Recommendations for Optimizing Cardiac Ischemia Detection for Physical Therapy Practice: Research Review

Purpose: The purpose of this study is to guide physical therapists in recognizing ischemia using electrocardiogram strips during graded exercise stress testing using methods other than relying on ST segment deviation for cardiac ischemia detection. Methods: A literature review of the English-language literature published between 1975 to 2022 on the detection and prediction accuracy of ECG abnormalities on cardiac ischemia during GXT was conducted using PubMed and CINAHL. Inclusion criteria included studies utilizing 12-lead ECG monitoring while performing GXT for the detection of cardiac ischemia. Exclusion criteria included studies that did not utilize GXT or ECG for detection of cardiac ischemia. Results: ECG Abnormalities ST-deviation ST deviation detection provides sensitivity ranging from 44- 71%.18 ST-segment deviation presentation has been shown to be a late sign of cardiac ischemia as most patients present with a main artery occlusion of 70% or higher after a positive stress test has been diagnosed.9,16,21 P-wave P-wave duration showed detection improvement in women from 29% to 64%.16 Additionally, when P wave duration and ST-segment change were combined, sensitivity increased to 79%.16 P-wave amplitude measured at rest and at 50% of exercise intensity increased the detection of coronary artery disease to a sensitivity of 69% and a specificity of 78%.9 Combining P-wave amplitude and duration was shown to be statistically significant at 0.001 during every minute of recovery for the detection of CAD.21 Combining ST-segment deviation, angina, and P-wave duration change increased sensitivity to 100% compared to ST-segment and angina at 57% or P-wave duration at 69%.21 R-wave R wave amplitude correction further increased the detection of ST depression with a localization of 52%-86%.27 Left main coronary artery disease localization was improved from 40% to 100% and left circumflex coronary artery disease localization was improved from 0% to 83% with the inclusion of R-wave amplitude correction.6,13,27 T-wave T-wave changes combined with ST deviation increased specificity from 22% to 97% for CAD location.11,15,17,25,28,29 U-wave Exercise-induced U waves in precordial leads have been correlated with anterior myocardial ischemia as well as highly predictive for severe disease of the LAD artery.20 Conclusion: In combination with GXT and ST-segment deviation, P-wave duration and magnitude, R-wave amplitude and progression, peaked T-waves, and presentation of inverted U-waves have all shown promise to being effective additive or alternative methods for cardiac ischemia detection

Trunk and Lower Extremity Muscle Activity During the Y Balance Test in Healthy Adults

Y balance test kitTM (YBT) is used to measure dynamic balance. YBT is an instrumented version of the Star Excursion Balance test that has Anterior (A), Posteromedial (PM), and Posterolateral (PL) directions. PURPOSE: To determine electromyographic (EMG) activity of the trunk and lower extremity (LE) muscles during YBT performance. METHODS: Surface EMG was collected on 10 males and 10 females healthy adults for the erector spinae (ES), external oblique (EOB), and rectus abdominis (RA) for both ipsilateral (i) and contralateral (c) sides of the stance leg, and gluteus medius (GMED), gluteus maximus (GMAX), Rectus Femoris (RF), Vastus Lateralis (VL), Vastus Medialis (VM), Medial Hamstrings (MH), Biceps Femoris (BF), Anterior Tibialis (AT), and Medial Gastrocnemius (MG) muscles of the stance leg during the performance of the YBT. A 2-way repeated measures analysis of variance (ANOVA) was used to determine the interaction between percentage maximal voluntary isometric contraction and reach directions of the YBT. Separate 1-way repeated measures ANOVA for each muscle was performed to compare the normalized EMG values of the same muscle across the 3 reach directions. Pairwise comparisons were performed using the Sidak post hoc test at an alpha level of .05. RESULTS: The 2-way repeated measures ANOVA with 2 repeated factors, muscle (15 levels) and reach direction (3 levels) interaction was statistically significant (

Effect of Stable and Unstable Surfaces on the Serratus Anterior Muscle Activation in a Kinetic-chain Exercise Among Healthy Adults

PURPOSE/HYPOTHESIS: The stabilizing action of the serratus anterior (SA) muscle is vital in maintaining proper scapulothoracic rhythm.1,2 Poor activation of SA muscle could lead to many shoulder dysfunctions.1,3 This warrants for exercises that are best to activate the SA muscle. Kinetic-chain recruitment during exercises has demonstrated increased SA activation due to the myofascial connections between various segments of the body.4–6 Variation of surfaces during an exercise has been shown to alter the muscle recruitment patterns.7–9 The primary purpose of this study was to determine if the unstable surface can influence SA muscle activity during the kinetic chain recruitment while performing the forward punch plus (FPP) exercise. The secondary purpose was to compare the effects of stable versus unstable surface during these exercises. NUMBER OF SUBJECTS: Twenty-one healthy men between the ages of 23 and 35 years with no history of neck and upper extremity (UE) injury or surgery were recruited for the study. MATERIALS/METHODS: Surface electromyographic (EMG) activity of the SA, latissimus dorsi (LD), external oblique (EB) on the dominant, and femoral adductor (FD) muscles on the non dominant side were analyzed in FPP and its 2 variations: FPP with closed chain serape (CS), FPP with open chain serape (OS) on stable and unstable surface. The percentage of maximum voluntary isometric contraction (percent MVIC) for each muscle was compared across 3 exercises using a separate 1-way repeated-measures ANOVA with Sidak pairwise comparison as post hoc test for stable and unstable surface. Multiple paired t tests were run for 3 exercises to compare percent MVIC of stable versus unstable surface for each muscle (P≤.05). RESULTS: Statistically significant main effects existed among all the exercises for the SA, EB, and FD within the same surface but not for LD. Pairwise comparisons within the same surface showed EMG activity of the SA to be significantly higher for the CS and the OS compared to the FPP. Regardless of the surface, there was no significant difference for the SA between the CS and the OS exercises. There was no significant difference in the mean EMG activity of any muscle on a stable surface when compared with the same exercise performed on an unstable surface. CONCLUSIONS: The variations of the FPP exercises designed to incorporate the kinetic chain (CS and OS) does increase the activation of the SA muscle when performed on both stable and unstable surface. However, the type of surface did not influence the activation of any muscle when compared to each other during FPP or its variations. CLINICAL RELEVANCE: The results of this study will further strengthen the concept of recruitment of kinetic chain during exercises. During rehabilitation of the UE muscles, it is recommended to recruit the lower extremity and trunk muscles regardless of the surface person stands on during exercises. Clinicians also need to be aware that adding an unstable surface to an exercise does not always imply higher activation of those muscles

Gender Differences Between Muscle Activation during Star Excursion Balance Test on Stable versus Unstable Surfaces

INTRODUCTION: Anterior (A), posteromedial (PM), and posterolateral (PL) directions of Star Excursion Balance Test (SEBT) are used for rehabilitation. Adding unstable surface to the task has been reported to change electromyographic (EMG) activity. Studies have also reported differences in EMG between males and females. PURPOSE: To compare EMG of lower extremity (LE) muscles between males and females during SEBT on stable and unstable surfaces. METHODS: Surface EMG was collected on 10 male and 10 female healthy adults for gluteus maximus, gluteus medius (GMED), medial hamstrings, biceps femoris (BF), vastus medialis (VM), rectus femoris (RF), vastus lateralis (VL), anterior tibialis (AT), and medial gastrocnemius (MG) on the stance leg during SEBT. Unstable surface was introduced using TherabandTM stability trainer. Independent t test assessed differences in EMG between males and females for each direction and each muscle during SEBT for both stable and unstable. Paired t tests were run separately for males and females to determine difference in each direction for each muscle between stable and unstable surface with α at 0.05. EMG were reported as the percentage of the maximal voluntary isometric contraction (%MVIC). RESULTS: Females showed significantly higher EMG than males for AT in PL direction (63±14 vs 47±12 %MVIC; P=0.01) on stable surface and A (63±14 vs 47±12 %MVIC; P=0.01) and PL (64±15 vs 47±14 %MVIC; P=0.02) directions on the unstable surface and MG in PM (44±17 vs 25±17 %MVIC; P=0.02) direction on stable surface and A (62±23 vs 37±20 %MVIC; P=0.02), PL (76±29 vs 45±25 %MVIC; P=0.02), and PM (58±26 vs 36±20 %MVIC; P=0.04) directions on unstable surface. EMG was higher for unstable surface in females for VM, RF, and VL in the A direction (p≤0.05) and MG in all three directions (p≤0.05) and in males for GMED, VM, RF, VL in the A direction (p≤0.05) and BF and MG in the PM direction (p≤0.05). CONCLUSION: Females produced higher muscle activation than males for ankle muscles. Adding unstable surface increased LE muscle activation during SEBT. Due to gender differences and surface variability in EMG during SEBT clinicians could consider incorporating both stable and unstable surfaces during rehabilitation especially for women to reduce ankle injuries

Lower Extremity and Trunk Electromyographic Muscle Activity During Performance of the Y-Balance Test on Stable and Unstable Surfaces.

Background: The Star Excursion Balance Test (SEBT) has been used as a rehabilitation exercise. To improve its efficacy, efficiency, and method variations, the Y-Balance Test (YBT) with anterior (A), posterolateral (PL), and posteromedial (PM) directions of the SEBT has been recommended. Electromyographic activity has been reported to change when the same task is performed on various surfaces. Hypothesis/Purpose: To compare the EMG activity of trunk and LE muscles during the performance of the YBT on stable and unstable surfaces. Study Design: Cross-Sectional study. Methods: Healthy adults with no history of chronic ankle instability were recruited for the study. Surface electromyography was collected for bilateral (ipsilateral [i] and contralateral [c]) rectus abdominis (RA), external oblique (EOB), erector spinae (ES). While, gluteus maximus (GMAX), gluteus medius (GMED), medial hamstrings (MH), biceps femoris (BF), vastus medialis (VM), rectus femoris (RF), vastus lateralis (VL), anterior tibialis (AT), and medial gastrocnemius (MG) on the stance leg (ipsilateral side), during the performance of the YBT. The unstable surface was introduced using a Thera-Band stability trainer. Differences in electromyography were examined for each reach direction and muscle between the stable and unstable surfaces (p≤ 0.05). Results: Twenty (10 male, 10 female) subjects participated (age: 27.5 ± 4.0 years, height:167 ± 1.0 cm, weight: 66.5 ± 13.0 kg, body fat: 14.1 ± 6.2%). Significantly higher muscle activity for the unstable surface (p0.05) between the stable and unstable surfaces were observed in iRA, cRA, cEOB, VL, and AT for any of the directions of the YBT. Conclusion: An increase in muscle activity was observed during YBT on unstable versus stable surfaces for some muscles. Level of Evidence: 2B

Perceptions of Incivility Among Students and Faculty in Entry-Level Health Professional Programs

Purpose: Online education is growing in popularity but has the potential to result in cyber incivility leading to disruptions in the learning environment. There is little known about the differences in attitudes between students and faculty in the online learning experience regarding cyber civility. The purpose of this study was to analytically measure student and faculty perceptions and attitudes of cyber incivility. Methods: A convenience sample of 180 (34 faculty and 146 students) participants from a health care university were recruited. A 27-item survey was given to record the perceptions of students and faculty on issues of cyber civility. An exploratory factor analysis was completed to validate the survey tool and determine the factors that made up the survey. A Mann Whitney U test was conducted to determine significant differences between student and faculty perceptions on the survey items. Results: Four factors were identified of the retained 19 items after the exploratory factor analysis: attitudes, presentation, appearance, and multitasking. There was a significant difference on 10 of the remaining survey items between students and faculty. Conclusions: Faculty perceived unprofessional dress, multitasking, and active display of complaints in the virtual environment more uncivil and disruptive than students. The themes show the differences between students and faculty perceptions in online platforms in healthcare educational programs. These differences highlight the need for healthcare educational programs to focus on strategies that align student and faculty expectations to positively impact the dynamics of the class and enhance learning in the virtual environment

Interrater Reliability of the Pediatric Neuromuscular Recovery Scale in Children with Spina Bifida

Purpose: There is a paucity of outcome measures to assess the quality of functional mobility in children with spina bifida1. The Pediatric Neuromuscular Recovery Scale (Peds NRS) is a valid and reliable outcome measure that was developed to assess the motor capacity of children with spinal cord injury2-6. The purpose of this study was to examine the interrater reliability of the Pediatric Neuromuscular Recovery Scale (Peds NRS) to classify motor capacity in children with myelomeningocele (MMC) form of spina bifida. Subjects: Twenty-one children with MMC (1.4- 10 years of age; mean age of 5.3 years) were recruited from clinics and support groups within a 250-mile radius of Austin, TX. Four clinicians, two physical therapists (PTs) and two occupational therapists (OTs) served as the raters for the study. Raters had an average of 14 years of clinical practice and 11 years of pediatric practice. Methods: Each child with MMC was scored on the Peds NRS three times: two live testing sessions and one video recorded session. Every child was scored by two PTs and one OT. Interrater reliability was analyzed using intraclass correlation coefficients (ICC) for individual items and the summary score. Results: The Peds NRS summary score demonstrated good reliability (ICC = 0.89; 95% CI, .80-.95). For the sixteen individual items, reliability was excellent for items forward reach and grasp (right and left), static stand, and walking (ICC= .919-.969), good for supine to sit, sit inside base of support, sit outside base of support, in-hand manipulation (right), overhead reach (right and left), sit to stand, dynamic stand, and step retraining (ICC= .765-.890) and moderate for in-hand manipulation (left), stand adaptability, step adaptability (.511-.745). None of the items had poor reliability. The summary score had consistent reliability across age categories and groups defined by modified Hoffer level. There was no difference in the summary scores among all raters at F(2,60)= .220, p=.804. Conclusions: Pediatric clinicians were able to reliably administer and score the Peds NRS on children with MMC, representing a wide range of ages and functional levels. Clinical Relevance: This is the first investigation of the use of the Peds NRS in children with MMC. This study adds to the literature regarding the psychometric properties of the Peds NRS and supports the use of this outcome measure as an instrument to assess motor capacity in children with MMC

Feasibility and Preliminary Outcomes of a Standardized Exercise Program in Adults with Down Syndrome: A Pilot Study

Purpose/ Hypothesis: Youth with Down Syndrome (DS) have limited participation in physical activity. When compared to their typically developing peers, adults with DS display decreased functional mobility and strength. Exercise has shown to improve the physical fitness, overall health, and quality of life in people with DS. The Lee Silverman Voice Treatment (LSVT® BIG) is an effective treatment approach designed for patients with Parkinson’s disease. The core components of LSVT® BIG include large amplitude movements, sensory calibration, high intensity, and maximum effort while performing the daily exercises. Due to hypotonicity associated with DS, these individuals typically display kyphotic posture, shortened step length and overall lower amplitude movements. The LSVT® BIG protocol has the potential to improve muscle tone and overall fitness in adults with DS similar to the improvements seen in the Parkinson’s disease population, but the effects have yet to be studied. The purpose of this pilot study was to test the feasibility of implementing a 4 week standardized group exercise program in adults with DS, and assess whether subjects improved after this protocol. Number of Subjects: A convenience sample of 8 adults with DS were recruited from a residential facility. Materials/Methods: This exploratory, feasibility pilot study employed a pretest-posttest design. Outcome measures were assessed at baseline and at one week post intervention. The independent variable for this study was the LSVT® BIG standardized exercise protocol. Outcome measures included: the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) and timed single leg stance (SLS) for balance, the 10 meter walk test (10MWT) for gait speed, the 30 second sit-to-stand test for lower extremity functional strength, and the timed-up-and-go (TUG) for overall functional mobility. Each participant completed the established LSVT® BIG protocol in a group exercise format, totaling 16 sessions. Results: LSVT® BIG certified instructors were able to lead the group exercises for all 8 adults with DS with no adverse effects. Attendance varied between 10 to 16 sessions, with an average participation rate of 13.75 days (SD = 2.17). Standard LSVT® BIG modifications were easy to implement when needed. There was a statistically significant increase in self-selected gait speed (median self-selected gait speed post-test score, Mdn = 1.01, vs. median pre-test score, Mdn = 0.78, z = 35, p = 0.02). There were no other significant changes in functional strength, balance or fast gait speed, however the median scores improved for all dependent variables except for one of the mCTSIB scores and 30 second sit-to-stand test. Conclusions: A 4 week high-amplitude standardized exercise program can improve self-selected gait speed in adults with DS, but may not have a statistically significant effect on their balance or functional strength. Clinical Relevance: The LSVT® BIG standardized exercise protocol can be used for adults with DS in a group exercise setting and may also improve the gait speed for this population

Is Vision Essential to Physical Therapist Practice? Perceptions of Interested Parties in DPT Education

Introduction: The perceptions of students, faculty, staff, and clinicians regarding blindness or visual impairment (BVI) and physical therapist practice were explored before, during, and after interactions with a Doctor of Physical Therapy (DPT) student with BVI. Review of Literature: Information is sparse about the prevalence of students with disabilities in DPT programs in the United States. Medical school programs that welcome students with disabilities report positive interactions with faculty and student peers. Subjects: 36 (20 students, 11 faculty, 2 staff, and 3 clinical instructors) Methods: A recent DPT graduate (pseudonym JM) with BVI classified as “near total blindness”, is now a licensed, full-time employee at an outpatient orthopedic clinic. We surveyed students, faculty, staff, and clinicians who interacted with JM as a DPT student, asking for perceptions about the education, clinical skills, and employment potential of a DPT student with BVI. Results: An increase toward more favorable perceptions of individuals with BVI was exhibited for all 10 of the Likert scale questions, X2(2)=38.00 to 59.42, p\u3c 0.001. Post hoc analysis demonstrated an increase between perceptions before and during interactions with JM for all questions, Z=-4.02 to -4.95, p\u3c 0.001. Six of 10 questions exhibited an increase between perceptions during and after interacting with JM, Z=-2.53 to -3.50 p≤ 0.011. Qualitative analysis revealed three themes: accommodations, personal qualities, and setting with an overarching theme of an approbative shift in perceptions. Discussion and Conclusion: The shift in perceptions about vision as essential for physical therapist practice is important and suggests that “essential functions” should be considered within the context of the individual’s characteristics and lived experiences. Reevaluation of DPT program applicant qualifications regarding vision may be warranted. Further, for clinical instructors, the benefits may outweigh the challenges of mentoring a student with accommodations for BVI

How has the OSD affected our state hospitals?

The long-awaited occupation-specific dispensation (OSD) process for state-employed doctors has now been concluded. The final offer, signed and accepted in the bargaining chamber despite being rejected by 92% of doctors in a SAMA survey, has not received much attention or fanfare. At the conclusion of this process, which has been drawn out over several years, many points have emerged that are extremely worrying for the future of health care in this country