The Role of Physical Therapy in Multiple Risk Factor Management Poststroke: A Scoping Review.

BACKGROUND AND PURPOSE: Individuals after stroke often have multiple chronic conditions, such as hypertension, diabetes, dyslipidemia, obesity, and tobacco use. These comorbidities not only are commonly found in individuals with stroke, but also negatively affect functional outcomes and increase risk for hospital readmission and overall mortality. It is important for physical therapists to address the whole person during treatment after stroke, including comorbidities, not just the problems resulting from the stroke itself. However, it is unclear how common it is for physical therapists to address multiple diagnoses at once using a wellness model. Therefore, the purpose of this scoping review was to examine current evidence regarding the role of physical therapy in addressing modifiable risk factors for individuals after stroke, to identify gaps in research associated with physical therapy management of related comorbid diagnoses during treatment for stroke. METHODS: A scoping review methodology was utilized searching PubMed and CINAHL databases to identify interventional research studies specifically addressing multiple modifiable risk factors utilizing physical therapy for individuals after stroke. RESULTS: The initial search yielded 5358 articles and 12 articles met full inclusion criteria. Only 2 studies included participants with significant mobility impairments, and none included individuals with communication impairments. Only 4 of the 12 studies provided education in their design. Eight studies did not include any patient-reported outcome measures. Only 3 studies included long-term follow-up assessments. DISCUSSION: Secondary stroke risk factors can be positively addressed using physical therapy interventions; however, more research is needed regarding individuals with moderate to severe mobility or communication deficits. Opportunities for physical therapy research to address stroke risk factors in this complex population include expanding follow-up periods, improving educational interventions, and including caregivers in study design. CONCLUSIONS: This review highlights the need for better integration of clinical considerations into stroke rehabilitation research as a whole, along with the need for additional research regarding the role physical therapy can play in addressing multimorbidity in individuals with stroke.

Orthopaedic Nurses' Perceptions of Preoperative Education for Total Knee Replacement.

BACKGROUND: Limited descriptions of preoperative education programs for total knee replacement (TKR) surgery are provided in the literature, and the most effective program design is currently unknown. PURPOSE: The purpose of this qualitative study is to describe orthopaedic nurses' perceptions of preoperative education prior to TKR surgery. METHODS: Ten participants completed phone interviews and transcripts were analyzed qualitatively for themes among participants. RESULTS: Participants believed that preoperative education was a significant component impacting patient outcomes following surgery. Interprofessional preoperative education was valued, but pragmatic factors were identified as barriers to the inclusion of other disciplines within these programs. Education programs were constantly evolving on the basis of evidence-based practice and changes to orthopaedic protocols. Pragmatic factors influenced all aspects of program design, such as the timing and length of education sessions. CONCLUSIONS: Results from this study provide descriptions of factors that influence program design and can be used to restructure education programs for improved patient outcomes.

Preoperative Education for Total Knee Replacement: A National Survey of Orthopaedic Nurses.

BACKGROUND: Preoperative education aids in reducing the incidence of poor outcomes after total knee replacement (TKR) and increasing patient readiness for discharge home but is not well described in the literature. PURPOSE: The purpose of the study is to describe the current design of preoperative education for TKR across the United States. METHODS: A large, national sample of orthopaedic nurses completed an online survey to describe preoperative education at their facilities. RESULTS: Most participants provided preoperative education as part of interprofessional teams in either a group format or combined group and individual education. Verbal instruction was the most common educational delivery method, followed by written instruction. Education typically lasted between 1 and 1.5 hours, was delivered in a single session, and included a variety of topics. CONCLUSION: Results of this study describe preoperative educational practices and can support future research to improve patient outcomes following TKR surgery.

The Prevalence of Multiple Comorbidities in Stroke Survivors in Rural Appalachia and the Clinical Care Implications.

BACKGROUND: The majority of studies on multimorbidity have been in aging populations and there is a paucity of data on individuals following stroke. OBJECTIVE: In order to better understand the overall complexity of the stroke population in rural Kentucky, we examined the prevalence of multimorbidity that impact the overall long-term health and health care for these individuals. METHODS: A secondary analysis examined whether there are gender or age differences in this stroke population related to the prevalence of multimorbidity. A total of 5325 individuals, 18 years of age and older, seen at an academic medical center for the primary diagnosis of acute ischemic stroke or transient ischemic attack between the years of 2010-2017 were identified using the Kentucky Appalachian Stroke Registry. Descriptive analysis was used to report the prevalence of each comorbidity in the rural population by age group, gender, and level of multimorbidity by looking at concurrent frequencies. RESULTS: Overall, hypertension, dyslipidemia, tobacco use, diabetes, and obesity were the comorbidities with the highest prevalence in our population irrespective of gender. Over 78% (n = 4153) of the individuals had 3 or more comorbidities while 61% (n = 3285) had at least 3 out of the top 5 comorbidities (hypertension, hyperlipidemia, tobacco, obesity, diabetes). With respect to age, 15% (n = 795) of the sample was under the age of 50, while 32% (n = 1704) were between the age of 50 and 64 and 53% (n = 2826) of the sample were 65 years or older. CONCLUSIONS: The results of this study indicate the majority of individuals affected by stroke in rural Appalachia Kentucky have multimorbidity. In addition, almost half of these individuals are having their strokes at a younger age, which will require a shift in the focus for therapeutic interventions (eg, reintegration into the workforce versus just community reintegration).

Engaging Individuals with Neurological Conditions and Caregivers in Rural Communities in a Health Research Team.

BACKGROUND: In rural communities, individuals living with neurological conditions, such as stroke, traumatic brain injury (TBI), or spinal cord injury (SCI) and their caregivers face limited resources, decreased support, and a lack of access to health information and research. Little information exists on how to engage these individuals in community-based research. OBJECTIVES: We sought to 1) determine the most effective method(s) for engaging individuals with stroke, TBI, or SCI, and their caregivers in rural communities; 2) determine the perceived value of patient-centered outcomes research (PCOR) in their health care and clinical decision making; 3) to determine their health needs and related research priorities; and 4) to establish a community-based research team to support the development of relevant questions. METHODS: Targeting a population of individuals with stroke, TBI, or SCI and their caregivers, as well as health care providers, 17 in-depth interviews were conducted, followed by seven focus groups, and two half-day meetings to establish a community-based research team and develop a research agenda. RESULTS: Recruitment through trusted community networks was found to be the most beneficial for engaging participants. Participants placed high value on health research, but reported difficulties in accessing health information and in finding the information most relevant to them. A research team was established and research priorities centered on access to care and education. CONCLUSIONS: It is imperative to involve those living with a diagnosis or in an under-resourced community to develop the solutions that will work for them in their settings.

Factors Influencing Discharge Readiness After Total Knee Replacement.

Total knee replacement (TKR) surgery has been found to achieve positive outcomes for many patients such as reduced pain and increased function. However, some patients experience suboptimal outcomes including falls, readmission to hospital, and reduced functional performance. Preparation for discharge after TKR surgery is often defined related to pain control, walking, knee function, and ability to climb stairs. These measures may not fully encompass aspects of recovery that impact patients' readiness for discharge after surgery. The purpose of this article is to review discharge readiness following TKR surgery and discuss factors that are known to impact preparedness for discharge.

Investigating the mechanisms of massage efficacy: the role of mechanical immunomodulation.

Massage has the potential to attenuate the inflammatory process, facilitate early recovery, and provide pain relief from muscular injuries. In this hypothesis-driven paper, we integrate the concept of mechanotransduction with the application of massage to explore beneficial mechanisms. By altering signaling pathways involved with the inflammatory process, massage may decrease secondary injury, nerve sensitization, and collateral sprouting, resulting in increased recovery from damage and reduction or prevention of pain. Our goal is to provide a framework that describes our current understanding of the mechanisms whereby massage therapy activates potentially beneficial immunomodulatory pathways.

Targeting quadriceps inhibition with electromyographic biofeedback: a neuroplastic approach.

Weakness of the quadriceps is a common occurrence in patients after knee injury or surgery; this weakness is due to a natural mechanism known as arthrogenic muscle inhibition. If inhibition of the quadriceps persists, it can become detrimental to a patient's function and lead to additional pathologies. A number of therapeutic interventions have be used in the rehabilitation of these patients, but few have proven to be successful. Electromyographic biofeedback is one modality that has demonstrated positive outcomes in patients by restoring quadriceps function. However, the reason for the effectiveness of this modality has yet to be fully explained in the area of rehabilitation. Neuroplasticity is a phenomenon that has gained much attention in rehabilitation, and its potential continues to grow. After an injury, the brain has the ability to enhance recovery by strengthening its neural circuitry. Through rehabilitation, clinicians can use attentional strategies to foster neuroplasticity and promote the recovery of their patients. In this article we provide reasoning for the effectiveness of electromyographic biofeedback using the evidence of neuroplasticity. With this information, we hope to provide clinicians a rationale for using this tool in the rehabilitation of patients with persistent quadriceps inhibition.

Effects of gabapentin on muscle spasticity and both induced as well as spontaneous autonomic dysreflexia after complete spinal cord injury.

We recently reported that the neuropathic pain medication, gabapentin (GBP; Neurontin), significantly attenuated both noxious colorectal distension (CRD)-induced autonomic dysreflexia (AD) and tail pinch-induced spasticity compared to saline-treated cohorts 2-3 weeks after complete high thoracic (T4) spinal cord injury (SCI). Here we employed long-term blood pressure telemetry to test, firstly, the efficacy of daily versus acute GBP treatment in modulating AD and tail spasticity in response to noxious stimuli at 2 and 3 weeks post-injury. Secondly, we determined whether daily GBP alters baseline cardiovascular parameters, as well as spontaneous AD events detected using a novel algorithm based on blood pressure telemetry data. At both 14 and 21 days after SCI, irrespective of daily treatment, acute GBP given 1 h prior to stimulus significantly attenuated CRD-induced AD and pinch-evoked tail spasticity; conversely, acute saline had no such effects. Moreover, daily GBP did not alter 24 h mean arterial pressure (MAP) or heart rate (HR) values compared to saline treatment, nor did it reduce the incidence of spontaneous AD events compared to saline over the three week assessment period. Power spectral density (PSD) analysis of the MAP signals demonstrated relative power losses in mid frequency ranges (0.2-0.8 Hz) for all injured animals relative to low frequency MAP power (0.02-0.08 Hz). However, there was no significant difference between groups over time post-injury; hence, GBP had no effect on the persistent loss of MAP fluctuations in the mid frequency range after injury. In summary, the mechanism(s) by which acute GBP treatment mitigate aberrant somatosensory and cardiophysiological responses to noxious stimuli after SCI remain unclear. Nevertheless, with further refinements in defining the dynamics associated with AD events, such as eliminating requisite concomitant bradycardia, the objective repeatability of automatic detection of hypertensive crises provides a potentially useful tool for assessing autonomic function pre- and post-SCI, in conjunction with experimental pharmacotherapeutics for neuropathic pain, such as GBP.

Facilitating neurorehabilitation through principles of engagement.

A primary goal of neurorehabilitation is to guide recovery of functional skills after injury through evidence-based interventions that operate to manipulate the sensorimotor environment of the client. While choice of intervention is an important decision for clinicians, we contend it is only one part of producing optimal activity-dependent neuroplastic changes. A key variable in the rehabilitation equation is engagement. Applying principles of engagement may yield greater neuroplastic changes and functional outcomes for clients. We review the principles of neuroplasticity and engagement and their potential linkage through concepts of attention and motivation and strategies such as mental practice and enriched environments. Clinical applications and challenges for enhancing engagement during rehabilitation are presented. Engagement strategies, such as building trust and rapport, motivational interviewing, enhancing the client education process, and interventions that empower clients, are reviewed. Well-controlled research is needed to test our theoretical framework and suggested outcomes. Clinicians may enhance engagement by investing time and energy in the growth and development of the therapeutic relationship with clients, as this is paramount to maintaining clients' investment in continuing therapy and also may act as a driver of neuroplastic changes.

Horizontal ladder task-specific re-training in adult rats with contusive thoracic spinal cord injury.

PURPOSE: Using the horizontal ladder task, we examined some issues that need to be resolved before task-specific rehabilitative training can be employed clinically for the frequent contusive spinal cord injury (SCI). We hypothesized that improving recovery in task performance after contusive thoracic SCI requires frequent re-training and initiating the re-training early during spontaneous recovery. METHODS: Contusive SCI was produced at the adult female Sprague Dawley rat T10 vertebra. Task re-training was initiated one week later when occasional weight-supported plantar steps were taken overground (n = 8). It consisted of 2 repetitions each day, 5 days each week, for 3 weeks. Task performance and overground locomotion were assessed weekly. Neurotransmission through the SCI ventrolateral funiculus was examined. SCI morphometry was determined. RESULTS: Re-training did not improve task performance recovery compared to untrained Controls (n = 7). Untrained overground locomotion and neurotransmission through the SCI did not change. Lesion area at the injury epicenter as a percentage of the total spinal cord area as well as total tissue, lesion, and spared tissue, white matter, or gray matter volumes did not differ. CONCLUSIONS: For the horizontal ladder task after contusive thoracic SCI, earlier re-training sessions with more repetitions and critical neural circuitry may be necessary to engender a rehabilitation effect.

Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury.

Two of the most prevalent secondary complications following spinal cord injury (SCI), besides loss of function and/or sensation below the level of injury, are uncontrolled muscle spasticity and hypertensive autonomic dysreflexia. Despite the desires of the SCI community, there have been few advances in the treatment and/or management of these fundamental impediments to the quality of life associated with chronic SCI. Therefore, the purpose of this review is to focus on current drug treatment strategies that alleviate symptoms of spasticity and autonomic dysfunction. Subsequently, looking ahead, we discuss whether individuals suffering from autonomic dysreflexia and/or muscle spasms can take certain compounds that specifically and rapidly block the neurotransmission of pain into the injured spinal cord to get rapid relief for both aberrant reflexes for which painful stimuli below the level of SCI are common precipitants.

Effectiveness of riluzole in suppressing spasticity in the spinal cord injured rat.

UNLABELLED: Spasticity poses a major detrimental impact on the quality of life in a significant number of people with spinal cord injury (SCI). Recent observations in our laboratory suggest that spinal transection at the sacral S(2) level induces a significant increase in glutamatergic input to sacrocaudal motoneurons during the time spasticity is present in the tail muscles. The present study examined the effectiveness of riluzole, an agent that has been shown to reduce glutamate release, in managing spasticity within the tail musculature. In this blinded, cross-over study animals with S(2) spinal transections were tested behaviorally for the progression of spasticity in the tail musculature using our established system. When the animals demonstrated a significant level of spastic behavior (e.g. increased response to quick stretch, noxious and non-noxious cutaneous stimuli), they received either saline or riluzole (8 or 10 mg/kg i.p.) and assessed behaviorally at 1, 3, 6, and 12 post-injection. RESULTS: riluzole at 8 mg/kg significantly decreased the response of the tail muscle to noxious and non-noxious cutaneous stimuli for the first 3 h post-administration, while administration of riluzole at 10 mg/kg significantly decreased the responsiveness of the tail to all of the behavioral assessments. However, a significant percentage of the animals displayed motor impairments at this higher dosage. CONCLUSION: suppression of glutamate release by the administration of riluzole can reduce several, but not all, aspects of spastic activity in the tail muscles at concentrations that do not elicit negative side-effects.