Evidence Based Practice. What Interventions Work in Improving Motor Function? Marjorie Woollacott

Evidence Based Practice What Interventions Work in Improving Motor Function? Marjorie Woollacott Evidence Based Practice Research Clinical Practice Ø Evidence based clinical practice: Integrating the best available research evidence with clinical expertise and patient preference (Sackett, 1998) 1

Research Evidence on Treatment: Summary Complete the motor matrix as you listen to the presentation - Examples, shown below: Individual Component Task/Activity Research Can Exercise Programs Focusing on Motor Systems Improve Balance and Gait Function? Impairment Level: Body alignment/range of motion Strength training Multi-system Exercise Programs Reactive Balance Training Constraint Induced Therapy Tai Chi Task-Oriented Training Treadmill Training Research Clinical Practice 2

Training Postural Alignment in Parkinson s patients: can it improve postural function? Schenkman et al 1998: RCT training axial musculature in Parkinson s to improve spinal flexibility and coordinated movement (decrease overactive flexor and increase underactive extensor muscle act.). 3x/wk for 1 wks. Could we use this evidence to support our balance retraining strategy for Bill? Or Jean? Research Evidence on Treatment: Summary Complete the motor matrix as you listen to the presentation - Examples, shown below: Individual Component Steady State Balance Alignment Task/Activity Sit/Stand Practicing trunk extension/trunk rotation Research Schenkman et al, 1998 3

Does Postural Alignment Training Improve Postural Symmetry Post-Stroke? De Haart et al, 24, 25: 37 Patients received individualized standing balance and walking therapy for 12 wks Asymmetry improved during 1 week recovery period after stroke (p=.1), with most change in first 4 wks Also reduced visual dependence Worse in Dual task condition (math task): shows conscious control required for symmetry Asymmetric Stance Shumway-Cook et al, 1989: Compared postural biofeedback (15 min, 2x/day, 2 wks) to usual care PT for retraining alignment. Biofeedback group improved more than usual PT, but did not remain at follow-up. Winstein et al, 1989: similar protocol: stance asymmetry improved, but not locomotor asymmetry. Could these studies be used to support symmetry training post stroke? Research Evidence on Treatment: Summary Complete the motor matrix as you listen to the presentation - Examples, shown below: Individual Component Steady State Balance Alignment Steady State Balance Asymmetric Alignment Task/Activity Sit/Stand Practicing trunk extension/trunk rotation Task Oriented Practice or Biofeedback Research Schenkman et al, 1998 De Haart et al 24; Shumway-Cook et al, 1989 4

Impairment Level: High Intensity Strength Training in Balance-Impaired Older Adults. What Aspect of Balance Improves? Hess & Woollacott 24 Mean age 81 Mildly-moderately balance impaired Training 3x/week, 1 wks Warm-up Strength-training in G, TA, H, Q 3 sets of 8 repetitions Progressive resistive training Strength improved Significantly Warm-ups Berg Balance Scale (Measures Steady State & Proactive Balance) Experimental group averaged 2.4 point increase in Berg scores Correlation between increase in Berg scores and increase in GA strength Score 53. 52. 51. 5. 49. 48. 47. 46. * Also improved signif. on TUG and ABC compared to controls Experimental pre post Control 5

Reactive Balance Control: Time to Stabilization & Mean Force Produced During Recovery Improved Backward Sway Condition Time to Stabilize Balance decreased as TA strength increased Suggests TA strength contributes to COP stabilization in response to a slip Could we use this evidence to support strength training to improve balance in Bill? Time to Stabilization Mean Force at R & L Ankle msec Nm/kg 26 23 2 17 14 11 8 5.16.12.8.4. * Experimental * pre-train post-train Control Experimental Control Experimental Control MAR * MAL pre-train post-train Motor Matrix Individual Component Steady State Balance Alignment Steady State Balance Asymmetric Alignment Reactive Balance Amplitude scaling Task/Activity Sit/Stand Practicing trunk extension/trunk rotation Task Oriented Practice or Biofeedback Strength training Research Schenkman et al, 1998 De Haart et al 24; Shumway-Cook et al, 1989 Hess & Woollacott, 24 6

Will Strength Training Improve Function Performance in Stroke? Weiss et al, 2 12 wks, 2X/wk, 7% 1 rep max Lower-limb mean muscle strength improved 68% on affected side, 48% on intact side. Largest change for hip (88% affected; 13% intact) Repeated chair rise time decreased 21% (p.<2) Static & Dynamic Balance (Berg) improved 12% (p.<4) Note that patients must have a minimal amount of strength in the paretic limb for it to benefit from strength training. Could we use this evidence to support strength training to improve balance in Jean or Thomas? Does Strength Training Improve Balance in Persons w/ Parkinson s Disease? YES Dibble et al, 26 Since strength deficits are associated with bradykinesia, strength training might reduce this. 12 wk high force resistance training compared to standard care controls Strength group had sign. increase in muscle mass, 6 min walk distance (A) and decrease in stair descent time (B) compared to controls 6 min walk distance Stair Descent time 7

Does strength training improve gait in children with CP? Damiano et al, 1995 14 children with CP (6-14 yrs) Quadriceps strength training (3x/wk, 6 wks) at 65% of maximum isotonic force production. Children improved Q muscle strength, which resulted in improvement in degree of crouch at floor contact and increase in stride length. Multisystems Balance Training: u Targeted Training of spinal segments for sitting u u u u u Reactive Balance Training Constraint-Induced Therapy for Balance Tai Chi Task-Oriented Balance Training Treadmill Training 8

4/3/12 Targeted Training: Do children with CP at GMFCS Levels III-V benefit from training specific spinal segments? School program 2-3 min 5 days per week 6 months (typically lowering support every 2 mos) Play reaching/throwing games on stable then unstable surface Upper Thoracic Mid Thoracic Lower Lumbar Upper Lumbar GMFM_66 3 pretest post test 25 2 Example: GMFCS Level III - Progressed to lower lumbar pelvis hips 15 1 5 GMFM_supine GMFM_sit Improvements reported by parents and teachers % subjects Improved Bilateral Upper Extremity Fn Improved eye contact Improved communication GMFCS III (n=1) 1% % % GMFCS IV (n=5) 1% 4% 2% GMFCS V (n=5) 1% 1% 1% 9

COP COP COP 4/3/12 Can Reactive Balance Training Improve Postural Control in Children with CP? 6 children with CP (mean age 9.3 yrs) 4 with spastic diplegia (level II on Gross Motor Function Classification System) 2 with spastic hemiplegia (Level I on GMFCS CP) Inclusion criteria: stand independently 3 sec. Intervention: 5 days forward and backward perturbation training @ 1/ day (3-6 cm at 12-24 cm/sec), while child watched video. Rests every 2-25 perturbations. (Shumway-Cook et al, Dev Med and Child Neurol, 23) 25 225 2 175 15 125 1 75 5 25-25 -5-75 -1-125 -15-175 -2-225 Center of Pressure Path During Balance Recovery & Time to Stabilize Balance was Reduced by Training COP Path in Response to a Perturbation Causing Forward Sway -25-25 -2-15 -1-5 5 1 15 2 25 25 21 18 15 12 9 6 3-3 -6-9 -12-12 -15-15 Pretest -18 Post-test -18 3 Day Follow-up -21-21 -25-25 -2-15 -1-5 5 1 15 2 25 21 18 15 12 9 6 3-3 -6-9 -25 25-25 -2-15 -1-5 5 1 15 2 25 Time to Stabilization (sec) 5 4 3 2 1 Mean Forward Sway Baseline Intervention Posttest SD1 SD2 SD3 SD4 SH1 SH2 1

What Changes in Neuromuscular Response Characteristics Underlie These Changes in Performance? - Children with Hemiplegia and Diplegia showed Faster Muscle Contraction Onset to Slips (Woollacott et al, 25) - Muscle sequencing was also improved (not shown) Can this study be used to justify Reactive Balance Training in Bill and Jean? Motor Matrix Individual Component Steady State Balance Alignment Steady State Balance Asymmetric Alignment Reactive Balance Amplitude scaling Reactive Balance Amplitude Scaling Task/Activity Sit/Stand Practicing trunk extension/trunk rotation Task Oriented Practice or Biofeedback Strength training Standing manual perturbations Vary speed Vary amplitude Research Schenkman et al, 1998 De Haart et al 24; Shumway-Cook et al, 1989 Hess & Woollacott, 24 Woollacott et al, 25 11

Do Orthotics Help or Hinder Reactive Balance in children with CP? It depends. PERCENT USE OF ANKLE STRATEGY WITH DIFFERENT AFOs PERCENT USE OF DISTAL- PROXIMAL SEQUENCING Typical children: orange CP: pink Forced Use Therapy for Balance Control in Stroke: What Aspects of Balance are Improved? A New Therapy used in Individuals Post-Stroke is Forced Use Therapy (Taub et al, 1993) Classic treatment for upper extremity: Restriction of use of the uninvolved upper extremity and training of the involved upper extremity for 6 hrs/day for 2 wks Modifications to classic treatment for balance training: Required equal use of both lower limbs in balance (Verrier et al, 25) and used Task-Oriented Approach Methods: 1 subjects (mean age 6 yrs) at least 1 yr post-stroke. Inclusion: minimum 3/56 Berg Balance Scale, 2/3 Upright motor test - extension (Perry, 1995), Walk 15.2 meters (5ft) with or w/o assistive device Intense training: 2 weeks training, 6 hrs per day 5 days/wk 12

Performance on Berg, ABC Clinical Tests was improved as a result of Training & remained high at 3 mo. Follow-up Number of Self-Reported Falls Was Reduced Subject 12 months Prior to Massed Practice 12 months Following Massed Practice S1 3 S2 4 S3 2 1 S4 4 1 S5 4 S6 3 S7 9 S8 S9 1 1 S1 1 Mean ± SD 3.1 ± 2.5.3 ±.5 * Paired t-test p<.9 Reactive Balance: Time to Stabilize Balance was reduced as a result of training Time (seconds) 3.2 3. 2.8 2.6 2.4 2.2 2. 1.8 1.6 1.4 1.2 1..8 ES=.79 p<.1 Time to Stabilization of the COP Mean of the Medians Within Phases Baseline Training Maintenance * * S1 S2 S3 S4 S5 S6 S7 S8 S9 S1 13

What were the Neural Mechanisms Underlying These Improvements in Reactive Control? Mean Onset Latencies for the Gastrocnemius were Significantly Shorter After Training Time (ms) 15 1 5 Pre-Test Post-Test 3M-FU Mean Onset Latencies for the Hamstrings were Significantly Shorter After Training Time (ms) 6 4 2 Pre-Test Post-Test 3M-FU Pre vs Post Massed-Practice (Forced-Use) Training: Level Walking Can we use this evidence to justify intensive Task-Oriented Training post-stroke in Jean? 14

Effects of Tai Chi Training on SS, Proactive & Reactive Balance in Balance-Impaired Older Adults Gatts and Woollacott, 26 22 Balance-Impaired subjects randomly divided into Tai Chi group or Control group (axial mobility and balance education) Training for both groups was 1.5 hours a day/5 days/week for 3 weeks. After post-testing the control group received the Tai Chi balance training. Post Training: Day 15 Ex: Of Woman Performing a Tai Chi Form in Lab Before vs After Training Can t hold leg up Well balanced 15

Change in Performance Time on Clinical Walking Test: (Timed Up and Go test) Tai Chi training improvement was sig (p<.1) while control was not Time in seconds Group 1 = Tai Chi Group 2a = axial flexibility/education Group 2b = Tai chi training after flexibility training Laboratory Tests of Balance: Balance Muscle Responses to slips were faster and organization improved (less co-contraction): TA Onset latency Group 2a milliseconds 25 2 15 1 5 * Group 1 Group 2a Group 2b * Pre Post Cocontraction % of Group 7% 6% 5% 4% 3% 2% 1% % Group1 Group 2a Group 2b Pre Post 16

After Training: Walking While Balancing Cane Can this research be used to justify using Tai-Chi when retraining balance in Bill? Tai Chi and Parkinson s Disease Hackney & Earhart, 28 33 people randomly assigned to Tai Chi or control group (no training) Tai chi: 2 1 hr training sessions in 1-13 wks Tai Chi sign. improved compared to controls Reported satisfaction with program and improved wellbeing Change in score Tai Chi UPDRS -1.5 (-5.6%) Berg Balance Tandem Stance (s) Six Minute walk (m) Control P value (between group comparison) 4.3 (17.2%) 3.3 (7%) -.5 (-1%) 8.3 (34.8%) -11.6 (-27%).25.1.18 44 (1%).8 (.2%).46 17

Au-Yeung et al / Tai Chi Improves Standing Balance i Tai Chi and Stroke Au-Yeung et al, 29 Randomized Controlled Trial 136 patients > 6 mos post stroke; 62 control Control: general exercise, breathing, memory training Tai Chi 12 forms by PT trained to teach Tai Ch (2-5/grp) Both groups: 12 weeks Training (1 hr group + 3 hrs self practice) Tai Chi showed shorter RT and better COP excursion and speed during lean in all 4 directions Can this be used to justify Tai Chi when retraining balance in Jean? Figure 3 Comparison Between Tai Chi and Control Groups in the Limit of Stability Test Over Time Nonaffected side seconds Affected side seconds Backward seconds Forward seconds 2.5 2 1.5 1.5 2.5 2 1.5 1.5 3.5 3 2.5 2 1.5 1 2.5 2 1.5 1.5 Reaction Time Time * ** End-point Excursion Control Tai Chi Week Week 6 Week 12 Week 18 Week Week 6 Week 12 Week 18 The results confirm that 12 weeks of regular Tai Chi practice at up to 4 hours a week can improve standing balance control in people with chronic stroke. Hart and coworkers 4 used Tai Chi to train stroke survivors for 12 weeks, but did not find any improvement on their balance in single leg standing. In contrast, the findings from our study clearly show that % limit of stability % limit of stability % limit of stability % limit of stability 7 65 6 55 5 45 6 55 5 45 4 35 45 4 35 3 25 2 45 4 35 3 25 * * * Time ** ** ** ** Note: Reaction time (left column) and end-point excursion (right column) of the body s center of gravity, upon voluntary weight shifting in 4 directions: forward, backward, and toward the affected and nonaffected side. Error bars are 1 SE of the mean. Daggers and double daggers denote P.167 and P.5 for significant within-group changes with reference to the baseline. Asterisks and double asterisks denote P.5 and P.5, respectively, for significant between-group differences analyzed with mixed-model analysis of variance. What is the Effect of Dynamic Balance Training vs Stretching/Weight Shifting Training on Discussion Reactive Balance in Stroke? Marigold et al, 25 Patients w/ chronic Stroke given Dynamic balance (1 hr/ 3x/wk, 1 wks): tandem, 1 ft, wt shift, walk with obstacles, diff step length, cross-over etc, standing pert, EO, EC, foam Stretching/wt shifting Both groups improved significantly on Berg, TUG Dynamic balance group showed faster onset Reactive postural control in Rectus Femoris Fewer falls in response to perturbations after training Solid line: pretest Dotted line: posttest TA RF * * * * subjects with Tai Chi training improved t tary weight-shifting to different spatial 6 weeks after training commenced. These gible in the control group receiving gene Note that subjects practicing the short-f continuously shift their weight and chang between their 2 feet while they perf arm movements. 29 The general exercises trol group did not put similar demand on lack of balance-training specificity could trols did not show any significant impro balance. Compared with the control program, 1 form Tai Chi was more effective in imp balance of people after stroke, in terms of during voluntary weight-shifting toward t well as increased COG excursion amplitude forward, backward, and toward the no improvements were noticed as early as 6 training commenced. Our previous stud seniors improved their standing balance a training at 1.5 hours a day, 5 days a wee present results are encouraging because jects with chronic stroke improved their ing balance control with Tai Chi training hours a week for 12 weeks. Furthermore in practice time after the training ended, s group maintained their gains. Stroke survivors have been shown to r for postural control in standing. 14,41 They be significantly impaired in integrating standing equilibrium when compared wit terparts. 13 On average, the stroke sur showed much lower equilibrium scores in zation test conditions that challenged m integration function for balance. After 1 Tai Chi, subjects showed improvements rium in conditions 4 (visual and vesti (mainly vestibular integration when visual and 6 (higher level vestibular integratio conflicted with somatosensory input) (Ta group did not show similar improvement ing. During Tai Chi practice, simulta movements relative to the trunk and the 4 changes of head-and-body orientation re ment are required. This could have resul tion of the visual and vestibular systems Negative findings in the control group co the lack of simultaneous eye, head, body, during weight shifting in the general e When compared with the controls receivi 12 weeks of short-form Tai Chi training i lar ratio in condition 5. However, this e tained at follow-up, probably becau self-practice after Tai Chi training ended Downloaded from http://nnr.sagepub.com at UNIV OF OREGON on August 12, 29 18

Is Treadmill Training Better than Regular Gait Training Post Stroke? Richards et al 24 RCT compared technology based treadmill training, strength training, limb-load monitor task-oriented training vs. functional mobility/gait activities w/o technology Both groups in sub-acute phase improved equally after 3 mos training and maintained it for 3 mos Cochrane Review (Moseley et al, 23) states that there is not yet enough evidence to state that Body weight support TT is better than regular mobility training in stroke. However, it was noted that it may be the best for patients with limited walking ability & the only type of training for patients unable to walk LEAPS study (Duncan et al, 211) 48 post stroke participants stratified by locomotor function Severe <.4m/s Moderate:.4 -.8 m/s Randomized to: BWSTT early (2 months) BWSTT & overground Tx Home program early (2 months) progressive, individualized strength & balance training, encouraged to walk daily (but walking not trained) BWSTT late (6 months) 3x week, 6 mins, 36 sessions Primary outcome: change in category of gait function (based on gait speed) at 1 year post stroke, secondary outcomes: Berg, ABC, 19

At 1 year LEAPS result 52% had increased functional walking ability (made the leap from one category to another) 6 months: Early training groups were better than the late training group who got usual care 1 year: No difference among the three groups on the primary or secondary measures Conclusion: BWSTT was not superior to a PT supervised exercise program in improving locomotor function. Usual care (as was currently done) was not sufficient. What is the optimal dose of exercise? (Sherrington et al, 28; Gillespie et al, 29) Depends on desired outcome If falls reduction is desired: Studies that show improvement have a total exercise dose of > 5 hours. Must include challenging balance exercise to reduced falls (must be progressive & intensive) Typical PT may be insufficient to achieve this desired outcome 2

Conclusions: 1. Training targeting individual subsystems (ROM, muscle strength) improves posture, stability in patients with neurological problems and balance-impaired older adults 2. Multidimensional programs training dynamic balance can also improve balance and reduce falls risk in older adults, patients with stroke, cerebral palsy, Parkinson s disease 3. We only know optimal exercise dose for reducing falls in OA more research is needed on other populations Small Groups: Treatment of Motor Components of Imbalance 21

Bill Treatment assignment: Motor Jean/Thomas Problem: Loss of balance when performing proactive balance tasks in standing and particularly walking. For example, loses balance when trying to step up curbs, when stepping over obstacles, when standing on one leg to put on trousers. Goal: to improve ability to perform functional tasks such as reaching, leaning, stepping up and over obstacles while standing and walking. Treatment strategies: Describe treatments strategies that will improve balance control particularly proactive balance problems. Be specific about what you will have Bill do, how you will progress his treatment, and what aspects of your treatment can be given as a home exercise program. What evidence do you have to justify your treatment ideas? Problem: Impaired reactive balance control. Reduced ability to recruit muscles in the legs for balance control and relies on arm(s) for recovery of balance. Goal: Increase use of leg muscles for reactive balance control. Treatment strategies: Describe treatment strategies that will improve balance control, specifically reactive balance control, in Jean or Thomas. Be specific about what you will have your patient do, how you will progress her treatment, and what aspects of your treatment can be given as a home exercise program. What evidence do you have to justify your treatment ideas? Treatment Assignment: Motor Individual Component Reactive Balance Amplitude scaling Task/Activity Strength training Research Hess & Woollacott, 24 Reactive Balance Amplitude Scaling Standing manual perturbations Vary speed Vary amplitude Woollacott et al, 25 22

Case Study Discussion Bill proactive balance Jean/Thomas Reactive balance Summary Training Motor Aspects of Balance Can we modify motor aspects of balance control? Yes, evidence suggests that training can modify motor components of balance (onset, amplitude, coordination etc) What strategies are effective? Strength training alone appears to be effective in some populations Task oriented training practicing functional tasks requiring different aspect of balance control Tai Chi Forced Use combined with task oriented training Targeted training aimed at progressive trunk control The extent to which practicing one balance task transfers to another is still unclear. 23