CPS II Presentation Alyssa Campbell
Purpose • To investigate the relationship between a given intervention and patient outcome using the best evidence available
Demographics and Patient Diagnosis • Patient was a 56 year old African American female • Initially admitted to outside hospital for embolization of L subclavian artery and thoracic aortic aneurysm via L brachial artery approach • Patient presented to outside hospital ICU with facial droop and L sided weakness and diagnosed with acute CVA (location of stroke occurrence unknown)
Patient Information from Current Visit • Patient re-admitted to hospital approximately one month following CVA (from inpatient rehab) with lower GI bleed and colonoscopy performed
Past Medical History • Anemia, aneurysm, anxiety disorder, aortic valve defect, arthritis of R knee, coronary artery disease, cancer of R breast, chronic kidney disease, heart murmur, hypertension, and depression • Surgical History: aortic valve replacement, breast biopsy (2012), colonoscopy (2014), coronary stent placement (2014), heart catheterization, and hysterectomy (2014)
Social History • Lives in a one story private residence with fiancé and 27 year old son • Has 2 steps to enter home with bilateral hand rails available • Only DME available is a blood pressure cuff • Was independent in functional mobility prior to initial admittance
PT Exam and Eval Findings • Orientation- alert and oriented x4, able to follow commands • Skin Integrity- skin intact • ROM- AROM and PROM generally decreased but functional • Strength- generally decreased with at least 3+/5 on R side and 2/5 on L side (no synergy patterns noted) • Sensation- Intact to light touch • Coordination- generally decreased but functional • Bed mobility- rolling with modA to R side and minA to L, supine to sit with modA and use of UEs, sit to supine with modA x2, and scooting with maxA • Balance- static sitting balance fair with us of RUE to maintain and dynamic sitting balance poor at this time
Vital Signs • Taken at start of session and remained stable throughout • BP: 136/52 • HR: 70 • Respiratory Rate: 28 • SpO2: 100% • Pain: 4/10 with pain mainly located in buttocks • Patient Height and Weight: 5’6” and 176 lbs • BMI of 28 kg/m2
Prognosis • Strong family support available • Deficits in several areas (ROM, strength, balance, endurance, functional mobility) • Complicated medical history • Overall, fair prognosis for this patient
Patient Goals • 1) Patient will perform a supine to sit transfer with minA in 7 days • 2) Patient will transfer from bed to chair with maxA in 7 days • 3) Patient will perform sit to stand transfer with modA x2 in 7 days • 4) Patient will sit unsupported for two minutes with minA to maintain balance for dynamic tasks in 7 days • 5) Patient will maintain midline EOB sitting for 2 minutes with only verbal cues in 7 days
PT Interventions • Bed mobility- rolling to both sides, supine to sit transfers • Sitting balance- provided cuing to avoid posterior lean, modA-minA needed to maintain • Dynamic sitting balance- reaching for objects outside BOS and across midline, poor to fair • Trunk rotations- performed to L side with modA to maintain sitting balance, attempted weight-bearing on L side but unable at this time due to pain • Posterior leans- leaned patient posteriorly and asked patient to pull self forward using trunk musculature, maxA needed • Bridging- patient able to contract trunk musculature but unable to clear self off bed
Outcomes of Treatment • Patient demonstrated small gains in functional mobility, strength, and balance following treatment sessions • This was evidenced by improvements in bed mobility, transfers, static sitting balance, and dynamic sitting balance
Clinical Intervention Question • In my 56 year old female patient with a history of a recent stroke, does trunk training exercises improve balance and increase functional recovery?
Article #1
Purpose • Following a stroke, patients can experience difficulties with trunk performance, including impairments of selective muscle activation, inter-segmental coordination, and functional trunk performance. These impairments can decrease balance, gait, and function (Verheyden et al., 2007). • This review wanted to assess how adding trunk exercises to a treatment program affects functional outcomes in stroke patients.
Methods • Completed a systematic review of articles published until July 2012 that evaluated the effect of trunk exercises on functional outcomes in stroke patients. • They searched 7 different databases using the search terms stroke, stroke patient, trunk exercise, truncal exercise, sitting balance, dynamic reaching, trunk control, ADLs, balance, and function. • They summarized the collective data using mean differences or standardized mean differences with 95% confidence intervals.
Inclusion Criteria • Inclusion Criteria: • RCT published in English • Involving adult survivors of ischemic or hemorrhagic stroke (within first three months following the stroke) • Include specific trunk exercises in lying and sitting or other specific interventions (sitting balance, weight shifts in sitting, arm reaching in sitting) in addition to conventional rehab program • Included a control group of conventional rehab • Used at least one valid outcome measure
Results • Six RCTs were included in the study with 155 participants and a mean PEDro score of 6.5 (ranged from 6-8) • Found a moderate (SMD=.5) but not statistically significant effect of additional trunk exercises on trunk performance (P=.19) • Found large effects (SMD=.72) on standing balance (P=.05) • Large effect (SMD=.81) was also found on walking ability (P=.002) • However, there was a small that was not statistically significant on functional independence (P=.44)
Conclusion • There is evidence that the addition of trunk exercises to a treatment program significantly improves standing balance and walking ability in stroke patients • However, the evidence did not support an effect of trunk exercises on functional independence
Strengths • Large effects found for balance and walking ability despite differences in trunk exercises used in experimental groups and outcome measures reported • Average PEDro score of 6.5 (all studies scored either 6 or 7)
Limitations • Relatively small sample size (155 patients across all studies) • One study included was at high risk of bias (due to lack of accessor blinding) • Dosage had high variability (5 hours to 20 hours)
Clinical Implications (Relating Back to Patient Case) • Patient experienced several of the expected impairments that occur with stroke (decreased strength, balance, trunk function, coordination, ect.) • Patient met the inclusion criteria for this study (adult, within first three months of stroke, participated in specific trunk exercises during treatment) • Performed many of the same exercises used in the included studies (sitting balance, weight shifts in sitting, reaching outside BOS, trunk rotations, trunk flexion/extension) • Studies showed significant improvements in standing balance and walking ability (patient eventually hopes to get close to PLOF where she was independent in functional mobility) • Therefore, including trunk exercises in the patient treatment program can be beneficial in several ways
Article #2
Purpose • It has been asserted that trunk function can help predict functional outcomes of patients at discharge (Duerte et al., 2002) • Sitting balance is crucial to functional tasks such as reaching and sit to stand transfers (Feigin et al., 1996) • This study looked to assess the available literature to see if trunk training exercises can improve trunk performance and sitting balance in stroke patients
Methods • Searched 12 different databases for RCTs assessing trunk training exercises in stroke survivors • “TTE was pragmatically defined as exercise training on trunk, performed in sitting or supine, specifically aimed at improving trunk performance and functional sitting balance under the supervision of a physiotherapist” • Primary outcomes used were trunk performance and sitting balance • Secondary outcomes were standing balance and walking ability
Inclusion Criteria • Inclusion Criteria: • Had to be a RCT • Studies involving adult patients suffering from sub- acute (0-3 months) or chronic (>3 months) strokes • Patients had to have the ability to follow instructions • Had to assess trunk training exercises on either a stable or unstable surface • Compared to a control group • Needed to use an outcome measure that was valid to assess the primary or secondary outcomes the study was addressing
Exclusion Criteria • Exclusion Criteria: • Patients with neurological diseases affecting balance • Patients with orthopedic problems impacting their ability to sit • Patients with visual impairments affecting their ability to pick up objects • Trunk training exercise programs that used electromechanical devices • Studies with bias due to not being randomized
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