with neurological injuries or chronic diseases through targeted vibroacoustics and stimulating movement. It explores how the body responds to vibro-acoustic frequencies based on an understanding of the sensational, biochemical and neuro-rhythmic response inherent in the human senso-motoric system. The proposed therapy aims to make the body structure more stable, improve sensory awareness, maximize limited movement options, and make movement more predictable. It involves socially-facilitated ambient acoustics and applies the latest understandings of empathetic ritual response and neural repair research to rehabilitation strategies. The goal is to ultimately change processes for restoring and enhancing function for those
This document provides recommendations for implementing a multidisciplinary approach to managing Duchenne muscular dystrophy (DMD). It discusses:
1) Physical therapy interventions like stretching, bracing, and assistive devices to prevent contractures and maintain mobility.
2) Surgical options for contractures depending on the patient's ambulatory stage, including tendon lengthening and transfers.
3) Recommendations for exercise emphasizing submaximum aerobic activity and avoiding high resistance to prevent injury.
This study examined the effects of kinesio taping in addition to physical therapy on seated postural control in 30 children with spastic diplegic cerebral palsy between 10-16 months of age. The children were randomly assigned to a study group that received kinesio taping applied to paraspinal muscles in addition to physical therapy, or a control group that received only physical therapy. Both groups showed improvements in kyphotic angle, Cobb's angle, and GMFM seated scores after treatment, but the study group showed significantly greater improvements, suggesting kinesio taping is a beneficial addition to physical therapy for improving seated posture and trunk control in children with spastic diplegic cerebral palsy.
This document contains summaries of several research articles on various topics related to physiotherapy and physical therapy. The articles discuss the effects of home exercise programs for older adults, interval bicycling interventions for Parkinson's disease, exergaming and treadmill training for Parkinson's disease, predictors of walking speed after stroke, reliability of chest x-ray interpretation by physiotherapy students, effects of home rehabilitation on activities of daily living and gait for older adults with heart failure, a model for teaching ethical reflection in service learning, and several other topics related to physiotherapy treatments and interventions.
68 trends in neuropediatric physical therapy - publicadoNathanael Amparo
The document summarizes trends in physical therapy protocols for children with neuromotor deficits such as cerebral palsy. It describes intensive therapy programs using special suits with elastic cords that position the child's body correctly and allow them to perform activities. These programs, involving 3-4 hours of therapy per day for 4-5 weeks, have shown significant rehabilitation results. Objective assessment tools are also increasingly used to precisely plan and monitor treatment. While more research is still needed, intensive physical therapy protocols combined with special suits and functional assessments are becoming standard practice for rehabilitating children with neuromotor impairments.
Short-term effects of teriparatide versus placebo on bone biomarkers, structu...Ellen Almirol
This pilot study evaluated the effects of 8 weeks of teriparatide (TPTD) versus placebo treatment on bone biomarkers, structure, and stress fracture healing in premenopausal women with lower-extremity stress fractures. The study found that TPTD treatment led to greater increases in bone formation markers and a larger "anabolic window" compared to placebo. TPTD treatment also showed improvements in bone structure at weight-bearing sites on imaging. A higher percentage of stress fractures showed improvement or healing with TPTD versus placebo on MRI, though the results were not statistically significant. The study provides preliminary evidence that TPTD may help hasten stress fracture healing in premenopausal women.
To Study the Efficacy of Electromyographic Biofeedback Training on Dynamic Eq...IOSR Journals
Abstract: Cerebral palsy (CP) is caused by static lesion to a developing nervous system that primarily affects
motor function. Spastic motor involvement is characteristic of most of these individual.Dynamicequinus is a
common deformity that worsens the ambulatory ability of both diplegic and hemiplegic conditions. The use of
electromyographic (EMG) biofeedback has been suggested as a training tool to improve the ability to increase
activation of weak and partially paralyzed muscles and to decrease the activation of muscles affected by spasm
or spasticity without regard to specific diagnosis. However, very few studies have reported the effects of EMG
biofeedback on ankle function among children with spastic cerebral palsy .Objectives of the study was to
increase the activation of tibialis anterior and to improve the functional ambulation.40 subjects were made part
of the study on the basis of inclusion and exclusion criteria divided into two groups group A and B.Group A
received traditional physical therapy exercises and electromypgraphic biofeedback and group B received only
exercise program.The treatment duration was for 4weeks 3 sessions a week.The results were analysed using
statistical tests that were paired and unpaired t-test and mannwhitneytest.The results showed significant
improvement in the pre and post treatment.The conclusion of the study lended a favourable outlook to use
biofeedback training in treatment of CP children, to improve functional ambulation and gait. Keywords: Cerebral palsy, dynamic equinus deformity, gait, electromyography, biofeedback.
The document summarizes key studies on the effectiveness of conservative treatment for multidirectional instability (MDI). Three studies found that conservative treatment including strengthening exercises improved some outcomes like muscle activation patterns and kinematics, but did not fully restore shoulders to normal. One study found that after 8 years, only 30% of patients had good results with conservative treatment alone. Overall, the studies suggest that while conservative treatment can provide some benefits for MDI, surgery may be needed for full resolution of symptoms for many patients.
Neuroplasticity, also known as brain plasticity, is an umbrella term that describes lasting change to the brain throughout an animal's life course. The term gained prominence in the latter half of the 20th century, when new research showed many aspects of the brain remain changeable (or "plastic") even into adulthood.
Similar to Computer games and spinal injuries (20)
This document provides a recording sheet for occupational therapy sessions using the Nintendo Wii game console. The sheet collects a client's name, date of birth, address, community health index number, date of the session, games played, length of time spent on each game, and any comments from the therapist.
The document is an assessment form for evaluating a client's skills and abilities using the Wii gaming system. It contains sections to assess the client's motivation, communication skills, process skills, motor skills, and recommendations. The therapist would fill out the form by commenting on the client's performance in each area and indicate whether a Wii system would be beneficial.
The document discusses how the Wii video game console can be used by occupational therapists to assess various patient skills and abilities, including mobility, upper limb function, motor skills, balance, hand-eye coordination, general fitness, concentration, attention span, motivation, visual field, problem solving skills, confidence, and proprioception. It notes that the Wii provides opportunities to assess these areas and more during gameplay sessions with patients.
Occupational therapists used the Wii gaming console in group sessions with clients to provide exercise, improve motor skills, and encourage social interaction. They assessed clients and the environment for compatibility, identified goals and outcome measures, and conducted 8 weekly one-hour sessions with 3 clients each playing games tailored to their needs. Clients and carers completed questionnaires, and sessions were adapted based on ongoing evaluation showing benefits of embracing technology to aid rehabilitation.
Gamers can rapidly process visual information and develop finely tuned motor skills similar to musicians. Playing video games like Gears of War can improve visual skills and decision making speed. Surgeons who played Super Monkey Ball before surgery made fewer errors and were faster at tasks. Games like Guitar Hero can help develop timing, coordination, and motor skills comparable to musicians.
Nintendo's Wii video game console is being used in nursing homes to help residents with physical therapy and rehabilitation. The Wii Fit balance board and motion-sensitive remote allow residents to play games that improve strength, balance and range of motion. Studies have shown the Wii can help motivate elderly residents to more actively participate in their physical therapy.
Guitar Hero allows players to feel like skilled guitarists without years of practice by pressing buttons on a game controller timed to on-screen cues. While technically not playing real music, the game is popular with both musicians and non-musicians alike. However, some argue that Guitar Hero may discourage players from mastering the real guitar if virtual guitar skills can be acquired so easily. Developers counter that the game exposes more people to the thrill of guitar playing who would otherwise not have access or patience to learn a real instrument.
Virtual reality games and interactive video games are increasingly being used in healthcare to help patients. They can help reduce pain, manage chronic diseases, treat PTSD, and promote exercise and rehabilitation. Games like Re-Mission help educate cancer patients and motivate them to stick with their treatment. SnowWorld helps reduce burn patients' perceived pain during wound care by fully immersing them in a virtual winter world. Virtual reality is also being used to help soldiers with PTSD by gradually exposing them to simulated trauma.
Video games are being used in new ways to improve health. Some games focus on diabetes education and management by teaching players how to balance blood sugar levels and make healthy food choices. Researchers are also studying the potential for active video games to increase physical activity and reduce obesity. Overall, interactive video games may help motivate players to learn about their health conditions and make positive lifestyle changes.
This study examined the effect of a computer game intervention on the attention capacity of 60 mentally retarded male children. The children were randomly assigned to experimental and control groups. The experimental group participated in 35 computer game sessions over time, while the control group received no intervention. Attention was measured before and after the intervention using the Toulouse-Pieron attention scale. Results showed the experimental group had significantly higher attention scores immediately after the intervention compared to the control group. However, 5 weeks later there was no significant difference between the groups, suggesting the attention improvements did not persist over time for these children.
A 29-year-old medical resident awoke with intense pain in his right shoulder after spending several hours playing tennis on the Nintendo Wii video game system. A diagnosis of "Wiiitis" or inflammation of the tendons from overuse of the Wii controller was made. The patient was treated with ibuprofen and told to abstain from playing Wii games, and he recovered fully. Physicians should be aware of the risk of muscle injuries from intensive use of new gaming systems like the Wii.
2. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
B
alance of the human body re- proaches, however, is maintaining biofeedback were created. This in-
quires timely control of the po- people’s interest in performing re- teractive exercise tool has been ap-
sition and motion of the center petitive tasks and ensuring that they plied to standing balance.25,26 Betker
of body mass relative to the base of complete the treatment program. A et al25 administered a questionnaire
support. Maintaining balance in a lack of interest or a short attention to 15 subjects (7 with balance disor-
short-sitting position at rest; during span also can impair the potential ders and 8 without balance disor-
voluntary head, arm, and body move- effectiveness of therapeutic exer- ders) after they played a 10-minute
ments; and during transfers and cises. Conversely, the use of reward- session of each game. The results
wheelchair use (both indoors and ing activities has been shown to were encouraging. The subjects indi-
outdoors) involves many essential improve people’s motivation to prac- cated that the games were challeng-
sensory and motor processes. Feed- tice.7–11 Various approaches have ing and fun and would be a welcome
forward predictive controls, which been put forth to couple motivating addition to current treatment pro-
initiate preparatory postural adjust- experiences with rehabilitation exer- grams. Subsequently, Betker et al26
ments (goal-directed voluntary cises. Biofeedback, in which a bio- reported on the feasibility and bene-
movements), are required to main- logical signal is recorded and pre- fits of interactive standing balance
tain balance during these move- sented to people, has long been used exercises carried out with the COP-
ments and to anticipate potential fu- clinically to create and strengthen controlled video game system for 3
ture disturbances.1 Sensory feedback the awareness of a given task or people who had chronic neurologi-
processes are essential for respond- performance.12–16 cal deficits. The postexercise obser-
ing in a timely fashion to unexpected vations demonstrated that the peo-
disturbances or to correct for move- Novel and promising methods of ap- ple exhibited few falls, decreased
ment errors. plying biofeedback to rehabilitation COP excursion limits for some tasks,
are virtual reality and video and increased attention span during
Restoration and maintenance of in- games.17–22 In a study by Webster et training.
dependent dynamic short-sitting bal- al,23 a virtual environment was cre-
ance* are priorities for many people ated to help people with the control In our treatment program, COP-
who use wheelchairs because of a and mobility of their wheelchairs, controlled video game-based exer-
spinal cord lesion or an acquired or and participants had to navigate cises were used to attempt to im-
traumatic brain injury. As in standing through a virtual obstacle course. Af- prove dynamic short-sitting balance
posture, poor balance in a short- ter treatment, the participants exhib- in people with central nervous sys-
sitting position will increase the fear ited a decrease in wheelchair acci- tem injuries. We thought that the
of falling, fall risk, and mobility limi- dents and falls and showed better inclusion of motivational and func-
tations, creating greater patient de- performance on an actual obstacle tional gaming in rehabilitation and
pendency in basic and instrumental course compared with subjects who sports training might increase the
activities of daily living. Poor posture did not have training with the virtual people’s desire to perform their ex-
also can have an effect on a person’s course. Video games were used by ercises and therefore result in im-
self-confidence in dealing with other O’Connor et al24 in an attempt to proved dynamic balance control af-
people.2 In turn, these issues can increase the physiologic responses ter the exercises.
cause reduced levels of physical ac- of people using manual wheelchairs
tivity, participation in sports, and, and to examine their effects on the Case Descriptions
more generally, quality of life. motivation of the people to perform Patient Histories
their exercises. The GAMEWheels Three people consented to be
Evidence from human studies shows system interfaced commercial video treated and provided the following
that goal-oriented, task-specific train- games with rollers, allowing station- information.
ing improves function and that in- ary propulsion of the wheelchairs.
creased amounts of training produce The observations showed that 87% Patient 1 was a 26-year-old man with
better outcomes3–5 (for a complete of the subjects found that the games spina bifida (myelomeningocele) ex-
review, see Kwakkel6). One problem motivated them to perform their tending from T10 to L1–L2 and re-
with task-specific treatment ap- exercises. sulting in complete paraplegia and
poorly developed lower extremities.
On the basis of these ideas and re- At the time of initial assessment, he
* Defined as maintaining an upright position sults, 3 interactive video game-based demonstrated good static and dy-
of the torso while sitting on the buttocks or
thighs (or both), with the shank hanging over exercises that are controlled by use namic short-sitting balance and was
the sitting surface. of center-of-pressure (COP) signal independent with all transfers, activ-
1390 f Physical Therapy Volume 87 Number 10 October 2007
3. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
ities of daily living, and work. As a hands for support because of im- their weight back and forth; and in
person who participated in Paralym- paired balance and trunk control. As both modes together, players must
pic sports, he actively raced for a result (and because of his size), he shift their weight in all directions.
Team Canada and was actively train- had to be transferred with a Hoyer Thus, movement range and speed in
ing to improve dynamic balance con- lift. He used a powered wheelchair all or targeted directions are exer-
trol, an important requirement for for mobility indoors and outdoors. cised. Difficulty levels can be config-
high-speed wheelchair racing. He had no sensory loss, and his in- ured through the receptacle size, the
tellectual and memory functions also object speed, the number of objects,
Patient 2 was a 52-year-old man with were intact. However, he was easily and the option of multiple objects
complete paraplegia (T11-L1) and a distracted during most activities and appearing at specified intervals.
transfemoral amputation; these inju- therapy, requiring constant cuing
ries resulted from a motor vehicle and verbal commands to stay fo- In Memory Match (Fig. 1b), the goal
accident 10 months before recruit- cused on the task at hand. is to select 2 matching cards from a
ment into our treatment program. 3 3 or 4 4 array of squares.
After the accident, he received in- COP-Controlled Video Game players select a card (square)
patient rehabilitation for 6 months. Game– based Exercise Tool by shifting their weight to move the
At the time of initial assessment, be- The COP position signal has long on-screen COP indicator to 1 of the 9
fore the current treatment program, been used as an indicator of balance or 16 possible cards (squares). Once
he demonstrated complete motor performance.27–30 We developed the the COP is held still in a square for a
and sensory loss below the T11 level, COP-controlled video game-based duration selected by the player, the
demonstrated dependent short- exercise tool for use with the Force- card is revealed. The second card
sitting balance (he sat with a ky- Sensitive Applications (FSA) soft- then is selected in a similar manner;
photic posture with bilateral upper- ware† and pressure mat.† The COP if the cards match, they remain face
extremity support and was unable to position signal input is acquired via a up. This process is repeated until all
perform any functional activity with flexible pressure mat measuring of the card pairs are selected. Diffi-
the upper extremities in an unsup- 53 53 0.036 cm and containing culty levels can be configured
ported short-sitting position), and re- a 16 16 grid of piezoelectricity- through the number of seconds the
quired moderate assistance from resistive sensors spaced 2.8575 cm players have to select their cards and
one person for transfers. His primary apart (other mat sizes are available). the number of cards displayed (9 or
treatment goal was to regain inde- The flexibility of the pressure mat 16).
pendent short-sitting balance for re- permits games to be performed on
turn to office work. solid, fixed surfaces and allows pro- In Balloon Burst (Fig. 1c), a newly
gression to compliant surfaces, with created game, the goal is to “pop”
Patient 3 was a 41-year-old man who the FSA pressure mat being placed balloons. Stationary balloons appear
had had a severe traumatic brain in- between the patient and the surface. at random locations on the screen.
jury more than 5 years before the The position of the COP is calculated Game players must shift their weight
current treatment program. He had from the pressures produced by the in all directions in order to move the
received physical therapy interven- patient seated on the pressure mat. on-screen COP marker over the bal-
tion several times during those 5 This COP position signal then is loon to pop it. The difficulty level
years for trunk and lower-extremity mapped as an input to each of 3 can be configured through the size
motor control and balance re- different games (Under Pressure, of the balloon.
education. His upper-limb function Memory Match, and Balloon Burst),
was good bilaterally, but he had poor which are described below. In order to allow a customized and
trunk and lower-limb motor control graded protocol for each player, the
and high muscle tone (velocity- In Under Pressure (Fig. 1a), game interactive video game system of-
dependent resistance to stretch), players shift their weight to move a fered the following features. The ad-
which fluctuated from extensor tone receptacle in order to “catch” an ob- justable difficulty levels within the
to flexor tone, depending on his po- ject. The game comprises 3 modes: game software helped to ensure that
sitioning. He had a progressive in the horizontal mode, players must each player was competitive and
plantar-flexion contracture of the shift their weight side to side; in the could successfully play the video
right ankle secondary to spasticity vertical mode, players must shift games while exercising his full range
(hypertonity of the plantar flexors). and speed of voluntary movement.
He was unable to maintain short- †Vista Medical, 3–55 Henlow Bay, Winnipeg, This feature is important to prevent a
sitting balance without the use of his Manitoba, Canada R3Y 1G4. player from becoming frustrated and
October 2007 Volume 87 Number 10 Physical Therapy f 1391
4. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
Figure 1.
Screenshots of games. (a) Under Pressure during horizontal mode. The game player must move the flower under the bee. The total
number of bees, the number of bees caught, and mediolateral (ML) and anteroposterior (AP) movement ranges (in centimeters) are
displayed. (b) Memory Match. The game player must select cards in order to find the pairs. The number of pairs found and the ML
and AP movement ranges (in centimeters) are displayed. (c) Balloon Burst. The game player must move the cursor over the balloon
to pop it. The total number of balloons, the number of balloons popped, and the ML and AP movement ranges (in centimeters) are
displayed.
quickly losing interest. The game games increase your motivation to plane; the disturbance can be multi-
software allows the player’s move- perform your exercises? Were the directional.32 For the purpose of our
ment range to be determined dynam- video game-based exercises chal- treatment program, an air bladder
ically or manually and can be scaled, lenging? Did the difficulty levels of was used to distort and produce an
allowing even people who are se- the video games enhance the exer- unstable support surface, in a man-
verely disabled to play and be cises? and Do you prefer video ner similar to the compliant foam
competitive. game-based balance exercises to tra- pad used during standing. The air
ditional balance exercises? The re- bladder modified the surface reac-
Evaluations and Outcome sponse options were: “strongly dis- tion forces under the seat; thus, the
Measures agree,” “disagree,” “agree,” and surface could not completely recip-
Two different test protocols were “strongly agree.” rocate the normal forces beneath the
used to obtain quantitative out- seat as the center of body mass
come measurements: (1) a question- Dynamic balance assessment. In moved. The result was an increase
naire that was administered after the keeping with the Sensory Organiza- in the magnitude and frequency
exercises and (2) stability measure- tion Test concept, Shumway-Cook of involuntary (unpredictable) body
ments that were obtained during a and Horak31 devised a clinical tool sway. To prevent a loss of balance,
set of 6 tasks performed under 2 for testing the sensory component a fall, or both, an individual must be
conditions (before and after exer- of balance: the Clinical Test of Sen- able to sense and respond to this
cise). The 2 protocols are described sory Interaction and Balance. In the condition. This condition consti-
below. Clinical Test of Sensory Interaction tutes a demand on whole-body
and Balance, a compliant foam pad balance reactions, and continuous
Questionnaire. After exercise, a is used as an unstable support base automatic postural adjustments are
questionnaire that included the fol- to simulate the Sensory Organization required to maintain upright short-
lowing questions was administered: Test in terms of somatosensory dis- sitting balance and postural stability.
Were the video game-based exer- tortion, with an added advantage The degree of difficulty of the bal-
cises fun to play? Did the video that it is not limited to the pitch ance tasks could be adjusted by se-
1392 f Physical Therapy Volume 87 Number 10 October 2007
5. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
Table 1.
Task Descriptions
Task Description
1 Maintain erect short-sitting balance with eyes open and looking straight ahead, as part
of the CTSIB.a
2 Maintain erect short-sitting balance with eyes closed, as part of the CTSIB.
3 Perform rhythmic left and right horizontal head rotations to visual targets placed 120°
apart.
4 Perform a rhythmic arm lifting and lowering task while holding a 50-cm lightweight
wooden pole, 1.91 cm in diameter, with the hands kept shoulder width apart.
Raise the pole to eye level and then back down to the legs, keeping elbows
extended.
5 Perform rhythmic left and right horizontal trunk rotations to approximately 30° in
each direction.
6 Perform rhythmic forward trunk bending and extension to return to the upright
(erect) short-sitting position. The amplitude of trunk flexion should be
approximately 30°.
a
CTSIB Clinical Test of Sensory Interaction and Balance.
lecting different shapes and sizes The 4 movements (tasks 3– 6) were based exercises; the patients did not
for the air bladder, just as different paced by the beat of a metronome, receive any other balance training or
thicknesses and densities could be set to a frequency of 0.4 Hz. These physical therapy intervention during
selected for the foam pad used dur- movements were selected because the treatment period. The patients
ing standing. they represent important functional were transferred from their wheel-
activities of daily living and work. chairs to a low treatment plinth for
A SwisDisk‡ was used for patients 2 The metronome frequency was se- all treatments.
and 3, and a deflated (80%–90% of lected to represent relatively slow
the air removed) yellow Physio Gym- self-paced movement speeds. For all Patient 1 played Under Pressure in all
nic§ ball (a more difficult and unsta- 6 tasks and both surfaces (cushion modes only. Patient 2 played Under
ble surface) was used to challenge and air bladder), a fall was recorded Pressure 80% of the time, played
patient 1. Patients were transferred if the patients could not maintain in- Memory Match 19% of the time, and
from their wheelchairs to a low treat- dependent balance for 20 seconds or tried the new game, Balloon Burst,
ment plinth for all testing. To mini- if they could not perform the move- for the remaining 1% of the time.
mize any skin irritation during test- ments without holding on with their Patient 3 played Under Pressure 70%
ing (and treatment), the patients hands. A physical therapist was po- of the time and Memory Match for
were seated on their regular seat sitioned directly behind the patients the remainder of the time. The
cushions (foam-type cushions de- to provide assistance, if needed. games were played with the patients
signed to help distribute forces sitting on the treatment plinth and
evenly, away from bony promi- Intervention progressed (as appropriate) to sitting
nences, thus reducing the risk of ul- All treatments were performed at an on a deflated Physio Gynmic ball or
ceration). Each patient was in- outpatient physical therapy clinic SwisDisk; the FSA pressure mat was
structed to perform 6 tasks (Tab. 1), operated by the Division of Physical placed between the patient and the
each 20 seconds in duration, under 2 Therapy, School of Medical Rehabil- surface (Fig. 2). The ball or disk
different conditions: first while sit- itation, University of Manitoba; the added uncertainty to the system, as it
ting on their regular seat cushions program was designed partially for would randomly modify the surface
and then while sitting on the air blad- the clinical training of undergraduate reaction forces; for people with sen-
ders. Hand support was not permit- physical therapist students under su- sation, it would distort or delay the
ted for this test. pervision. Each patient attended pressure information from seat-to-
twelve 30- to 45-minute exercise ses- surface contact.
‡ PI Professional Therapy Products Inc, PO sions 2 or 3 times per week. The
Box 1067, Athens, TN 37371.
§
Ledraplastic Spa, Via Brigata Re 1, Osoppo, exercise regimen consisted solely of As improvements in game play
Udine, Italy 33010. our COP-controlled video game- scores were noted and as improve-
October 2007 Volume 87 Number 10 Physical Therapy f 1393
6. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
Figure 2.
System setup. The patient sits on the pressure mat (1), which is connected to the laptop by the interface box (2). The laptop currently
displays the game Balloon Burst. The pressure mat is currently placed on top of the SwisDisk (3); the Physio Gymnic (4) ball also is
depicted.
ments in balance and head-arm-trunk computer display. Initially, the movement. Alternately, very slow
control were observed, the treat- program was set so that a rela- speeds required the patients to
ment program progressed. In gen- tively small COP excursion pro- hold the COP position at the de-
eral, the minimum game play score duced a moderate to large game sired locations for longer periods
was set at 50% success—for exam- cursor movement. As game play of time. For example, when a lat-
ple, catching the object 50% of the scores improved and as balance eral or anterior trunk tilt was re-
time in Under Pressure. or trunk control improved, scal- quired to catch the object at a
ing was increased so that larger very slow target speed, the pa-
There were a number of game pa- and larger COP excursions were tient would have to hold the tilted
rameters and task conditions that required to move the game position for a few seconds. Game
could be adjusted and modified cursor. speed was adjusted, scaling was
when appropriate in order to permit adjusted, or both as game play
the treatment program to progress 2. The speed of the game targets scores improved and as balance
and to challenge the patients. These (objects) was adjusted. Initially, improved.
included the following 5 items: the speed was set to slow; this
setting permitted more time for 3. The exercise interval was in-
1. A scaling factor was used to map the patients to move and posi- creased by increasing the number
the magnitude of COP excursion tion the game cursor (COP) to of game targets, that is, the num-
(movement range) to the excur- catch the object. Increasing the ber of objects. Initially, the in-
sion of the game cursor on the game speed required faster COP terval duration was set to be-
1394 f Physical Therapy Volume 87 Number 10 October 2007
7. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
tween 15 and 30 seconds of Dynamic Balance Assessment recorded before exercise for patient
game play. As tolerated, this dura- The results of the dynamic balance 3. In addition, hand support was re-
tion was increased to 60 to 90 assessment are shown in Table 2. quired during all 6 tasks on both sur-
seconds in order to increase the faces (cushion and disk). After exer-
number of repetitions and to Before exercise, patient 1 main- cise, patient 3 was able to maintain
build endurance. tained independent short-sitting bal- independent short-sitting balance for
ance for the full 20 seconds during 20 seconds during all tasks on both
4. Reliance on hand support for bal- all 6 tasks when he sat on his regular surfaces.
ance progressed to less reliance, wheelchair cushion; in addition,
from using both hands to using short-sitting balance was maintained Discussion
one hand and then using no hand for the eyes-open, head rotation, and Here we report on the feasibility and
support. arm lifting tasks when he sat on the benefits of interactive COP-controlled
deflated Physio Gymnic ball. How- video game-based exercises for short-
5. Air bladders were used to intro- ever, for 3 other conditions, when sitting balance rehabilitation. Our ob-
duce a destabilizing compliant patient 1 sat on the deflated Physio servations demonstrate that improved
support surface. Once the pa- Gymnic ball, he clearly lost short- rehabilitative interventions, which in-
tients were able to play the games sitting balance, and therapist inter- corporate a functional approach to
without hand support, a compli- vention was required to prevent a training and graded balance condi-
ant support surface was intro- fall. After exercise, patient 1 main- tions or disturbances (ie, sensory feed-
duced. By changing the amount tained independent short-sitting bal- back and increased muscle activity),
of air in the Physio Gymnic ball or ance for the full 20 seconds during can produce substantial improve-
SwisDisk, an appropriate training all 6 tasks on both surfaces. ments in dynamic short-sitting bal-
level was achieved and progress ance. Complete spinal cord lesions
was made. For patients 2 and 3, For patient 2, 9 falls were recorded below T10, T11, or T12 will abolish
within 3 treatment sessions, air before exercise. Patient 2 was able to proprioceptive and cutaneous or
bladders were being used for the maintain independent short-sitting pressure sensation in the hip joints
entire treatment session. For pa- balance (without the use of his and in the pelvis structures and
tient 1, an air bladder was used hands for support) only while sitting thereby will reduce the available spa-
immediately, as this type of sup- on the wheelchair cushion in the tial information, which is needed to
port surface was required to chal- eyes-open, head rotation, and arm maintain short-sitting balance in the
lenge his balance control. lifting tasks. After exercise, patient 2 unsupported upright position. This ef-
was able to maintain independent fect is amplified without vision—that
Outcomes short-sitting balance for the full 20 is, in dark or low-light conditions—
Questionnaire seconds during all tasks on both sur- and during sitting on different compli-
The questionnaire results were very faces (cushion and disk). ant surfaces. Learning a new balance
positive, with all patients answering sense is an important objective during
“strongly agree” to all 5 questions. Before training with the COP- rehabilitation for people with com-
All of the patients indicated that they controlled video game-based system, plete thoracic spinal cord lesions and
enjoyed the video game-based tool, patient 3 typically would attend only traumatic brain injuries. Functionally,
preferring it over exercise programs to balance exercises for 20 to 30 sec- during game play, interactive move-
that they had performed in the past, onds at a time, with the training ses- ments are random, varying in direc-
and indicated that they would like to sions typically lasting for only 10 to tion, amplitude, and precision; thus,
continue the treatment. The adjust- 15 minutes. After practice with the during game play, people need to
able parameters and different modes COP-controlled video game-based make slow, maintained goal-directed
of the tool offered sufficient diffi- system, patient 3 was able to main- movements or quick shifts in the COP
culty levels; even patient 1, who par- tain concentration during the games trajectory. At moderate to high target
ticipated in Paralympic sports, found (balance exercises) for up to 2 to 3 (object) speed settings, these body
the games to be challenging. In ad- minutes at a time and would repeat movements require active mediolat-
dition, patient 2 particularly enjoyed this activity 10 to 15 times. The du- eral and anteroposterior weight
the new game, Balloon Burst, prefer- ration of the exercises increased shifts—for example, acceleration of
ring it over the other games. from short-interval training (approx- the center of mass toward the in-
imately 20 seconds for 10 –15 min- tended target, followed quickly by
utes) to 2-minute interval training for body deceleration to stop the
20 to 30 minutes. Twelve falls were movement.
October 2007 Volume 87 Number 10 Physical Therapy f 1395
8. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
Table 2.
Dynamic Balance Assessment Resultsa
Surface Task Result for:
Patient 1 Patient 2 Patient 3
Before After Before After Before After
Exercise Exercise Exercise Exercise Exercise Exercise
Cushion 1 — — — — Fall —
2 — — Fall — Fall —
3 — — — — Fall —
4 — — — — Fall —
5 — — Fall — Fall —
6 — — Fall — Fall —
Air bladder 1 — — Fall — Fall —
2 Fall — Fall — Fall —
3 — — Fall — Fall —
4 — — Fall — Fall —
5 Fall — Fall — Fall —
6 Fall — Fall — Fall —
a
Dashes indicate that no fall occurred.
The interactive gaming activities (ex- fects produced in the COP trajectory In future treatment programs, the
ercises) were designed around a flex- by different materials.33 questions used to quantify the level
ible pressure mat for COP recording. of motivation or fun during a partic-
This method allows training to be A main observation in this case re- ular therapy program will be neutral
conducted on compliant or uneven port was that the interactive gaming in order to not lead or bias an indi-
surfaces; that is, the mat may be intervention can motivate people vidual’s responses.
placed on top of a compliant or ir- with chronic spinal cord and trau-
regular surface rather than on a force matic brain injuries to practice dy- Another observation was that after
platform. The ability to apply a namic movement tasks. This ap- exercise, all patients exhibited de-
graded compliant support surface, proach was applied effectively to creased fall rates. In particular, after
along with the adjustable parameters people with severe balance and mo- exercise, patients 2 and 3 were able
of the tool, offers a variety of diffi- bility limitations and to an individual to maintain independent short-
culty levels. For example, a deflated who actively participated in sports. sitting balance while performing
Physio Gymnic ball was required to All 3 people indicated that they en- many demanding functional tasks.
challenge the balance of patient 1, joyed the video game-based tool, pre- This observation is consistent with
who is active in wheelchair racing ferring it to normal treatment regi- the observation that intense practice
and team sports. Similarly, a Swis- mens, and that they would like to of a motor task following a complete
Disk was used to increase the bal- continue the treatment. These obser- spinal cord lesion can result in sub-
ance requirements of the exercises vations showed that our COP- stantial functional improvements.
for patients 2 and 3. Thus, each game controlled video game system pro-
and session could be enhanced to vided a motivational and challenging During game play, voluntary move-
meet the needs and performance lev- environment. It has been shown that ments were generated in multiple
els of each patient. Such flexibility with the proper experiences and vol- directions and were varied in ampli-
can better prepare people to interact ume of practice, the spinal cord can tude and speed. The patients pro-
and deal with more dynamic envi- establish new neuronal associations duced accurate targeted movements,
ronmental conditions. Flexible pres- and demonstrate functional improve- were competitive at least 50% of the
sure mats permit accurate COP ments.34,35 One limitation of our time, and did not fall. It was evident
recording while eliminating the non- treatment program is the potentially that there was a temporary loss of
linear distortions and damping ef- biased language in the questionnaire. balance and unwanted movements
1396 f Physical Therapy Volume 87 Number 10 October 2007
9. Game-based Exercises for People With Chronic Spinal Cord and Traumatic Brain Injuries
(because of poor sensory control, be coupled effectively with video 2 Douglas J. Wheelchair exercises for fitness
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Heinemann Ltd; 1998.
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5 Richards CL, Malouin F, Bravo G, et al. The
thus movement speeds; the ability role of technology in task-oriented training
Like current biofeedback and virtual to select accuracy from small to large in persons with subacute stroke: a ran-
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ity: a holistic approach to rehabilitation.
cost-effective. Stud Health Technol Inform. 1999;
Further motivation might be 62:90 –93.
achieved through the development Ms Betker, Mr Desai, and Dr Szturm pro-
11 Tsang WW, Hui-Chan CW. Effects of exer-
cise on joint sense and balance in elderly
of a universal input device to allow vided concept/idea/project design and writ- men: Tai Chi versus golf. Med Sci Sports
the pressure mat to be used with ing. Mr Desai, Ms Nett, and Ms Kapadia Exerc. 2004;36:658 – 667.
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sai, and Ms Kapadia provided data analysis. Biofeedback therapy in stroke rehabilita-
ification will increase the selection tion: a review. J R Soc Med. 1997;
Ms Betker and Dr Szturm provided project
of games (an important factor in management and facilities/equipment. Ms
90:33–39.
keeping players motivated and inter- Nett and Dr Szturm provided patients. Dr 13 Dozza M, Chiari L, Chan B, et al. Influence
of a portable audio-biofeedback device on
ested) and eliminate the cost of hav- Szturm provided institutional liaisons. All au- structural properties of postural sway.
ing to program new games. Masked, thors provided consultation (including re- J Neuroengineering Rehabil. 2005;2:13.
randomized clinical trials also are re- view of manuscript before submission). 14 Geiger RA, Allen JB, O’Keefe J, Hicks RR.
Balance and mobility following stroke: ef-
quired to confirm these preliminary This work was funded by a Manitoba Health fects of physical therapy interventions
observations and to provide a com- Research Council Studentship and a Natural with and without biofeedback/forceplate
Sciences and Engineering Research Council training. Phys Ther. 2001;81:995–1005.
parison of the effects of this treat-
Fellowship. 15 Bourbonnais D, Bilodeau S, Lepage Y,
ment with the effects of other, con- et al. Effect of force-feedback treatments
ventional therapies in parallel groups This article was submitted August 10, 2006, in patients with chronic motor deficits af-
and was accepted May 23, 2007. ter a stroke. Am J Phys Med Rehabil.
of patients. 2002;81:890 – 897.
DOI: 10.2522/ptj.20060229 16 Yoo E-Y, Chung B-I. The effect of visual
Conclusions feedback plus mental practice on symmet-
rical weight-bearing training in people
Here we report on the benefits of with hemiparesis. Clin Rehabil. 2006;
our video game-based exercise regi- 20:388 –397.
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