Normative Values for the Head Shake Sensory Organization Test in an Active Duty Military Cohort.

INTRODUCTION: The Head Shake Sensory Organization Test (HS-SOT) assesses postural stability while the head is moving and may also identify deficits in attention associated with the dual task conditions of moving the head at a specified speed while maintaining balance. Normative values for the HS-SOT have not been established in a healthy military population or other highly trained populations such as athletes. Establishing normative values in a military population will enable clinicians to compare the scores of patients with medical conditions that affect postural stability and sensory integration such as concussion or traumatic brain injury, vestibular dysfunction, or migraine to those of a healthy population to determine a need for intervention and for return to duty considerations. The purposes of this cross-sectional study were to establish normative values for the HS-SOT within the military population, to determine whether HS-SOT scores differed between men and women or among age groups, and to determine whether HS-SOT scores differed from scores on similar conditions of the Sensory Organization Test (SOT). MATERIALS AND METHODS: Active duty service members (n = 237, 54 female) at Joint Base Lewis-McChord, Washington, Fort Campbell, Kentucky, and the National Capitol Region (Washington, D.C, Maryland, and Virginia) completed the SOT and HS-SOT on the NeuroCom® Balance Master™. Parametric and non-parametric comparisons were analyzed for the equilibrium scores for the SOT and HS-SOT conditions 2 (SOT-2, HS-SOT-2, respectively) and 5 (SOT-5, HS-SOT-5, respectively) and the equilibrium score ratios (ESRs) for HS-SOT-2 and HS-SOT-5 for the total sample, men and women, and age group categories (18-26 years, 27-35 years, and 36-45 years). RESULTS: There were no differences in HS-SOT-2 or HS-SOT-5 equilibrium ratio scores between men (0.99 ±.029 and 0.83 ±0.25, respectively) and women (1.00 ±0.03 and 0.81 ±0.21, respectively). There were no differences in the SOT-2 equilibrium scores (F = 2.29, P = 0.10) or SOT-5 equilibrium scores (Kruskal-Wallis H = 3.26, P = 0.20) among the different age groups. SOT-2 equilibrium scores were higher than the HS-SOT-2 equilibrium scores (Z = -4.10, P < 0.001). SOT-5 equilibrium scores were also higher than HS-SOT-5 equilibrium scores (Z = -12.22, P < 0.001), and the HS-SOT-2 and HS-SOT-5 equilibrium scores differed from each other (Z = -13.26, P < 0.001). CONCLUSIONS: This study established normative values for the HS-SOT in a military population. Equilibrium scores did not differ between men and women or among age groups, suggesting that these values can be used as reference points for most service members. Postural stability was found to be significantly challenged during head motion, indicating the HS-SOT is a valuable tool for identifying subtle impairments in postural stability. These findings have important implications for early detection and intervention in individuals with medical conditions affecting balance, particularly concussions or vestibular disorders.

Predictors of functional shoulder recovery at 1 and 12 months after breast cancer surgery.

The objective of this study are (1) to determine if upper extremity function, as represented by shoulder ROM, self-reported symptoms and upper extremity functional limitations in activities of daily living could be predictively related to demographic and cancer characteristics post-surgery for breast cancer. And (2) to examine if variables related to early onset impairment contribute to late onset impairments in women after breast cancer surgery. Subjects were assessed preoperatively and 1, 3, 6, 9, and 12+ months post breast cancer surgery for impairments and symptoms and at 12+ months for shoulder functional limitations using a physical therapy surveillance model. Body weight, shoulder ROM, manual muscle testing, and upper limb volume were recorded. At 12+ months, the Harvard Alumni Health Study Physical Activity Questionnaire, and an Upper Limb Disability Questionnaire were administered. Symptoms and ROM impairments were compared by functional limitations. Characteristics significantly associated with early ROM impairment (but not later impairment) were axillary lymph node dissection, removal of ≥15 nodes, mastectomy surgery and stage II breast cancer. Positive nodes, older age, and BMI≥25 were significantly associated with reduced shoulder ROM at 12+ months. At 12+ months, only 10 % of the patients experienced ROM impairments while rates of self-reported symptoms in the affected upper extremity at 12+ months were as follows: pain-49%, weakness-47.1%, numbness-55.9%, feeling tired-42.5%. The majority of patients used the affected upper extremity for reaching without limitation, but ≥35% reported limitation with household chores, carrying and lifting. Difficulty carrying and lifting could be predicted by BMI≥25 and use of the dominant affected upper limb. Different factors are associated with early versus later ROM loss. Symptoms reported by breast cancer survivors are frequently associated with functional limitations in upper extremity tasks and warrant intervention. Physical therapy using a prospective surveillance model of care may reduce severity of ROM loss, symptoms and functional upper extremity limitations 1 year after breast cancer surgery.

Factors predicting clinically significant fatigue in women following treatment for primary breast cancer.

Cancer-related fatigue is common, complex, and distressing. It affects 70-100% of patients receiving chemotherapy and a significant number who have completed their treatments. We assessed a number of variables in women newly diagnosed with primary breast cancer (BrCa) to determine whether biological and/or functional measures are likely to be associated with the development of clinically significant fatigue (CSF). Two hundred twenty-three women participated in a study designed to document the impact of the diagnosis and treatment of primary breast cancer on function. Forty-four had complete data on all variables of interest at the time of confirmed diagnosis but prior to treatment (baseline) and ≥ 9 months post-diagnosis. Objective measures and descriptive variables included history, physical examination, limb volume, hemoglobin, white blood cell count, and glucose. Patient-reported outcomes included a verbal numerical rating of fatigue (0-10, a score of ≥ 4 was CSF), five subscales of the SF-36, Physical Activity Survey, and Sleep Questionnaire. At baseline, the entire cohort (n = 223) and the subset (n = 44) were not significantly different for demographic, biological, and self-reported data, except for younger age (p = 0.03) and ER+ (p = 0.01). Forty-five percent had body mass index (BMI) ≥ 25, 52% were post-menopause, and 52% received modified radical mastectomy, 39% lumpectomy, 52% chemotherapy, 68% radiation, and 86% hormonal therapy. Number of patients with CSF increased from 1 at baseline to 11 at ≥ 9 months of follow-up. CSF at ≥ 9 months significantly correlated with BMI ≥ 25, abnormal white blood cell count, and increase in limb volume and inversely correlated with vigorous activity and physical function (p < 0.05). Fatigue increases significantly following the treatment of BrCa. Predictors of CSF include high BMI and WBC count, increase in limb volume, and low level of physical activity. These are remediable.

Normative values for the Sensory Organization Test in an active duty military cohort.

BACKGROUND: Computerized dynamic posturography is commonly used to assess balance in service members, but normative values for the military population have not been established. RESEARCH QUESTION: What are the normative values for the Motor Control Test (MCT), Sensory Organization Test (SOT) and the enhanced SOT (eSOT) within the military population and at which point do they differ? METHODS: Cross-sectional study. 237 active duty service members (78 % male) completed the MCT, SOT and the eSOT with the sway manipulated at a gain of 1.2, 1.4, 1.6, 1.8, or 2.0. A Mann-Whitney U test was used to compare the means of men and women for the SOT and MCT composite scores. A Kruskal-Wallis H test was used to compare the means of age groups for the SOT composite score. An independent t-test was used to compare the SOT composite scores from our military population to the manufacturer's normative (civilian) data. The means and standard deviations for the eSOT scores were reported for each gain. Paired-samples t-tests were performed to compare the SOT composite score with the eSOT composite score for each level of gain. RESULTS: There was no difference between SOT composite scores for men and women (Mann-Whitney U = 4363.50, p = 0.19) or among age groups (Kruskal-Wallis = 2.77, p = 0.25). The mean SOT composite scores were not different from the manufacturer's normative values (p = 0.155). SOT composite scores were significantly higher than eSOT composite scores for gains of 1.4 (t = 3.16, p = 0.003), 1.6 (t = 5.73, p < 0.001), 1.8 (t = 5.26, p < 0.001) and 2.0 (t = 5.89, p < 0.001). MCT composite scores were lower in the 18-26 year old than the 36-45 year old age group (p = 0.013). SIGNIFICANCE: This study establishes normative values for the MCT, SOT and eSOT in active duty military service members. The results suggest that the manufacturer's normal values are appropriate for making judgments about the postural stability of service members.

Pre-operative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer.

In order to determine the extent and time course of upper limb impairment and dysfunction in women being treated for breast cancer (BC), and followed prospectively, a novel physical therapy surveillance model post-treatment was used. Subjects included adult women with newly diagnosed, untreated, unilateral, Stage I to III BC, and normal physiological and biomechanical shoulder function. Subjects were excluded if they had a previous history of BC, or prior injury or surgery of the affected upper limb. Measurements included body weight, shoulder ranges of motion (ROM), manual muscle tests, pain levels, upper limb volume, and an upper limb disability questionnaire (ULDQ). Measurements were taken at baseline (pre-surgery), and 1, 3-6, and 12 months post-surgery. All subjects received pre-operative education and exercise instruction and specific physical therapy (PT) protocol after surgery including ROM and strengthening exercises. All measures of function were significantly reduced 1 month post-surgery, but most recovered to baseline levels by 1-year post-surgery. Some subjects developed signs of lymphedema 3-12 months post-surgery, but this did not compromise function. Shoulder abduction, flexion, and external rotation, but not internal rotation ROM, were associated with the ULDQ. Most women in this cohort undergoing surgery for BC who receive PT intervention may expect a return to baseline ROM and strength by 3 months. Those who do not reach baseline, often continue to improve and reach their pre-operative levels by 1-year post-surgery. Lymphedema develops independently of shoulder function 3-12 months post-surgery, necessitating continued monitoring. A prospective physical therapy model of surveillance allows for detection of early and later onset of impairment following surgery for BC in this specific cohort of patients.

Characterization of lateral abdominal muscle thickness in persons with lower extremity amputations.

STUDY DESIGN: Retrospective review. OBJECTIVES: To describe bilateral thickness of the lateral abdominal muscles at baseline and during an abdominal drawing-in maneuver (ADIM) in individuals with unilateral transtibial (TTA) or transfemoral (TFA) amputations. BACKGROUND: Although side-to-side symmetry of lateral abdominal muscle thickness has been established in healthy individuals, the degree of symmetry in those with unilateral lower extremity amputations remains unknown. Differences in lateral abdominal muscle thickness may exist based on prior findings of asymmetry and differences measured based on level of amputation in both the size and function of the iliopsoas and back extensor muscles. METHODS AND MEASURES: Seventy patients (69 males, 1 female) with traumatic unilateral lower extremity amputations (TTA, n = 39; TFA, n = 31) received a rehabilitative ultrasound imaging examination. Absolute thickness of the transversus abdominis (TrA) and the external and internal oblique muscles combined (EO+IO) were assessed bilaterally at baseline and during the ADIM. Symmetry was assessed using relative muscle thickness values at baseline. Percent increase in muscle thickness during the ADIM was used to investigate muscle function. Separate 2-by-2 mixed-model ANOVAs were used to compare both within-group (side of amputation versus nonamputated side) and between-group (TTA versus TFA) differences for thickness and function of the TrA and the EO+IO muscles. RESULTS: On the side of the amputation, the relative baseline thickness of the EO+IO measurement was greater (P < .05), while the relative baseline thickness of the TrA muscle was smaller (P < .05). But the mean differences side to side were small (1.3%) and unlikely to be clinically significant. Further, there were no differences in baseline muscle thickness between groups for the TrA (P = .95) or the EO+IO (P = .94) muscles. For thickness measurements during the ADIM, the TrA showed no side-to-side (P = .74) or group (P = .07) differences. Similarly, no side-to-side (P = .60) or group (P = .09) differences were found in the EO+IO thickness during the ADIM. CONCLUSIONS: Despite the limitations of retrospective review, these findings provide an initial reference data set for future studies. Bilateral symmetry of the lateral abdominal wall muscle thicknesses at baseline and during the ADIM for those with unilateral lower extremity amputations is comparable to healthy individuals. Future studies should consider the potential influences of low back pain and gait training on symmetry of muscle thickness and muscle function based on level of amputation.

Normative values for the unipedal stance test with eyes open and closed.

PURPOSE: Limited normative data are available for the unipedal stance test (UPST), making it difficult for clinicians to use it confidently to detect subtle balance impairments. The purpose of this study was to generate normative values for repeated trials of the UPST with eyes opened and eyes closed across age groups and gender. METHODS: This prospective, mixed-model design was set in a tertiary care medical center. Healthy subjects (n= 549), 18 years or older, performed the UPST with eyes open and closed. Mean and best of 3 UPST times for males and females of 6 age groups (18-39, 40-49, 50-59, 60-69, 70-79, and 80+) were documented and inter-rater reliability was tested. RESULTS: There was a significant age dependent decrease in UPST time during both conditions. Inter-rater reliability for the best of 3 trials was determined to be excellent with an intra-class correlation coefficient of 0.994 (95% confidence interval 0.989-0.996) for eyes open and 0.998 (95% confidence interval 0.996-0.999) for eyes closed. CONCLUSIONS: This study adds to the understanding of typical performance on the UPST. Performance is age-specific and not related to gender. Clinicians now have more extensive normative values to which individuals can be compared.

Relationships among lateral abdominal muscles, gender, body mass index, and hand dominance.

STUDY DESIGN: Exploratory. OBJECTIVES: To explore whether hand dominance, gender, and body mass index (BMI) influence the thickness of the lateral abdominal muscles as measured by ultrasound imaging. To document the extent of improvement in response stability when an average of multiple measures was utilized. BACKGROUND: Ultrasound imaging is a relatively new tool used to assess the lateral abdominal muscles. A better understanding of how these muscles contract in a healthy population can provide a reference for comparison to patients with low back pain (LBP). METHODS AND MEASURES: Thirty-two healthy participants (17 males, 15 females) aged 18 to 45 years (mean +/- SD, 31.9 +/- 7.8 years) were studied. Measurements of muscular thickness of the lateral abdominal muscles were obtained bilaterally while the subjects were at rest, and while they performed the abdominal drawing-in maneuver. To determine the possible influence of hand dominance and gender on muscle thickness, t tests were used. Correlation coefficients were used to assess the relationship between BMI and muscle thickness. Standard error of the measurement was used to assess response stability of the ultrasound imaging technique. RESULTS: No differences in the thicknesses of the transversus abdominis (TrA) muscle were measured during rest or while contracted, based on hand dominance (P > or = .73). Men had greater muscular thickness (P<.01), while the TrA in women represented a greater proportion of the total lateral abdominal muscles (P<.01). BMI was positively associated with muscle thickness (r> or =.66). Compared to a singular measurement, response stability improved by greater than 50% when an average of 3 measurements was used. CONCLUSIONS: Future researchers should assess the need to control for gender and BMI as potential covariates in ultrasound imaging studies of the lateral abdominal muscles. Asymmetry in the lateral abdominal muscles in those with LBP would be in direct contrast to the bilateral symmetry measured in those without LBP.

Process of care for battle casualties at Walter Reed Army Medical Center: Part II. Physical therapy service.

Physical therapists, physical therapy assistants, and physical therapy technicians provide care to soldiers, sailors, Marines, and airmen returning from Operation Enduring Freedom and Operation Iraqi Freedom. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned at the beginning of the war.

Ride 2 Recovery's Project HERO: using cycling as part of rehabilitation.

Ride 2 Recovery was founded in 2008 by a former world-class cycling competitor and coach to enhance the physical and psychological recovery of our nation's wounded, ill and injured service members and veterans through the sport of cycling. Ride 2 Recovery's most notable endeavor is Project HERO (Healing Exercise Rehabilitation Opportunity) which uses staff members and volunteers to promote cycling as an integral part of rehabilitation at select military facilities to enhance physical, psychological, spiritual and social recovery. Project HERO is directed by a retired military physical therapist that spent the last decade caring for service men and women wounded in Iraq and Afghanistan. This article describes all facets of the Project HERO initiative and highlights the profound impact it has had in the lives of US military members and veterans.

Acetabular labral tears: diagnostic accuracy of clinical examination by a physical therapist, orthopaedic surgeon, and orthopaedic residents.

BACKGROUND: Previous studies have shown military physical therapists (PT) to have comparable clinical diagnostic accuracy (CDA) and interobserver agreement to orthopaedic surgeons (OS). However, no studies have examined hip pathology or used intraoperative findings as the reference standard for diagnosis. OBJECTIVE: To compare the CDA of physical examination findings among a PT, an OS, and two surgical orthopaedic residents (ORs) for hip labral tears. METHODS: Thirty-six patients (15 males, 21 females) aged 18-47 (mean + SD, 31.4 + 8.1 years) with 37 symptomatic hips were enrolled in a prospective study and underwent a standardized clinical examination followed by hip arthroscopy. A PT, an OS, and two ORs independently performed history and examinations with the emphasis of diagnosis on the results of six special tests. RESULTS: Thirty-two of 37 individuals (86%) had labral tears to the hip at arthroscopy. Analysis of agreement between clinical diagnosis and intra-operative findings of a labral tear produced a CDA of 85.3% (29/34 correct) for the PT, 84.4% (27/32 correct) for the OS, and 80.0% (24/30 correct) for ORs. No significant difference in CDA occurred in comparing the PT, OS, and ORs. CONCLUSIONS: Using arthroscopy as the reference standard, hip labral tears were clinically suspected with 80-85% accuracy. The clinical diagnostic accuracy of the PT, OS, and ORs was high with no significant difference between examiners. In this study, an experienced PT, an OS, and two ORs demonstrated similarly high diagnostic skills.