New York Physical Therapy Association Research Programming Conference Proceedings 2013 Conference Albany, New York

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1 New York Physical Therapy Association Research Programming Conference Proceedings 2013 Conference Albany, New York Salant Award Winner The New York Chapter has long recognized the importance of research for the profession. In 1979 the Chapter renamed its research award as the Robert Salant Research Award in memory of Mr. Salant who along with his wife, Marilyn Moffat Salant, was a staunch supporter of physical therapy. Each year, the Robert S. Salant Research Awards are granted for the outstanding research and special interest presentations, which may be in platform or poster format. Each award includes $ to be shared by the authors. The criteria by which the award is judged include content, originality and independence of the work, style and clarity of the presentation and applicability to the physical therapy practice. Recipients of the Robert S. Salant Research Awards are designated by the banner above. Please consult for the criteria for Research Abstract submissions.

2 Platform Presentations Presenters Title Page Laura Z. Gras, PT, DPT, DSc, GCS Balance and gait deficits in adults with very mild Alzheimer s disease Kelly Piche, DPT and Andrea Nicosia, DPT Ruth L. Hansen, PT, DPT, CCS Is the level of physical activity in young children during physical education classes dependent on BMI? Physical therapist s practices in the education of stroke survivors on exercise and physical activity guidelines 2013 NYPTA Conference Proceedings (Albany, New York) 2

3 Salant Award Winner Balance and gait deficits in adults with very mild Alzheimer s disease Background & Purpose: The hallmark of Alzheimer s Disease (AD) is progressive cognitive dysfunction, however recent studies have revealed that mobility may be affected in those with moderate and severe AD. The purpose of this study was to determine if balance and gait deficits are present in those with very mild AD. Research Design: Observational. Research Methods: Subjects were 17 adults with a Clinical Dementia Rating of 0.5 indicating that they had very mild AD. Diagnosis was made by a board-certified neurologist specializing in AD. A group, sex- and agematched, of 17 adults free of neurological and orthopedic disorders served as a control group. All subjects were community-dwellers and independent in community ambulation. A battery of cognitive tests, including the Digit Span, Verbal Fluency, Trail Making, and Mini Mental Status Examination (MMSE) was administered. Mobility was measured with the Sharpened Romberg test with eyes open and closed, the Timed-Up-and Go (TUG), and 10 meter walks at comfortable and fast speeds. Gait was analyzed using an instrumented gait mat. Independent sample t-tests were used to examine group differences. Results: Subjects had an average age of yrs and yrs of education. There was no significant difference in age or years of education between groups. Those with very mild AD scored lower than the control group in most cognitive tests including the forward and backward digit spans, category fluency, trail making tests, and the MMSE (p s < 0.013). Subjects with AD had poorer balance than controls. In the Romberg eyes open test, controls balanced the full 60 s. Those with AD balanced for s (p=0.000). With eyes closed, controls balanced for s but those with AD only s (p = 0.002). Significant group differences were also found in the TUG (p = 0.000) with scores of s for controls and s for AD, comfortable gait speed (p = 0.008) with a speed of m/s for controls and m/s for AD, and stance time (p = 0.000) which was s for controls and s for AD. Those with AD also walked slower than controls on the gait mat (p = 0.000). Paired t-tests revealed that controls walked faster on the gait mat compared to their comfortable 10 meter walk speed, p = ( m/s versus m/s). The group with AD walked slower on the gait mat ( m/s) compared to their comfortable 10-meter walk speed ( m/s), p = There were no group differences in the 10 meter fast gait speed ( m/s for controls, m/s for AD) or in step length ( m for controls, for AD). Conclusion: Balance and gait deficits may be present in those with AD, even in the early stages of the disease when cognitive impairments are minimal and people are functioning in the community. More research is needed to determine if navigating a novel surface alters the gait of those with AD. Relevance to Physical Therapy: Adults with very mild AD may be candidates for physical therapy interventions targeted at balance and gait NYPTA Conference Proceedings (Albany, New York) 3

4 Is the level of physical activity in young children during physical education classes dependent on BMI? Background & Purpose: Childhood obesity is considered a serious health threat globally. Over the past 30 years, childhood obesity in the U.S. has quadrupled in prevalence. Children who are overweight (OW) and obese (OB) are increasingly diagnosed with musculoskeletal disorders, type 2 diabetes, cardiopulmonary conditions, and several psychosocial disorders. Physical activity (PA) is deemed a key component in preventing obesity and the associated health complications. Determining whether children receive the recommended amount of PA is critical. There has been limited work on assessing PA in children 9 years of age during physical education classes. The primary purpose of this study was to evaluate the differences in PA of young children, who were classified as non-overweight (NW), OW, and OB, during physical education classes. Research Design: Cross-sectional design Research Methods: Eighty-two children (7.5 ± 1.2 yr) from kindergarten through 3 rd grade participated in the study. PA was measured using pedometers during at least 10 physical education classes for each participant. Body mass index (BMI) was calculated. Based on international BMI cut-off points, participants were classified into the following groups: NW (n = 45; 7.6 ± 1.2 yr), OW (n = 12; 7.5 ± 1.1 yr), and OB (n = 25; 7.5 ± 1.3 yr). Levels of PA were compared among the 3 groups using a one-way ANOVA. Additionally, for each grade level, differences in levels of PA were compared between the NW and combined OW/OB groups using independent t- tests. Pearson correlation was used to determine the association between PA and BMI of the entire sample. SPSS 20.0 was used to perform data analyses. The alpha level was set a priori at P < Results: The one-way ANOVA and post hoc analyses showed that for the entire sample of children, there were significant differences in the average number of steps taken between the NW and OW groups (NW group: ± steps, OW group: ± steps; P =.026), as well as the NW and OB groups (OB group: ± steps; P =.03). Independent t-tests revealed significant differences in step counts between the NW and combined OW/OB groups for 2 nd grade (P =.044), but not for kindergarten, 1st grade, or 3 rd grade. Pearson correlation revealed a low, negative relationship between PA and BMI for the entire sample (r = -.326, P =.003). Conclusion: Our findings suggest that differences existed in the average number of steps taken during physical education classes in young children dependent on their BMI status. There was a significant, yet low and negative relationship between PA during physical education classes and BMI. Relevance to Physical Therapy: The increasing prevalence of obesity in children leads to more comorbidities that affect the delivery of physical therapy services to this population. These results indicate that a child s activity level may be related to BMI status. This should be considered when establishing appropriate activities to engage students from all BMI categories to promote improved health and wellness and prevent childhood obesity NYPTA Conference Proceedings (Albany, New York) 4

5 Physical therapist s practices in the education of stroke survivors on exercise and physical activity guidelines Background and Purpose: Patients who have had a stroke are at risk for development of cardiac disease. Physical therapists (PTs) have the responsibility to educate these patients on risk factor modification for cardiac disease. However, there have been no studies examining practice patterns for cardiac education in the stroke population. The purpose of this study was to survey PTs to determine practice patterns in this area. With the greater emphasis on screening, prevention and wellness in Doctoral of Physical Therapy programs (DPT) it was hypothesized that PT degree and years in practice would affect practice patterns for cardiac education in the stroke population. Research Design: The study used a non-experimental, retrospective cross-sectional design utilizing a survey. Research Methods: The survey consisted of 17 questions consisting of demographics, questions relating to: general cardiac education patterns, preventative role of exercise in cardiac disease and exercise guideline education. The survey was validated for face validity by conducting a pilot study on 36 New York State (NYS) PTs with appropriate modifications performed based on feedback. Content and construct validity were determined by a group of physical therapists specializing in either cardiac (n=4) or neurological (n=4) PTs. Appropriate modifications were made based on their feedback. All experts agreed that the survey had adequate content and construct validity. The participants of the present study were incidentally selected from listings and ground mail addresses obtained from The New York Physical Therapy Association (NYPTA) website. A total of 1600 surveys were sent (1435 by and 165 by ground mail). A total of 166 validated/completed surveys were utilized for a response rate of 10.3%. Frequencies were utilized to describe the data ANOVA was utilized to determine practice pattern differences for type of PT degree and for years of practice. Alpha was set at p<0.05. Results: The mean years practicing as a PT was Time spent working with patients with stroke: mean = ± years. 6% of the PTs had certificates, 49% had Bachelors, 34% had Masters and 11% had DPT degrees. 17% of the PTs never counsel their patient on CV risk, 20% counsel between 1 and 25%, 13 % counsel between 20 and 50%, 11% counsel between 51 and 75% and 28% counsel between 76 and 100% of their patients. 4% of the PTs never educate their patients on proper exercise, 19% spend 1-5% of treatment time, 22% between 6 and 1-%, 13% between 11 and 20%, 14% between 21 and 30% and 13% >30% of their time education stroke patients on exercise. Degree was not significantly associated with percentage of treatment time spend educating stroke survivors on cardiac risk reduction (f(6)=0.299; p=0.826) role of exercise for risk reduction (f(6)=0.778; p=0.508) and safety of exercise (f(6)=0.500 p=0.683). Years of practice was not significantly associated with percentage of treatment time spend educating stroke survivors on cardiac risk reduction (f(3)=1.432; p=0.207) role of exercise for risk reduction (f(3)=0.353; p=0.907) and safety of exercise (f(3)=1.056; p=0.392).. Conclusions: The majority of the PTs responding to the survey reported counseling less than 50% of their patient on risk of CV disease. Additionally, only a small amount of time was spent in patient CV risk education. Neither the physical therapy degree level nor the PT s years of experience treating stroke survivors affected how many clients were counseled regarding stroke and increased risk of CV disease, the role of endurance exercise in cardiac and health risk reduction, and with client/family education pertaining to safe performance of an endurance exercise program for fitness, wellness and prevention. Limitations: The limitations of this study are the low response rate, limited external validity as all PTs were from NYS, and possible response bias as those answering may not be representative of the entire sample. Relevance to Physical Therapy: Based on the results of this study, time educating stroke survivors on cardiac risk and the role of exercise in cardiac risk reduction is not a priority among practicing physical therapists. However, this population is at increased risk for cardiac events and PT s should take a more active role in educating this population on primary and secondary prevention. Additionally, given these findings, this concept should be emphasized in PT educational programs NYPTA Conference Proceedings (Albany, New York) 5

6 Poster Presentations Presenter Title Page Wayne Croyle, PT, DPT Tara Dawn Bach- Martinez, PT, DPT; Claudia B. Fenderson, PT, EdD, PCS, Marc Campo, PT, PhD The Effects of Orthotic Shoe Inserts on Balance Parameters in Asymptomatic Adults: A Pilot Study Teresa M. Ingenito PT, MS, DPT; Peter Douris, PT, DPT, EdD Laura Gras, PT, PhD Gabriele Moriello, PT, PhD Neeti Pathare, PT, PhD Chronic Stretching Improves Arterial Compliance in Middle Aged Adults Improving Balance by Education, Walking and the Wii Comparison of Forward Versus Backward Walking Using Body Weight Supported Treadmill Training in Someone with a Spinal Cord Injury: A Single Subject Design 2013 NYPTA Conference Proceedings (Albany, New York) 6

7 The Effects of Orthotic Shoe Inserts on Balance Parameters in Asymptomatic Adults: A Pilot Study Background & Purpose: To date, there is a scarcity of literature investigating the effects of custommolded and prefabricated shoe inserts on postural steadiness in healthy asymptomatic adults using the Balance Master. The aim of this pilot study was to examine whether orthotic shoe inserts have an effect on balance parameters in healthy asymptomatic adults using the Balance Master s Limits of Stability (LOS) and modified Clinical Test of Sensory Integration on Balance (mctsib). Research Design: The design was an experimental, prospective, randomized, single factor, repeated measures within subjects design. Research Methods: Eight healthy asymptomatic shoe insert users aged years of age were obtained using incidental sampling; mean age The study was approved by the Mercy College IRB. Balance parameters were assessed for each participant on a single occasion using the Basic Balance Master under three randomized conditions: barefoot, shoes alone, and orthotic inserts with shoes. The primary outcome measure was balance assessed with the Balance Master s modified Clinical Test of Sensory Interaction on Balance and Limits of Stability tests. Results: To examine if orthotic shoe inserts affect balance parameters, an ANOVA for repeated measures was conducted, using SPSS version 19.0 to determine the mean differences between foot conditions for each participant. Alpha level (p-value) was set at < If p-value was < 0.05 a paired sample t test was performed to determine which foot conditions were significantly different from each other. There was no significant difference found between barefoot, shoes alone and shoes with orthotic inserts conditions for composite postural sway velocity, reaction time, maximum excursion, and endpoint excursion. For directional control, a significant difference was found (p =.01). Participants demonstrated a decrease in directional control while wearing shoes with orthotic inserts compared to shoes alone and barefoot conditions. Conclusion: Orthotic shoe inserts compared to barefoot and shoes alone foot conditions, significantly decreased directional control and had no significant effect on postural sway. Results are contrary to Mattacolla et al and other studies reporting a decrease in postural sway with the use of orthotic shoe inserts in healthy asymptomatic adults when compared to shoes alone. The findings are in agreement with Hertel et al and other studies who reported orthotic shoe inserts show no significant difference in postural sway in healthy adults compared to shoes alone. There are no studies at this time that report the effects of orthotic shoe inserts on directional control. Relevance to Physical Therapy: Despite the results suggesting that orthotic shoe inserts may have a negative effect on balance parameters in healthy adults, this cannot be applied to clinical practice due to the limitations of this study. However, physical therapists should be mindful of the implications that shoe inserts may have on the balance of their patients NYPTA Conference Proceedings (Albany, New York) 7

8 Chronic Stretching Improves Arterial Compliance in Middle Aged Adults Background and Purpose: Arterial compliance decreases with age and is related to an increased risk of coronary artery disease. Poor trunk flexibility has been shown to be associated with decreased arterial compliance in middle-aged subjects. The purpose of our research study was to measure arterial compliance and flexibility in healthy middle-aged martial artists compared to age-and sex- matched healthy sedentary controls. Research Design and Methods: Twenty healthy volunteers, 10 martial artists (54.0 ± 2.0 years), who practice Soo Bahk Do (SBD), a Korean martial art, and 10 sedentary subjects (54.7 ± 1.8 years) took part in this cross-sectional study. The practice of SBD as with most martial arts includes a great deal of stretching exercises and movements requiring total body flexibility. The martial art practitioners in the present study were all regularly practicing black belts with an average experience of approximately twenty years in SBD. Arterial compliance was assessed in all subjects using pulse wave velocity, a recognized index of arterial compliance. Flexibility of the trunk and hamstring were also measured. The independent variables were the martial artists and matched sedentary controls. The dependent variables were pulse wave velocity and flexibility. Significant differences between the groups for the dependent variables were assessed by a multivariate analysis of variance (MANOVA). Results: The MANOVA was statistically significant (p= 0.001). This allowed us to perform comparisons utilizing univariate analysis between the dependent variables. There were significant differences, between the SBD practitioners and sedentary controls, in pulse wave velocity (p= 0.004), in trunk flexibility (p= 0.002), and in hamstring length (p= 0.003). Conclusion: The middle-aged martial artists were more flexible in their trunk and hamstrings and had greater arterial compliance compared to the healthy sedentary controls. The flexibility component of martial art training or flexibility exercises in general may be considered as a possible intervention to reduce the effects of aging on arterial compliance. Relevance to Physical Therapy: Therapeutic exercise and hands on physical therapy techniques to increase patients flexibility is common practice in Physical Therapy. Age-related changes in arterial compliance may correspond to age-related changes in musculotendinous flexibility. Maintaining overall flexibility of the musculotendinous units and joint structures may also contribute to maintaining the compliance of the vascular system. The connective tissue of the musculotendinous units and vascular system may respond to the mechanical stress of stretching in a similar manner. Our results indicate that flexibility training should be considered as a benefit and integral part of a comprehensive exercise program to modify a patient s risk for age related decreases in arterial compliance and decrease the risk of cardiovascular disease NYPTA Conference Proceedings (Albany, New York) 8

9 Improving Balance by Education, Walking and the Wii Background and Purpose: Fall related injuries are the leading cause of death due to injuries in Americans over age 65. Falls are linked to impaired balance and impaired gait. Multi-factorial fall intervention programs have been noted as the most effective fall prevention strategy for this population. The purpose of this research is to determine whether balance education, walking and Wii bowling improve balance confidence and reduce the risk of falls in older adults. Research Design: This was a quasi-experimental pretest-posttest experiment with 17 participants, sixty-five years and older, who were recruited from a senior center (3 subjects) and retirement community (14 subjects) in Troy, NY. Research Methods: The program included education on fall prevention, a walking program, and Wii bowling. Each session consisted of 20 minutes of walking, 20 minutes of balance education and 20 minutes of Wii bowling twice a week for eight weeks. Pretest, posttest and a follow-up consisted of the Berg Balance Scale, the Timed Up & Go, and the Activities-specific Balance Confidence Scale as well as verbal report if the subject had fallen. The Wilcoxon signed-rank test was used to examine statistical significance and the minimal detectable change score for each measure was used to examine clinical relevance. Results: The results were statistically significant for all outcome measures from pre-test to post-test. Statistical significance and clinical relevance was seen for the Berg Balance Scale (p=.000; mean change score=5.941) and the Timed Up & Go (p=.019; mean change score=2.491sec) but not for the Activities-Specific Balance Confidence Scale (p=.463; mean change score=2.872). There were no reported falls at follow-up. Conclusions: Subjects went from below to above the cut-off score of 45/56 for fall risk on the Berg Balance Scale (mean= 41.59/56 to 47.53/56) and below the cut off score of 14 seconds for fall risk on the Timed Up & Go (mean=14.07sec to 11.58sec) due to the intervention. The subjects balance confidence did not change, but the scores were higher than the cut-off for fall risk of 67% (mean score at post-test was 74.87%). A multifactorial balance program including education, walking and Wii bowling may be an effective intervention to improve balance and decrease fall risk for older adults. Relevance to Physical Therapy: Physical therapists can use education, walking and Wii bowling in their balance programs as an intervention for older adults who are at a risk for falls NYPTA Conference Proceedings (Albany, New York) 9

10 Salant Award Winner Comparison of Forward Versus Backward Walking Using Body Weight Supported Treadmill Training in Someone with a Spinal Cord Injury: A Single Subject Design BACKGROUND & PURPOSE: Body weight supported treadmill training (BWSTT) is a task-specific rehabilitation strategy that enhances functional locomotion. There is research to support the use of forward walking BWSTT to improve gait parameters in individuals with SCI. It has been suggested that incorporation of backward walking can further improve gait patterns as well as provide cardiovascular benefits. However, there is no research evaluating the effect of backward walking BWSTT in those with SCI. The purpose of this single subject design was to examine the differences between forward and backward walking on gait parameters, function, and cardiovascular measures in an individual with SCI using BWSTT. RESEARCH DESIGN: An ABABAB single subject experimental design was utilized. RESEARCH METHODS: The participant was a 57 year-old male presenting with a C3-C6 ASIA D injury in a central cord pattern. He received BWSTT two times per week with each phase lasting 3 weeks. Each A phase consisted of an intense program of backward walking on the treadmill while each B phase involved forward walking on the treadmill. Each individual session consisted of 3 bouts of treadmill walking; 2 bouts were designed for speed and 1 for distance. Outcome measures were conducted every session and included stride length, single support time and gait velocity as measured by the GAITRite portable walkway system, a timed 4 meter walk, the 5-repetition sit-to-stand test (STST), tandem stance time, 6 minute walk test (6MWT), post 6MWT heart rate, and post 6MWT blood pressure. All outcome measures were analyzed using visual analysis and split middle method analysis. Consistent changes in trend line results in all 3 sets of data were used to determine if there were any differences between the two interventions. RESULTS: Split middle method analysis demonstrated that backward walking training was more effective than forward walking training in all 3 sets at improving lower extremity function as measured by the 5- repetition STST. There were no differences between forward and backward training on any of the other parameters when comparing all three data sets. However, the following measures favored backward walking for the last 2 data sets: stride length bilaterally, single support time for the right limb, and 6MWT. CONCLUSION: These findings suggest that the addition of backward walking using BWSTT to rehabilitation sessions of an individual who had an incomplete SCI improved the 5-repetition STST to a greater extent with backward walking. The increased effort required by the extensor muscles during backward walking training could possibly translate into increased stability and efficiency of musculature used to complete sit to stand transfers. RELEVANCE TO PHYSICAL THERAPY: This study is the first of its kind to provide data comparing outcomes during forward and backward walking training using BWSTT in an individual with SCI. The results of this study suggest that therapists might consider the addition of backward walking to improve performance in sit to stand transfers in individuals with SCI NYPTA Conference Proceedings (Albany, New York) 10