GeriNotes
2025 • Vol. 32 No. 1
GeriNotes
In This Issue
5 Happy Birthday: A History Primer of The Journal of Geriatric Physical Therapy! by Tim Kauffman, Mike Moran, Jennifer Bottomley and Neva Greenwald
7 Solving a Clinical Problem Through Invention: A New Four-Square Step Test Tool by Ian Sikora, PT, DPT
9 Unlocking Sleep: The Link Between Cognitive and Mental Health and Sleep: Part 2 of 3 by Alex Alexander, PT, DPT and Cathy Stucker, PT, DSc, CMPT
11 Walk to End ALZ: An Opportunity for Advocacy by Tori Kitts, PT, DPT & Bonnie L. Rogulj, PT, DPT
13 Using Available Literature: Guillain-Barre Syndrome by Taylor Drayton, PT, DPT and Suzanne Rodriguez, PT, DPT, MS
17 From Unsteady Gait to Trekking in Alaska: Use of a Clinical Practice Guideline for Functional Outcomes by Kathlene Camp, PT, DPT
22 Promote Physical Activity after Exercise Interventions in Parkinson’s Disease by Jessica Watson, PT, DPT and Jennifer Howanitz, PT, DPT
26 Congratulations to Another Cohort of APTA-Geriatrics Credentialed Balance & Falls Prevention Professionals! February 2025 • Vol. 32 No. 1
From the President
Cathy Ciolek President, APTA Geriatrics
While 2025 is starting with significant uncertainty in many aspects of research, policy and healthcare practices, I want to share that APTA Geriatrics is positioned to continue to provide services and advocacy for best practice physical therapy for older adults.
At the end of the year, we celebrated moving from a deficit budget projection to a balanced budget for the upcoming year. As everyone’s personal expenses have risen, we have also been faced with increasing expenses along with some investments to better position the Academy for the future. We are appreciative of wise investment by our previous leadership that helped us sustain services since the onset of Covid. For 2025, the board voted once again to maintain our current dues structure.
We had several long-term projects come to fruition in 2024. The revision of the Entry-Level Essential Competencies in the Care of Older Adults updated the 2011 first edition and linked the Geriatric 5M’s to the Domains of Competency. If you provide academic or clinical education to entry-level physical therapy students, please use the updated competencies while modifying your curricular content in geriatrics. Thank you to the team led by Karen Blood and including Justin Mierzwicki, Barbara Billek-Sawhney, Jill Heitzman, Lisa Dehner, Nicole Dawson and Greg Hartley. This document will assist with updating similar documents for post-professional training and the physical therapist assistant.
APTA Geriatrics Board of Directors
President: Cathy Ciolek, PT, DPT, FAPTA
Vice President: Myles Quiben, PT, DPT, MS, PhD
Secretary: Mariana Wingood, PT, DPT, PhD
Treasurer: Ken Miller, PT, DPT
Chief Delegate: Beth Black, PT
Director: Jill Fitzgerald, PT, DPT
Director: Suzanne Ryer, PT, DPT
Director: Annalisa Na, PT, DPT, PhD
Director: Kaelee Brockway PT, DPT
Another long-term project is the transition of the CEEAA credential program to move from 3 full weekends in-person, to a new hybrid format requiring only 1 in-person weekend. We hired Walden Group who specializes in adult education online learning along with Hybrid CEEAA coordinators Robin Schroeder and Jackie Osborne to review the content and create online modules to allow self-paced learning on a more convenient schedule. This course met our attendance objectives in its first year and will have expanded offerings in 2025! A big thank you to Jill Heitzman and Tamara Gravano who coordinated the CEEAA in-person program and to all the faculty over the years who helped deliver the training in exercise to elevate care for older adults.
The Board of Directors spent a good portion of 2024 preparing the 2025-2027 strategic plan. This started with an all member survey, some further digging focused surveys, and working with a consultant and our amazing staff to re-envision APTA Geriatrics Mission and Vision, and update our strategic priorities. APTA Geriatrics' vision is to champion exceptional practices that empower every person to achieve what matters most. APTA Geriatrics’ mission is to optimize the experience of aging by:
• Promoting the value, quality and accessibility of geriatric care.
• Providing life-long learning and mentorship that promotes innovative person-centered care.
• Building a passionate community for those called and committed to improving the human experience.
We hope you see yourselves and your work in this updated vision and mission. We are appreciative of your continued membership and the work you do each and every day for our patients, clients and students.
APTA Geriatrics Special Interest Group Chairs
Balance & Falls: Caryl Ventura,, PT, DPT
Bone Health: Aliya Decates-Miller, PT, DPT,
Cognitive & Mental Health: Alexandra Alexander, PT, DPT
Global Health for Ageing Adults: Mindy Oxman Renfro, PT, DPT, PhD
Health Promotion & Wellness: Heidi Moyer, PT, DPT
Residency & Fellowship: Chelsea Lavelle, PT, DPT
Skilled Nursing Facilities: Rich White, PT, DPT
Questions for APTA Geriatrics leaders and staff can be submitted to geriatrics@aptageriatrics.org.
APTA Geriatrics, An Academy of the American Physical Therapy Association
1818 Parmenter St, Ste 300 Middleton, WI 53562
APTA Geriatrics Staff
Executive Director: Christina McCoy, CAE
Education Manager: Jonathan Vega
Program Coordinator: Taylor St. John
Membership Manager: Kim Thompson
Marketing and Communications Manager: Abby Wicker/ Alex Connelly
Financials Manager: Gina Staskal, CNAP
APTA Geriatrics, An Academy of the American Physical Therapy Association
From the Editor
Michele Stanley Editor, GeriNotes
There’s always something new, changing, something to learn and experiment with. In this chaotic time, that has never been more true. In this issue, we experiment with a different process for publishing this magazine. While it is not as pretty as the ISSUU flip pages, we hope that you will find this pdf version more useful: feel free to download, print, and share articles that interest you. It should now be an Easy-Peasy process. Please send feedback!
At CSM the ongoing process of publication was often discussed and other ideas to supplement the print (and searchable) version of this magazine were put forward. There is an ongoing TaskForce for Reimagining GeriNotes and new volunteers have been added. Among ideas under consideration is a podcast following/in conjunction with each issue, or perhaps a virtual discussion similar to our Journal Club offerings. Stay Tuned! The one constancy of life, organizations, and publications is change.
In this issue, note the history of our journal. Thanks to former leaders and editors of APTA Geriatrics publications for sharing how progress evolves.
Register for the free Journal Club discussion webinars and earn 1.5 contact hours. Questions for presenters may be emailed to gerinoteseditor@gmail.com before or on the day of the webinar. See what's coming up at https://aptageriatrics.thinkific.com/collections.
GeriNotes
GeriNotes Editorial Board
Michele Stanley, PT, DPT
Debra Barrett, PT
Jennifer Bottomley, PT, MS, PhD
Kathy Brewer, PT, DPT, MEd
Chris Childers, PT, PhD
Jennifer Gindoff, PT, DPT, DHSc
Jill Heitzman, PT, DPT, PhD
William Staples, PT, DPT, DHSc, FAPTA
Ellen Strunk, PT, MS
GeriNotes Editor
Michele Stanley, PT, DPT
gerinoteseditor@gmail.com
Copyright © 2025 All rights reserved.
Published in January April June August November
Copy Deadlines
February 1
April 1
July 1
September 15
November 1
GeriNotes is the official magazine of the Academy of Geriatric Physical Therapy. It is not, however, a peer-reviewed publication. Opinions expressed by the authors are their own and do not necessarily reflect the views of the APTA Geriatrics. The Editor reserves the right to edit manuscripts as necessary for publication.
APTA Geriatrics does not endorse, publish, or promote products, services, or events sponsored or hosted by for-profit commercial entities. For-profit companies and corporations may request to advertise on any of APTA Geriatrics’ platforms at the published rates. All advertisements that appear in or accompany GeriNotes are accepted on the basis of conformation to ethical physical therapy standards. Advertising does not imply endorsement by APTA Geriatrics.
Mission: To provide engaging content that empowers the community of physical therapy clinicians to build expertise and expand the delivery of evidence‐informed care that promotes health and wellness in aging adults.
Vision: To create an evolving online community through which clinicians develop their knowledge and skills based in shared ideals that are person‐centered; and promote a world where aging adults move, live, and age well.
Happy Birthday: A History Primer of The Journal of Geriatric Physical Therapy!
by Tim Kauffman, Mike Moran, Jennifer Bottomley and Neva Greenwald
A resounding congratulations and thanks are due to the Section on Geriatrics leaders of 30 years ago for starting its reereed journal, entitled originally, Issues on Aging; this evolved into the present Journal of Geriatric Physical Therapy. One of the most significant advances over the past 50 years has been the splitting of our publications:
1) GeriNotes, a magazine with clinically relevant information and resources.
2) Journal of Geriatric Physical Therapy, a peer reviewed publication that provides invaluable research specific to geriatric physical therapy, is indexed in CINAHL and recognized by the medical community for the richness and integrity of the articles published. The quality, depth and relevancy of this publication has been remarkably enhanced and enriched since its conception and is recognized as a top-notch source for geriatric research on a national and international level.
APTA Geriatrics has experienced a tremendous amount of progress and change over the past 5 decades. The healthcare environment in which we now practice is considerably different than it was when the inspiration to develop a section (now academy) specific to the needs and interests of those therapists caring for older adults was pursued. The vision of our founders was remarkable and on target. It was ahead of the “age wave.” The necessity for the establishment of a journal specific to research in the area of Geriatrics came along with our push towards specialization. The Academy has become a strong advocate and influential leader for the unique therapeutic and legislative requirements of the older adults that we serve, within the APTA, but also on a national/federal policy level, and an international level with our involvement within WCPT and other international organizations. The need to solidify an “evidence-based” practice led to the publication of a research journal.
History is foundational, important, and too often “swept under the table.” We have much to celebrate as the journal has been published for 3 decades and the Academy of Geriatric Physical Therapy reaches its Golden Anniversary in 2028.
It all started when in 1969 Joan Mills accepted a physical therapy position in a general hospital that had a 200-bed long term care unit. She found patients with contractures, bedbound, or chair- ridden. Joan was frustrated with the debasing ageist attitudes from other care providers. She found no help from the medical library. One physician told her: “…don’t waste time on
those old people — there is enough to do in the acute hospital. We can give them Thorazine and make them happy.” At that time, Medicare was in effect only 3 years and life expectancy in the United States was 70.1 years.
Undaunted, Joan established clinical affiliations with academic programs so that PT students would gain experience treating aging patients. Additionally, she gathered interest among other physical therapists and followed the American Physical Therapy Association’s procedure to submit a petition to start a new “Long Term Care Section.” In 1977, the APTA Board of Directors (BOD) rejected her petition and asked questions about “long term care” as part of physical therapy for all age groups, such as persons with spina bifida, cerebral palsy, strokes and other conditions. Is this possible new section focused on a “special area of therapy” such as geriatrics?
The following year, the APTA BOD approved the formation of the newly named Section on Geriatrics (SOG). The cost of joining the Section was $10.00. Joan Mills was chosen as the Chairman; Ray Gatian was named the Newsletter Chairman. For several years the Newsletter had no special name, but the Summer 1981 Issue was published as Geri-topics. Fran Kern was the Publications Chairman/Editor and Clara Bright, the Subscription Mgr. Other members of the Publications Committee were Osa Jackson, Carole Lewis, Marilyn Miller, and Otto Payton.
Fifteen years after the SOG inception, recognizing that more scientific articles were being published in the newsletter, the SOG BOD decided to start a separate more professional journal. Issues on Aging began in 1993 with the Winter Issue, Volume 16, Number 1. Then SOG president Neva Greenwald formalized the continuing split between newsletter and journal “a separate more scientific publication devoted to geriatrics/gerontology from the physical therapy perspective (Issues on Aging).” The refereed journal started as Volume 17, Issue 1 in November 1994. Thus, the Journal of Geriatric Physical Therapy became 30 years old in 2024. Michael Moran PT, ScD was named editor; by the 2nd issue, Edmund Kosmahl PT, EdD became Associate Editor. The journal evolved into a publication that was recognized as “top notch” research – beyond the realm of PT. The Editorial Board included Dale Avers, John Barr, Jennifer Bottomley, Mark Brimer, Marybeth Brown, Neva Greenwald, Tim Kauffman, Jane Koons, Dave Patrick and LaDora Thompson. Sharon Klinski provided all the nitty gritty of editorial publication and was invaluable to the success
of the Journal. One significant achievement was that the new journal was indexed in CINAHL after only two issues.
With the Fall 1996 issue, Ron Scott, JD, PT, OSC took over the leadership and Ed Kosmahl stayed as Associate Editor. Kate Kline-Mangione PT, PhD assumed the position of interim Editor in 2001; at that time the name was changed to the Journal of Geriatric Physical Therapy, Volume 24, Number 3, 2001.
Richard Bohannon, PT, EdD. assumed the Editorin-Chief position with the first issue in 2002. He led the journal until 2007, Volume 30, Number 1 at which time he announced that the Journal of Geriatric Physical therapy had been recognized by acceptance into the Cumulative Index for Nursing and Allied Health; the Allied and Complementary Medicine Database; PubMed/Medline, and Embase. Our refereed journal was available worldwide!
Michelle Lusardi, PT, PhD assumed the tutelage in 2007, Volume 30, Number 1, 2007. During her leadership,
she added Associate Editors, and the Journal increased to 48 pages and to a quarterly publication in 2009. In her last issue as Editor, she reported that the Journal was ranked as 35 of 45 journals in the content area of geriatrics and gerontology.
The Editor-in-Chief position was re-assumed by Richard Bohannon with Volume 36, Number 2, 2013 during which time the number of submissions increased as did the impact factor of the Journal.
Leslie Allison, PT, PhD, our present Editor, took command in 2018, Volume 41, Number 3 and gives her utmost to produce a valuable resource to the members of the Academy of Geriatric Physical Therapy. The Journal is now available to readers across the world in medical libraries in most countries.
Happy Belated Birthday Journal of Geriatric Physical Therapy!
Solving a Clinical Problem Through Invention: A New Four-Square Step Test Tool
by Ian Sikora, PT, DPT
Some DPT programs now integrate basic business education into the curriculum by inviting practice owners to provide students with information that complements the basic sciences and hands-on techniques that typically characterize physical therapy education. Students are rarely exposed to the business of product design. Before I began inventing, I was unfamiliar with the design, manufacture, legal, and marketing aspects of intellectual property. I hope to give aspiring movement professionals insight into the inventing process by sharing my experience developing a physical therapy product.
Physical therapists are problem solvers by nature. When clinical dilemmas occur, they must think quickly to design appropriate interventions using the tools of the trade (boxes, balance pads, elastic bands, weights, etc.) to challenge their clients effectively. But what happens when the available equipment doesn't meet the therapist’s needs?
I found myself in that situation a few years ago. As a PT who works primarily with older adults, I use the FourSquare Step Test (FSST) with many people but felt the intervention had more potential, especially for patients ready for more challenges.
Existing solutions to this dilemma took more time than I had set up. As busy physical therapists know, any assembly that detracts from patient care or point-of-service billing isn’t ideal. I set about designing a FSST tool that was easily adjustable for patients of all abilities.
This idea required designing and building multiple prototypes. It entailed learning the details of injection molding, manufacturing processes, and international shipping. I also needed to become familiar with legal issues related to inventing, such as provisional patents, utility patents, and trademarks. It required studying the benefits and drawbacks of the various inventor business relationships, and I needed to learn the nuances of communication with team members in different countries.
The first challenge to overcome was producing a functional prototype. I constructed simple models of my ideas using basic tools (table saws, screwdriver). I was familiar with the rudimentary use of these tools, but I would not describe myself as particularly “handy,” so I relied on internet tutorials to guide me through more complex techniques. The supplies I needed (wood, screws, glue, and nails) were readily available at the local hardware store. Any specialized material I required was easily found online. Those familiar with product design software (Solid Works, for example) and 3-D printing could produce prototypes in a more sophisticated manner,
but I have found my methods to be sufficient for generating effective models (pictures of prototypes)
Before sharing my designs with others, I filed a Provisional Patent Application (PPA) with the United States Patent and Trademark Office (USPTO). A PPA provides inventors an economical way to shop their product to potential customers for a year before committing to a full Utility Patent, which can cost over $10,000. While some inventors feel comfortable filing a PPA without the help of a lawyer, I enlisted the assistance of a Registered Patent Attorney. I also filed for a trademark on my product’s name. As my ideas and prototypes changed, I filed additional PPAs to protect each new product iteration. Internet resources helped to limit my costs during this stage, as I prepared large portions of the PPAs myself. Inventors can also utilize free services at local law schools for information and help with patent matters.
With legal protection in hand, I considered how to bring my idea to market. Inventors have various options when selling their products, including venturing, licensing, and partnering. Venturing a product requires an inventor to fund, design, build, market, and distribute their product. Licensing an idea shifts many business responsibilities to an established company; the inventor collects a royalty payment for each product sold. A licensing inventor may make less money from their idea but they don’t have the costs, responsibilities, or stresses accompanying venturing. Business burdens in a partnership are shared between the manufacturer and the inventor.
It is critical to understand royalty rates if one plans to license an invention. Many companies will offer inventors a royalty rate between 3-5% of an item's wholesale price (roughly half of the retail price). Before a PT inventor thinks of signing their last SOAP note and buying a beach house with their invention proceeds, they should first estimate how many units they would need to sell to finance such a purchase. A $50 item might pay its inventor between $.75 and $1.25 per unit sold (between 3-5% of the wholesale price of $25). If a successful PT product sells 10,000 units annually, the inventor will earn between $7500 and $12,500. Many PT products will sell substantially fewer than 10,000 units per year, so inventors should be realistic regarding income potential if they plan to license their physical therapy tool.
Venturing offers an inventor a much greater financial reward, but it comes with a substantial increase in time commitment and financial responsibilities. Choosing
the right approach (venturing, licensing, or partnership) depends on measuring your free time, financial resources, risk tolerance, and business acumen.
The licensing approach attracted me as a full-time physical therapist with limited business experience. Before contacting any potential licensees, I needed a sell sheet (a one-page promotional advertisement) and a demonstration video. I had no experience with Photoshop and minimal familiarity with video editing software. Through the use of internet tutorials, I developed simple promotional material that promoted the benefits of my idea.
Examples of Invention & Use
View videos here: vimeo.com/1025875655 vimeo.com/1026095091 vimeo.com/1025876402
Outfitted with a sell sheet and video, I began searching for a company interested in my idea. This aspect of inventing is time-consuming, as it can take weeks or even months to establish contact with a company and sometimes longer to encourage a potential licensee to review an idea submission. None of the physical therapy or physical education equipment manufacturers I contacted (approximately 30) were interested in my initial product designs, stating that the appeal of my idea was too narrow. This encouraged me to refine the invention and marketing materials to appeal to a broader audience. When I settled on my final design, I reconfigured my sell sheet and demonstration video to reflect the improvements and began contacting companies again. I was fortunate to find an equipment manufacturer who
saw the value of my FSST tool. We settled on a partnership rather than a licensing agreement, meaning I would shoulder more responsibility for designing and promoting the product.
At this point in my endeavor, I learned that my prototype could not be produced as I had designed. It needed the input of an industrial designer. Design professionals are familiar with injection molding, which produces the plastic components found in everyday items. It is crucial to have an appropriate design, as injection molds are quite expensive, and any errors will delay a product launch and incur extra expenses. I sent my prototype to an industrial designer and received plans for a proper injection molding design.
My partner company then introduced me to their foreign manufacturer and translated my vision for the product to a team overseas. The initial prototypes I received were not strong enough to withstand the rigors of clinical use and cracked when patients stepped on them. Each new iteration of the idea took weeks (if not months) of turnaround time due to shipping delays and communication difficulties. This part of the inventing process was frustrating for a physical therapist accustomed to the speed of point-of-service documentation.
Once the manufacturing details were settled, I converted my PPA to a full Utility Patent. This was a big step for me, as I was cautioned that fewer than 5% of inventions will generate enough income to cover the expense of filing such protection. Before this decision, my investment in the invention was only time, negligible equipment expenses, and approximately $3000 in legal fees related to PPAs and trademark applications. The total cost of a Utility Patent depends on your patent attorney’s hourly rate, the amount of work the inventor contributes to the patent preparation, and the amount of office actions required by the USPTO.
Now that the design is finalized, the manufacturing is settled, and legal protection has been initiated, my role in the invention's success is producing educational videos, coordinating graphic design and manufacturing details, marketing, and developing extensions of the original idea.
The designing, patenting, manufacturing, and marketing of my idea has been a difficult but rewarding experience. It required a spark of creativity, a little disposable income, some risk tolerance, a lot of patience, a willingness to learn new skills, and the devotion of significant time to bring it to life. Ultimately, I hope my product assists physical therapists assess and train balance, producing better outcomes for the people they serve. By sharing my invention journey, I also endeavor to help other therapists translate their clinical knowledge and ingenuity into novel tools that elevate our profession.
Ian Sikora, PT, DPT is a Board Certified Geriatric Clinical Specialist and Credentialed Balance and Fall Prevention Professional. He works at Active Life and Sports Physical Therapy in Perry Hall, MD.
Unlocking Sleep: The Link Between Cognitive and Mental Health and Sleep: Part 2 of 3
by Alex Alexander, PT, DPT and Cathy Stucker, PT, DSc, CMPT
Good sleep quality becomes increasingly important with aging. For those over the age of sixty-five it is recommended that an individual get at least seven hours of sleep each night. Recent research shows 28.1% of people over the age of sixty-five do not get the recommended hours of sleep.1 Chronic late-life insomnia can affect up to 50% of older adults, with incidence in women typically higher than in men.2 Sleep parameters, including REM sleep and delta wave amplitude, are reduced with aging resulting in fragmented sleep, difficulty falling asleep and maintaining sleep. This sleep deprivation is associated with predictable cognitive deficits beyond those associated with normal aging. This effect on cognition can manifest in declines in balance, attention, reaction time, episodic memory, learning, temporal order judgment and time estimation, allocating attention to a target, and executive function.3
Poor sleep quality affects the ability to perform and participate in day-to-day tasks, especially in those people who also have pre-existing cognitive decline. Some consistent findings related to poor sleep quality can include:
• Daytime sleepiness
• Mood changes including frustration, anger, anxiety, or depression
• Difficulty concentrating, focusing, or performing executive functions
• Experiencing hunger, especially for unhealthy snacks and sweets
• Reports of snoring, restlessness, or gasping for air while sleeping
• Reduced reaction time
Prevalence Of Sleep Disorders
According to the American Psychiatric Association, more than 50 million Americans suffer from sleep related disorders.4 The most common sleep related disorders include: insomnia, sleep apnea, hypersomnolence, narcolepsy, and restless leg syndrome (RLS). Of the sleep related disorders, insomnia and sleep apnea are the most prevalent with insomnia affecting roughly 33% of adults and obstructive sleep apnea (OSA) affecting up to 38% of adults. Another staggering statistic estimates up to 50% of people with insomnia are also struggling with another mental disorder.4
Screening For Sleep Habits
Identifying sleep deficits is important to include during the patient intake process. The following questions
should be added to the patient intake process/form:
• How would you rate the quality of your sleep on a scale from 1 to 10?
• Do you have any medical conditions that may affect your sleep (e.g., pain, respiratory issues)?
• Have you been told you have a sleep disorder (e.g., insomnia, sleep apnea, restless leg syndrome)?
• When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?
Screening tools can be provided to further identify issues with sleep and screen for sleep related disorders. The following screening tools are self reported measures that can be added to the patient intake process. They can be valuable for identifying details about sleep and sleep habits to help guide recommendations:
• Pittsburgh Sleep Quality Index: A 24-item questionnaire that addresses typical sleep patterns, sleep quality, use of sleep medication, overall participation, and reported sleep issues from a partner. It is a good screening tool for identifying sleep habits and characteristics of a patient’s sleep quality. A score >5 suggests significant sleep difficulties.5
• Epworth Sleepiness Scale: An 8-item questionnaire asking how likely the person is to fall asleep in different scenarios. A score of ≥10 indicates concern.
• Sleep Hygiene Index: A 13-item questionnaire that identifies typical behaviors that provide information about a person’s sleep habits. Scores range from 0 to 52. Score >35 are indicative of poor sleep hygiene.
Sleep Disorders Assessment Tools
Specific assessment tools are available to identify those individuals who would benefit from referral to a sleep expert. These tools can be used to identify severity of symptoms and make appropriate referrals but should not be used to provide a medical diagnosis. The most common sleep disorders are being addressed here, but other conditions may also benefit from referral to a sleep specialist. Good sleep hygiene is very important for overall health, therefore if any concerns arise with a patient do not hesitate to recommend follow-up with a sleep specialist.
Insomnia Severity Index (ISI)
The Insomnia Severity Index rates the impact of insomnia on day-to-day life. The range of scoring is from 0-28, with ≥10 suggesting severe clinical insomnia with
86.1% sensitivity and 87.7% specificity.6 The ISI consists of 5 questions that address the severity of symptoms, satisfaction with sleep pattern, extent that insomnia interferes with function, how noticeable the problems are, and how much it worries or distresses them. The scores are based on a 5-point Likert scale.
STOP-BANG Questionnaire
The STOP-BANG Sleep Apnea Questionnaire is an assessment tool to determine risk for obstructive sleep apnea (OSA). Sensitivity for the STOP-BANG ranges from 83.6%-100% depending on the severity of OSA with higher sensitivity observed in individuals with more severe OSA.7 The acronym STOP includes questions on Snoring, Tiredness, Observation of stopping breathing while sleeping, and high blood Pressure. The BANG acronym includes BMI, Age, Neck circumference, and Gender. It is a YES/NO scale ranging from 0-8 with points assigned to every YES response. A score of 5-8 is indicative of a high risk of OSA and a score of 3-4 indicates intermediate risk.
Restless Legs Syndrome (RLS) Assessment
Restless Legs Syndrome is a condition of persistent and overwhelming urge to move the legs while resting and can be accompanied with unpleasant sensations. It is a neurologic condition affecting 5-10% of adults. An answer of “YES” to the following simple screening question has 100% sensitivity and 96.8% specificity for the likely diagnosis of RLS and is easily included on a patient intake form: “When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?”8 The Restless Legs Syndrome Rating Scale is an additional assessment tool that provides more detail related to RLS. It consists of 10 questions rated on a 5-point Likert scale with a total of 40 points and an ordinal severity scale completed by the patient. A score of 21-30 is indicative of severe RLS while a score of 31-40 indicates very severe symptoms.
Next Steps
If you suspect your patient is suffering from a sleep related disorder and they score high or screen positive on the above referenced tools, please refer the patient back to their primary care provider or a board certified sleep specialist to discuss their concerns. Diagnosing these conditions must be left to the physician and is not within a physical therapist’s scope of care, unless specially trained and certified.
Sleep Decision Tree
The sleep decision tree is a tool to be utilized to help determine the next course of action based on patient symptoms that was created by Alex Alexander, PT, DPT and Cathy Stucker, PT, DSc, CMPT to determine how
physical therapy can make an impact on sleep quality and mental health:
• Include sleep screenings in evaluations and remain diligent in identifying mental health components
• Establish policies that provide direction for referral when sleep issues are identified
• Understand the challenges of sleep health across the lifespan
• Work to eliminate causes of sleep health disparities and promote healthier environments to support sleep health through education
Watch for Part 3 of this series which will include a Sleep Hygiene Patient Handout that is ready to share with your patients!
References
1. Marshall S. Sleep statistics and facts. NCOA Adviser. https://www. ncoa.org/adviser/sleep/sleep-statistics/#:~:text=More%20than%20 a%20third%20of,38%25%20of%20the%20general%20population. Published March 11, 2024. Accessed September 26, 2024.
2. Lichstein KL, Durrence HH, Riedel BW, Taylor DJ, Bush AJ. Epidemiology of sleep: Age, gender, and ethnicity. Psychology Press, 2013.
3. Haismov I, Shatil E. Cognitive training improves sleep quality and cognitive function among older adults with insomnia. PLOS One. 2013;8(4):1-17. e61390. doi:10.1371/journal.pone.0061390.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), Fifth edition - Text Revision.2022.
5. Buysse DJ, Reynolds CF, MonkTH, Berman SR, Kupfer DJ (1989). The Pittsburgh Sleep Quality Index (PSQI): A new instrument for psychiatric research and practice. Psychiatry Research. 1989; 28(2):193-213.
6. Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601-608. doi:10.1093/sleep/34.5.601
7. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. doi:10.1097/ALN.0b013e31816d83e4
8. Ferri R, Lanuzza B, Cosentino FI, Iero I, Tripodi M, Spada RS, Toscano G, Marelli S, Arico D, Bella R, Hening WA. A single question for the rapid screening of restless legs syndrome in the neurological clinical practice. European journal of neurology. 2007;14(9):1016-21. https:// doi.org/10.1111/j.1468-1331.2007.01862.x.
Alexandra Alexander PT, DPT, GCS is a Board-Certified Clinical Specialist in Geriatric Physical Therapy and is chair of APTA Geriatrics Cognitive and Mental Health SIG. Alex graduated with her Doctor of Physical Therapy from Carroll University in Waukesha, WI in 2017. Alex works in the home health setting right outside of Nashville, TN. She is a big proponent for older adults and optimal/healthy aging. She is passionate about hospice and works as a hospice PT at her agency.
Cathy Stucker,PT, DSc, CMPT, GCS, CEEAA has practiced for over 30 years in various practice areas, including outpatient orthopedics, sports medicine, industrial rehab, acute care, skilled nursing facilities, and home health. She continues to practice per diem in the home health setting. She is a Clinical Associate Professor with Northern Arizona University Hybrid DPT Program.
Walk to End ALZ: An Opportunity for Advocacy
by Tori Kitts, PT, DPT and Bonnie L. Rogulj, PT, DPT
Alzheimer’s disease (AD) is the most common type of dementia.1 Although Alzheimer’s is not a normal part of aging, the best known risk factor for the disease is aging.1 Presently, nearly 7 million Americans are living with the progressive disease and the number is expected to rise to an astonishing 14 million by 2060.1-3 As the number of individuals diagnosed with Alzheimer’s is projected to increase, the annual costs associated with treating the disease are estimated to more than $500 billion by 2040 and nearly $1 trillion by 2050.1,4
In my roles as both a licensed Physical Therapist (PT) and active community member, it is imperative to advocate for awareness of Alzheimer’s disease (AD). In the clinical setting, I am able to advocate for early diagnosis and intervention among at-risk individuals such as older adults and individuals with a family history.1 Examples may include performing routine screenings and providing education on warning signs, such as memory loss that disrupts daily life, changes in mood and personality, and difficulty with spatial relations.5 In the community setting, I am able to advocate by participating in local events such as the “Walk to End Alzheimer’s”, fundraising, and sharing with others the commitment by the Alzheimer’s Association® to end Alzheimer’s.
The “Walk to End Alzheimer’s” is hosted annually in more than 600 community locations across the nation by the Alzheimer’s Association.®2 The event has grown in popularity to become the world’s largest fundraiser to fight Alzheimer’s.2 The funds raised by participants in the “Walk to End Alzheimer’s” contribute toward efforts including (but not limited to) providing critical support, research, treatment, and finding a cure.2
I participated in last year’s “Walk to End Alzheimer’s” in my local community of Jacksonville, Florida. I was able to successfully fundraise over $500 and spread awareness through social media platforms (e.g., Facebook and Instagram). Many others felt inspired by my advocacy efforts and began to share their own personal experiences related to Alzheimer’s disease.
Once again, I am registered to participate in my local “Walk to End Alzheimer’s” event with the goal of encouraging fellow PT professionals to advocate for the more than 55 million individuals living with dementia worldwide and to join the fight to end Alzheimer’s.2 To become a registered participant for a future “Walk to End Alzheimer’s” event, individuals will need to first access the Alzheimer’s Association® website at www.alz.org, then start or join a team, and finally spread the word!
References
1. Alzheimer’s Disease and Healthy Aging. Centers for Disease Control and Prevention. Updated October 26, 2020. Accessed September 2, 2024. https://www.cdc.gov/aging/alzheimers-disease-dementia/about-alzheimers.html
2. Walk to End Alzheimer’s. Alzheimer’s Association. 2024. Accessed September 2, 2024. https://act.alz.org/site/SPageServer/?pagename=walk_ homepage&utm_source=google&utm_medium=paidsearch&utm_campaign=walk24&s_subsrc=digitaladsearchwalk24new&gad_source=1&gclid= CjwKCAjwxNW2BhAkEiwA24Cm9Nq23n7fRZK7VRYFq056NMlidP_X6vQmO3jYjYOvyRC1eo7AWsV_NxoC9x0QAvD_BwE
3. Matthews KA, Xu W, Gaglioti AH, et al. Racial and ethnic estimates of Alzheimer's disease and related dementias in the United States (2015-2060) in adults aged ≥65 years. Alzheimers Dement.2019;15(1):17-24.
4. Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med. 2013;368(14):1326-1334.
5. Alzheimer’s Disease and Healthy Aging: 10 Warning Signs of Alzheimer’s. Centers for Disease Control and Prevention. Updated October 26, 2020. Accessed September 2, 2024. https://www.cdc.gov/aging/healthybrain/ten-warning-signs.html
Tori Kitts, PT, DPT graduated from the University of St. Augustine for Health Sciences in 2024. She is deeply committed to empowering her patients through individualized care. Her passion for volunteer work and community advocacy shines through in her involvement with events like the "Walk to End Alzheimer’s," where she blends her professional expertise with a heartfelt dedication to making a difference. Dr. Tori Kitts believes in the power of movement, both in therapy and in life, to create lasting change.
Dr. Bonnie L. Rogulj is an Assistant Professor at the University of St. Augustine for Health Sciences (USAHS) and was mentor to Dr. Kitts in writing this article. She completed an accredited geriatric residency and is a board-certified geriatric specialist (GCS). Dr. Rogulj is a credentialed APTA Falls and Balance Professional and has completed certifications in Stepping On, OTAGO, STEADI, and Mental Health First Aid (MHFA). Presently, Dr. Rogulj is completing a PhD degree at Liberty University. Dr. Rogulj is interested in research related to aging, health/wellness, and higher education.
Using Available Literature: Guillain-Barre Syndrome
By Taylor Drayton, PT, DPT and Suzanne Rodriguez, PT, DPT, MS
Therapists working in subacute care facilities frequently encounter a wide range of diagnoses common among older adults, including medical, neurological, and orthopedic conditions. These conditions often result in prolonged immobility, leading to generalized weakness and reduced activity tolerance, which can severely impact a person’s ability to move and function independently. In subacute settings, patients receive both nursing care and rehabilitative services aimed at addressing their medical and functional needs, with the ultimate goal of helping them return to their previous living environment at or near their premorbid functional level. Occasionally, therapists come across rare diagnoses that are less commonly seen—Guillain-Barré syndrome is one such example.
Guillain-Barré syndrome (GBS) is an acute autoimmune inflammatory neuropathy, characterized by demyelinating polyneuropathy, and is the leading cause of acute flaccid paralysis worldwide.1,2 It is considered a neurological emergency due to the severe complications that can arise from its onset.1,2 In approximately two-thirds of cases, GBS is triggered by a preceding upper respiratory or gastrointestinal infection, which leads to progressive, ascending weakness in the limbs.1-3 The most common form, acute inflammatory demyelinating polyradiculoneuropathy (AIDP), presents with primary demyelination, progressive paralysis, and areflexia.1-4 Although GBS can affect individuals of any age, it is most frequently seen in young adults and those in their 50s to 80s, with a slightly higher incidence in white men.1,3 Patients typically experience the peak of their weakness within 2 to 4 weeks, followed by a plateau phase lasting another 2 to 4 weeks, before recovery begins in a proximal-to-distal pattern—a process that can take months or even years.1,3
Treatment for Guillain-Barré Syndrome is tailored to the severity of the condition and the stage of recovery. Medical management typically includes high-dose intravenous immunoglobulin therapy and plasmapheresis to address the autoimmune response effectively.1-3
Although mortality rates among individuals with GBS are generally low, complications can arise, including respiratory failure requiring mechanical ventilation, cardiovascular instability, blood pressure fluctuations, and cardiac arrhythmias.1,5 Poor prognostic factors include older age at onset, a prolonged period before recovery begins, and the necessity for mechanical ventilation.1,3,5 While the majority of individuals achieve full recovery, up to 20% may experience lasting neurological deficits.1,3 Persistent complications following recovery can include neuropathic pain, autonomic dysfunction, and distal extremity weakness.1,3
Case Presentation: Mr. T, a 69-year-old male, presented to the emergency department with complaints of progressive lower extremity weakness and a noticeable reduction in his vocal strength. His symptoms had gradually developed over the previous twelve days, following an episode of food poisoning.
In the hospital, Mr. T underwent an extensive evaluation, with differential diagnoses including peripheral neuropathy and multiple sclerosis. His acute diagnostic workup included MRI, CT scan, lumbar puncture, blood tests, and nerve conduction velocity studies. Ultimately, Mr. T met the criteria for a diagnosis of Guillain-Barré syndrome and was admitted for treatment. Upon admission, he required mechanical ventilation via endotracheal intubation, which was later transitioned to a tracheostomy for continued respiratory support. Additionally, a percutaneous endoscopic gastrostomy (PEG) tube was placed to manage his nutritional needs.
Mr. T spent a total of 12 weeks between the acute care hospital and a Long-Term Acute Care Hospital (LTACH), during which he was successfully weaned off both the ventilator and PEG feeding. Following this, he was discharged to a subacute rehabilitation facility to continue his recovery and rehabilitation.
Mr. T had a notable history of chronic mechanical low back pain and reported having undergone twelve spinal surgeries, though he continued to experience right foot drop despite these interventions. He also had a long history of heavy smoking but quit 2 years prior to his current diagnosis. Additionally, Mr. T managed type II diabetes through glucose monitoring and medication. During his stay in the acute hospital, no immunological interventions were administered.
During his subacute stay, a key pharmacological intervention to improve participation in rehabilitation services included the administration of Lyrica, prescribed to address significant nerve pain and discomfort as function and sensation improved. Additional medications administered during this period included Ambien, Crestor, Cymbalta, Flomax, Albuterol, Levothyroxine, Midodrine, Oxycodone, MiraLAX, and Senna.
Prior level of function/ Social History: Mr. T lives with his wife in a two-story home with several steps at the entrance. His primary bedroom and bathroom are located on the second floor. A successful business owner, Mr. T, worked full-time managing his business ventures until his recent hospitalization. Prior to being admitted, he was able to walk both household and community distances without the need for an assistive device. He was independent in all activities of daily living and maintained
a moderately active lifestyle, primarily to oversee his various business operations, though he was not particularly active outside of work.
Examination: In the subacute care setting, examination revealed a tall, alert male lying in a hospital bed, fully oriented to person, place, time, and situation. Mr. T wore glasses with a prism lens modification on his right eye to address double vision. He exhibited generalized lower extremity weakness, as evidenced by manual muscle testing (MMT). The most significant motor loss was in the distal lower extremities, with ankle dorsiflexion and plantar flexion both rated 0/5 MMT during the initial evaluation. Knee flexors and extensors were graded at 1+/5 MMT, while hip flexors (assessed in a gravity-eliminated position) were rated 2/5 MMT. Upper extremity strength showed better volitional control, with shoulder and elbow flexors and extensors rated 2/5 MMT, although hand strength remained weak, measured at 1/5 MMT. Sensory loss was noted symmetrically in the lower extremities below the knees and in both hands, following a stocking-glove distribution. Mr. T had no sensation of bowel or bladder function and was managed for urinary incontinence with a Foley catheter. A functional assessment indicated that he required maximal assistance from two people for bed mobility, slide board transfers from wheelchair to bed, and a Hoyer lift was necessary for nursing staff to assist him.
Assessment: A comprehensive examination was performed after collecting relevant medical history, details about Mr. T’s living environment, and current medical interventions through chart review, interviews with the patient and family, and communication with the interdisciplinary team. Mr. T presented with generalized weakness in his extremities, impaired functional mobility, inability to ambulate, poor balance, and reduced activity tolerance. Skilled physical therapy was recommended to target these impairments and improve Mr. T’s overall functional mobility, with the goal of helping him regain his baseline level of independence.
Intervention: Therapeutic exercises were implemented to promote muscle activation in the lower extremities and improve overall function. While there are no established clinical practice guidelines (CPGs) for the treatment of Guillain-Barré syndrome, current research supports the effectiveness of high-intensity exercise in facilitating recovery.6-9 Early treatment focused on closely monitoring for signs of muscle overuse, as GBS-related fatigue or relapse can occur.5,7 Consequently, the therapeutic approach during the initial stages with Mr. T was more conservative to prevent overexertion.
Initial lower extremity therapeutic exercises included active-assisted movements in gravity-eliminated positions, such as supine and side-lying, with gradual progression to active exercises incorporating progressive overload. Electrical stimulation was used to facilitate contraction of the anterior tibialis muscle to promote
active dorsiflexion. Core and trunk strengthening exercises were also introduced, starting in supine and progressing through supported sitting, unsupported sitting, prone, quadruped, and eventually standing positions. As the program advanced, strengthening activities were intensified, aiming for a 6-8/10 on the Rate of Perceived Effort (RPE) scale to appropriately challenge the body and stimulate progressive overload for strength gains. 6,7,10,11
Mr. T exhibited a quicker recovery of upper extremity function compared to lower extremity function.
Postural control was a key focus in the early stages, particularly in unsupported sitting, where external perturbations such as nudges and reaching activities were used to engage the abdominal muscles. Weightbearing exercises were incorporated to improve tolerance to upright positions and reduce the negative effects of immobility. Early standing trials were performed in a standing frame with moderate assistance from both the occupational therapist (OT) and physical therapist (PT), eventually progressing to standing in the parallel bars with maximum assistance from one person for lower extremity management and moderate to maximum assistance from two for upper extremity support. Standing trials were initially limited due to orthostatic hypotension, which was closely monitored throughout his care. With medical management, including fluid administration, medication adjustments, use of an abdominal binder, and TED stockings, Mr. T gradually tolerated longer standing trials. This led to the eventual resolution of his orthostatic hypotension and the discontinuation of both the abdominal binder and TED stockings.
As Mr. T advanced in his standing ability, the Lite Gait system was introduced for initial gait training.12 He required moderate to maximum assistance for lower leg placement, along with an ankle-foot orthosis (AFO) to provide support for lateral ankle instability. Guided by the CPG for locomotion in individuals with chronic stroke, incomplete spinal cord injury, and brain injury, highintensity gait training was incorporated into the plan of care, with appropriate safety precautions and close monitoring.13 At the time of discharge, Mr. T was able to ambulate 120 feet using a rolling walker with contact guard assistance from one person and dorsiflexion assistive devices for bilateral foot clearance.
Transfer training initially emphasized bed mobility using a bed rail with progression from maximum assistance of two people to minimal assistance of one person at time of discharge. Initial surface to surface transfer training occurred with a slideboard and maximal assistance from two caregivers. Through repetition and practice, Mr. T advanced to a supervision level for slideboard transfers, successfully demonstrating independence in managing the board. Subsequently, he progressed to utilizing a stand-assist device for functional transfers, showing proficiency in sit-to-stand movements. At time of discharge, therapy facilitated further progress to
stand-pivot transfers with the aid of a rolling walker and contact guard assistance.
In the subacute care setting, Mr. T participated in therapy 5-7 days per week over a span of 100 days, utilizing his full Medicare Part A benefits. Through a collaborative interdisciplinary approach, he worked Syndromediligently to maximize his functional gains during rehabilitation. As his discharge date approached, a home safety evaluation was conducted with his primary physical and occupational therapists, with Mr. T present during the visit. Recommendations were provided for home modifications and necessary equipment to ensure a safe transition. Mr. T was successfully discharged home with the support of his wife, a referral for home care services, and a personalized home exercise program.
Results: A progress note at the ten-week mark indicated significant functional improvements for Mr. T. Hip flexor strength had increased from 2/5 to 3+/5 on manual muscle testing (MMT), with the right lower extremity showing greater strength than the left. Motor control had returned in a proximal-to-distal pattern, though Mr. T continued to experience notable deficits in lower leg function. Bilateral ankle dorsiflexion remained weak at 1/5 MMT; however, following functional electrical stimulation, dorsiflexion could be elicited at 2/5 MMT.
At the time of discharge, Mr. T exhibited notable strength improvements: hip flexor strength increased from 3+/5 to 4/5 MMT, and ankle dorsiflexion improved from 1/5 to 2/5 MMT. Functionally, he achieved significant progress, performing bed mobility independently with the aid of a bed rail, completing transfers independently using a pop-over transfer, and requiring only contact guard assistance for stand-pivot transfers with a rolling walker (RW). Additionally, he was able to ambulate 120 feet with a RW and bilateral dorsiflexion assistance devices, requiring only contact guard assistance. Mr. T began stair training and successfully ascended and descended a single 6-inch step with minimal assistance from one person and bilateral upper extremity support. To address the challenge of navigating stairs at home, a stair chair was installed, eliminating the need for immediate stair negotiation upon discharge home.
As Mr. T's functional mobility progressed, the use of a functional outcome measure became feasible. The Timed Up and Go (TUG) test, recommended by the APTA’s Clinical Summary for Guillain-Barré Syndrome, was selected for this case.14 At discharge, Mr. T completed the TUG in an average of 1 min and 7 seconds over three trials, using a RW and bilateral dorsiflexion assist devices. Due to his earlier limitations in ambulation, the TUG could not be performed previously, precluding a test-retest comparison. Mr. T’s TUG score at discharge indicated an increased fall risk, further reinforcing the need for continued physical therapy services after discharge.
Discussion: Guillain-Barré Syndrome is a neurological autoimmune disorder characterized by symmetrical muscle paralysis that typically progresses in an ascending pattern from distal to proximal regions.1,2 The severity of GBS can range from mild to severe, and in a small percentage of cases, it may result in death.1,5 Early identification and prompt referral are critical to reducing the risk of complications and improving patient outcomes.1,5
Although a Clinical Practice Guideline for GBS is not available, the APTA’s Clinical Summary for GBS served as the primary resource for developing the plan of care. This summary provides a comprehensive framework, including examination strategies with an emphasis on a thorough systems review, validated tests and measures, and phase-specific interventions. It highlights key priorities for the acute, subacute, and chronic phases of recovery, ensuring a structured and evidence-based approach to client management.
Various databases were utilized to identify additional literature to inform and support the development of the plan of care. While the available articles were primarily classified as low-level evidence or were published over a decade ago, they still provided valuable insights. Key components from these sources were carefully incorporated to justify and guide treatment decisions.
Using the available literature, a comprehensive plan of care was developed for Mr. T, who demonstrated consistent improvements in functional mobility throughout his short-term rehabilitation stay. The outcomes align with the APTA’s Clinical Summary recommendation that a multidisciplinary, high-intensity rehabilitation program can be highly effective.14 The plan of care evolved from a low- to moderate-intensity approach, initially designed to prevent muscle overuse, to a high-intensity regimen with close monitoring.6,7 Components of the Clinical Practice Guideline CPG for improving locomotion following chronic stroke, incomplete spinal cord injury, and brain injury were integrated into the plan of care to facilitate high-intensity gait training.13 This approach yielded positive outcomes and strong patient engagement. The improvement in the Timed Up and Go (TUG) test highlighted measurable progress in gait and overall mobility.
Collaboratively, the patient and therapist developed a home exercise program tailored to Mr. T's available resources and living space. At the time of discharge, Mr. T was scheduled to receive comprehensive interdisciplinary home care services, including nursing, a nursing assistant, physical therapy, and occupational therapy. These services were designed to address his activity and participation limitations and support his successful reintegration into the community.
Conclusion: This clinical example details a treatment approach informed by available literature to enhance functional mobility and quality of life in a 69-year-old man with Guillain-Barré Syndrome. His impairments included
deficits in strength, postural control, activity tolerance, sensation, pain, orthostatic hypotension, and diminished overall well-being. Initially, he exhibited significant functional dependency, requiring either a mechanical lift or maximal assistance of 2 for transfers. By incorporating principles of progressive overload and maintaining an appropriate RPE level of 6-8/10 to ensure high-intensity training, this person achieved significant progress. At discharge, he was able to perform transfers with contact-guard assistance from one person and ambulate household distances using a rolling walker with contact guard assistance. In conclusion, this case study highlights the successful implementation of a structured subacute rehabilitation program and its positive impact on functional recovery in an individual with GBS.
References
1. Gisbert R, Fuller KS. Chapter 39: The Peripheral Nervous System. In: Goodman CC, Fuller KS, eds. Goodman and Fuller's Pathology: Implications for the Physical Therapist. 5th ed. Elsevier; 2021: 1655-1657.
2. Shahrizaila N, Lehmann HC, Kuwabara S. Guillain-Barré syndrome. Lancet. 2021;397(10280):1214-1228. doi:10.1016/S01406736(21)00517-1
3. Hughes RA, Rees JH. Clinical and epidemiologic features of Guillain‐Barré syndrome. J Infect Dis. 1997;176(Suppl. 2):S92‐S98
4. Tham SL, Prasad K, Umapathi T. Guillain-Barré syndrome mimics. Brain Behav. 2018;8(5):e00960. Published 2018 Apr 10. doi:10.1002/ brb3.960
5. van den Berg B, Bunschoten C, van Doorn PA, Jacobs BC. Mortality in Guillain-Barre Syndrome. Neurology. 2013;80(18):1650-1654. doi:10.1212/WNL.0b013e3182904fcc
6. Simatos Arsenault N, Vincent PO, Yu BH, Bastien R, Sweeney A. Influence of Exercise on Patients with Guillain-Barré Syndrome: A Systematic Review. Physiother Can. 2016;68(4):367-376. doi:10.3138/ptc.2015-58
7. Bassile, CC. Guillain-Barré Syndrome and Exercise Guidelines. Neuro ogy Report. 1996;20(2):31-36. (Bassile, 1996)
8. Prada V, Massa F, Salerno A, Fregosi D, Beronio A, Serrati C, Mannironi A, Mancardi G, Schenone A, Benedetti L. Importance of intensive and prolonged rehabilitative treatment on the Guillain-Barrè syndrome long-term outcome: a retrospective study. Neurological Sciences. 2020;41:321–327.
9. Schnetzer C. Physical Therapy Management of a Patient with Guillain-Barré Syndrome During Inpatient Rehabilitation Stay: A Case Report. University of Iowa.
IN MEMORIAM
10. Eston R, Connolly D. The use of ratings of perceived exertion for exercise prescription in patients receiving beta-blocker therapy. Sports Med. 1996;21(3):176-190. doi:10.2165/00007256-199621030-00003
11. Nguyen TP, Taylor RS. Guillain-Barre Syndrome. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/ NBK532254/
12. Tuckey J, Greenwood R. Rehabilitation after severe Guillain–Barré syndrome: the use of partial body weight support: A Case Report. Physiotherapy Research International. 2004;9(2):96–103.
13. Hornby TG, Reisman DS, Ward IG, Scheets PL, Miller A, Haddad D. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. JNPT. 2020;44:49-100. DOI: 10.1097/NPT.0000000000000303
14. Plummer L, Brown L, Riley E. Guillain-Barré Syndrome: Clinical Summary. APTA. May 22, May 2017. Accessed August 4, 2024. https://www.apta.org/patient-care/evidence-based-practice-resources/ clinical-summaries/guillain-barre-syndrome.
Taylor Drayton, PT, DPT is a physical therapist treating in the home-based outpatient setting through Fox Rehabilitation. Taylor recently graduated from Mozaic Senior Life’s Geriatric Residency Program in Bridgeport Connecticut, affiliated with Sacred Heart University. She is deeply passionate about working with older adults and is dedicated to enhancing their lives through the transformative power of physical therapy.
Suzanne Rodriguez, PT, DPT, MS, GCS, GTCCS, LSVT is a board-certified Geriatric Specialist with a Masters in Geriatric Health and Wellness. Suzanne graduated from the University of Miami Geriatric Residency Program in 2007 and has worked across multiple settings in the field of geriatrics including: skilled nursing facilities, acute rehabilitation, acute care, outpatient, home care and home-based outpatient. She is currently the Geriatric Residency Director and Clinical Faculty at Sacred Heart University in partnership with Mozaic Senior Life. Suzanne is currently a co-chair for the Geriatric SIG for APTA CT, and a co-state advocate for APTA Geriatrics in CT.
Honoring the Legacy of Christine McDonough
Christine was a deeply influential member of our community, and we invite colleagues to join us in celebrating her impact on the field. Thank you for helping us pay tribute to a remarkable advocate for geriatric physical therapy.
From Unsteady Gait to Trekking in Alaska: Use of a Clinical Practice Guideline for Functional Outcomes
by Kathlene Camp, PT, DPT
Editor’s Note: This clinical case commentary was part of content for the January 2025 Journal Club. These case studies are intended to demystify the more formal statistics and format of a peer-reviewed article and translate key concepts into clinically usable information. Join us for Journal Club on the third Tuesdays of January, March, June, July, August, October, and November at 8 pm ET to discuss current concepts with a wide range of peers.
Case study presentation based on the research article from Journal of Geriatric Physical Therapy: Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy. Hartley GW, Roach KE, Nithman RW, et al. J Geriatr Phys Ther. 2022; 45(2):E106-E119.1
Mr. O, an 86-year-old successful local business entrepreneur was referred to outpatient physical therapy for “unsteady gait”. He served as a caregiver for his wife who had dementia until she passed away 6 months prior. He reports her mobility declined significantly over the 1½ years prior to her passing which led to both of them becoming less active. This inactivity followed a decline in activity due to restrictions from the COVID epidemic. Mr. O’s caregiver, who also served as assist to his wife, provides support 4 hours every weekday for driving and community activity. His children and grandchildren are very present in his life running the family business and engaging in regular family gatherings locally and at a family farm about 2 hours out of town. He visits the farm at least monthly where he likes to walk the pasture to check on livestock. Navigating the unlevel ground at the farm is a challenge that concerns his family. Regular activity is a recumbent exercise bike which he has recently returned to using for about 20 minutes, 3-4 times/day and regular lunch with his son. Mr. O would like to resume travel and is considering a trip to Alaska to visit a grandson in 3 months. If it goes well, he would like to plan a trip with a friend to go to Germany 2 months later.
During the evaluation, Mr. O reports daily issues with feeling unsteady, especially in the early morning, late evening, or in the community “when I don’t pay attention to my feet.” He reports a fall about 5 years ago after falling forward and landing on his head; a cervical spine fracture resulted that was treated with collar immobilization only. He recently experienced a fall while at a family dinner gathering, stating that he fell on a step that led to an elevated dining area. No significant injuries were sustained, “other than my pride.” His family would like him to use a walker and feels he needs to get assistance to gain some strength and balance. He would prefer not to use a walker; his wife struggled to use one and his home environment with a sunken living area is not accommodating to use. He has several canes available that he has not been using. There is a walk-in shower with grab bars. Appetite and nutrition intake are reported as good except he feels he should drink more water. Regular bedtimes and awakenings are reported although he notes
2-3 nighttime voids that disturbs sleep resulting in about 4 hours of sleep/night. He sleeps primarily on his back and uses 2 pillows. He admits to daytime drowsiness, often falling asleep in his chair.
His past medical history includes hypertension (HTN), hyperlipidemia (HLD), osteoporosis (OP), gastroesophageal reflux disease (GERD), restless leg syndrome (RLS), thyroid cancer (thyroidectomy with radical neck dissection), bilateral knee osteoarthritis (with prior repeated knee injections). He reports scoliosis which was first identified while he was in high school. Patient does not recall when his OP was diagnosed but he was referred to the OP specialty clinic. No DXA reports available at evaluation and no report of fractures other than the C-spine fracture 5 years prior. Lifestyle factors include non-smoker, non-alcoholic drinker. No family history of OP or fractures. Positive for medications with possible negative bone health impact. He no longer requires follow-up with an oncologist but is seeing a dermatologist for evaluation of skin lesions and neoplasm. He is scheduled with a local Osteoporosis specialty clinic within the month and DXA reports have been requested by PCP. FRAX® risk calculation, without BMD, is 23% risk for major OP fracture and 14% for a hip fracture, both significant for 10-yr risk for a fracture.2
Medications include: amlodipine besylate, losartan potassium, Synthroid, rosuvastatin calcium, Calcitrate +D, vitamin D3, pramipexole dihydrochloride, esomeprazole, tamsulosin, magnesium, and zoledronic acid.
Examination
Mr O was polite, well-dressed, wearing good footwear, and using a single point cane (SPC) when he arrived with his caregiver for the initial visit. He was alert, fully oriented, and able to provide accurate and complete medical history. He reports annual eye exams with removal of cataracts about 1 year prior. Denies decreased hearing. No report of significant pain other than bilateral knee discomfort with increased activity or weather changes. Vitals revealed elevated blood pressure, 158/88, and normal oxygen saturations 97%, respirations
12 breaths/min, and regular heart rate, 88 bpm. Posture in sitting presented with kyphotic, sacral-sitting presentation; in standing kyphosis more evident with right thoracic scoliosis, decreased lordosis, forward head, rounded shoulders, and bilateral genu varus. Cervical range of motion (ROM) limited in extension, 25%- 50% symmetrical decrease in cervical rotation/lateral flexion, and normal flexion.
Active and passive range of motion (AROM/PROM) of upper extremities was assessed for overhead reach function. End range feel was firm with slight anterior shoulder discomfort reported on R. Lower extremity PROM at hips with limited to no internal rotation with a firm to hard end feel (Table 1).
Strength was diminished symmetrically in bilateral lower extremities (Table 2)3
Table 1. Extremity Range of Motion- Baseline (degrees)
Joint (AROM/PROM) Right
Left
Shoulder flexion 120 / 125 (discomfort) 120 / 135
Hip internal rotation 0-5 (no pain) 0-5 (no pain)
Hip internal rotation 42 40
Knee flexion 125 125
Ankle dorsiflexion 15 15
SLR/Hamstring flexibility 57 (firm, no pain) 62 (firm, no pain)
Table 2. Initial Lower Extremity Strength- Baseline
Joint (AROM/PROM) Right Left
Joint movement
Hip extension (supine)
Knee extension
Knee flexion 5/5 5/5
Ankle dorsiflexion 5/5 5/5
Standing heel raise test 2/5 2/5
Outcome measures selected for baseline and repeated measures for progress included occiput to wall distance (OWD), 30-second sit to stand (STS), and both self-selected and fast gait speed (Table 3).
Table 3. Extremity Range of Motion- Baseline (degrees)
30-second STS 7 reps (stress on knees); excessive trunk flexion 7 reps (stress on quadriceps); improved alignment/ form Gait
OWD: Occiput to wall distance
Static balance was also assessed for fall risk and change with inter vention using the modified Clinical Test of Sensory Integration for Balance (m-CTSIB), tandem stance, and single limb stance (SLS) (Table 4).
Table 4. Static Balance Measures Evaluation and Discharge
m-CTSIB: performance (score)
m-CTSIB condition 1:
m-CTSIB condition 4:
Tandem stance: L / R
SLS: L / R
EO: eyes open, EC: eyes closed, firm surface, soft surface (medium density foam)
Assessment
A comprehensive assessment and review were performed after the examination and was used to provide education to the patient for rationale of treatment and an intervention approach. Mr. O’s examination revealed significant hyperkyphosis as assessed with the OWD measure value greater than 6.5 cm,3 a potential indicator of the presence of vertebral fractures3,4 and a recommended screening tool in primary care osteoporosis management.5 His results, even in his ‘best’ posture are associated with an increased risk for falls (>7.5 cm) in men,6 vertebral fracture risk (>4.0 cm),7 potential impaired pulmonary function, and pain.8 Lower extremity weakness was noted in proximal musculature and ankle plantar flexors, potentially impacting his functional transfers, balance with narrow (tandem) or single limb stance (SLS), and slow gait speed. His performance with the 30-second STS measure indicated low performance for his age and gender suggesting a risk for falls;9 following inquiry he stated the stress of the test was felt primarily in his knees. Gait speed was also lower than ideal, normal (0.67 m/s) and fast (1.07 m/s), to support independence with activities of daily living (ADLs) and community demands.10 The m-CTSIB suggested some instability without visual inputs and on compliant surfaces but was most concerning for limited vestibular inputs supporting balance suggesting increased risk of falls in situations where low light and unlevel surfaces could be present, such as nighttime voids walking on carpet or walking his pasture in the evening or with visual distraction. His performance on tandem stance (<10 sec)11 and SLS (<6.5 sec)12 were both suggestive for risk for falls.
Medications concerning for negative impact on his bone health are (esomeprazole) and fall risk (trazadone). Although beneficial for bone health, he was taking multiple supplements with Vitamin D which may be excessive. A communication was sent to the primary geriatrician for a potential consult benefit from our pharmacist to review medication.
Intervention
The plan of care was established for 6 visits, with sessions every 2 weeks over a 3-month course, planned to allow for progressive instruction and implementation into a home exercise program. He was highly motivated, able to follow multi-step instructions, and had the support of his caregiver as an accountability partner. In summary, goals were to improve postural awareness to promote proper alignment to decrease fall and fracture risk, increase LE strength to improve control and function with transfers, enhance gait speed to support community demands, and improve balance to decrease risk of falls –especially in the context of upcoming travel demands.
Following the evaluation, Mr. O was educated on postural alignment using a skeletal model to reinforce “spine-sparing” principles during task demands.13 We reviewed postural habits which may have a negative influence on the forward head and hyperkyphosis presentation and recommendations to mitigate factors. Suggestions included reducing pillow use (from 2 to 1), increasing more back than side-sleeping time, and avoidance of napping in his chair during the day causing his head fall forward. We employed mental imagery of “eyes in his chest” looking up and forward while reading, eating, riding in the car, walking, etc. to promote correct posture. Education and practice with fit and use of a single-tipcane to support his nighttime voiding and community mobility was performed. Lastly, we discussed proper set-up of his recumbent bicycle and outlined a progressive intensity aerobic program to promote cardiovascular endurance to prepare for upcoming travel.
On Visit 2 (week 3), we initiated pole walking to provide support to upright walking and allow reciprocal arm swing to promote dynamic weight bearing and low force exercises to improve his health, function, and progression towards goals for traveling.1 Following practice of a progressive walking sequence, including increasing stride length and brief intervals of increased cadence, a runner’s lunge was added to provide a combination hip flexor and calf stretch, bilaterally, to support increased stride length and foot clearance. On the mat table, manual therapy was provided with soft tissue techniques to the suboccipital and pectoralis minor muscles for correcting forward head and rounded shoulder posture.14 This was followed by supine lower trunk rotation and SL upper trunk rotation to improve spinal mobility. Initial spinal extensor strengthening was performed in supine with head press, scapular press, and abdominal bracing with bridging13 to address core stability and back extension exercises.15,16 He was provided with written instructions and a follow-up email with resource links for attaining hiking poles.
On Visit 3 (week 5), training on the ‘hip hinge’ to promote postural alignment and flexion at hip and progressed to squats from a 23" height chair to reinforce alignment and LE strength, completing 2 sets of 8-12 repetitions.16 Demonstration and practice for safe techniques with proper spinal alignment were practiced for floor transfers using a chair for support to allow patient to perform exercises on the floor, since his bed was reported as too soft. This practice also addressed patient concern about his ability to get up from the ground safely. A half 3-ft soft foam roller was utilized to assist with spinal mobility, soft tissue flexibility, and core stability. While lying lengthwise on the rounded surface, he alternated reaching overhead while elongating through the thoracic cage and facilitating a lateral flexion movement through the T-spine. Progression of arm movement limiting opposite hand support on the ground provided a
stabilization challenge. A progression to bilateral overhead reach facilitated thoracic extension and further stability changes. Pectoralis stretching with arms at 90 and 120 degrees with slow, diaphragmatic breaths provided further anterior soft tissue stretch. He was again provided with written instructions and resources for purchase of a foam roller. Education on aerobic exercise with cycling vs walking program was discussed, including attention to proper hydration – especially while walking at his farm.
On visit 4 (week 7), resistance training for upper body musculature was added using resistance bands for middle and lower trapezius in supine (red); latissimus dorsi and rhomboids in standing (green), all performed with 2 sets, 8-12 reps. Lower extremity strengthening was progressed with lowering the depth of chair squats to 21 and 19 inches, 2 sets x 12 reps. Heel raises were also added on an incline, 2 sets of 15 reps. Hip hinge movement with spinal extensors and abdominal bracing engaged was reinforced with a deadlift using a 13lb kettlebell, 5 sets of 5 reps.17 He was provided with written instructions to continue with resistance exercises at least 2-3 times/week total with a day of rest between. Red and green resistance bands and recommendations for modifying a water jug with sand to serve as a kettlebell for provided for HEP application.
On visit 5 (week 9), education on safe but challenging balance exercises was introduced. Concepts for progressively narrowing base of support (BOS), use of different surfaces (compliant increasing challenge), and decreasing visual input (head turns vs closing eyes). Practice of multiple challenges in the clinic using visual cues (opening eyes) for recovery vs use of countertop nearby. Step-ups were added using a 6" step to simulate a curb. Upper extremity support on both sides (mat table + single hiking pole) were utilized initially and faded to just single UE support with pole. Education on progression with height of step (8") and safety with integration into HEP was reviewed. Floor transfers were reviewed and practiced. Quadriped LE lift was added for hip extension strengthening and UE weight-bearing, 1 set of 8 repetitions. Tactile cues for abdominal stabilization, LE alignment, and cervical retraction. Written instructions for HEP provided.
On visit 6 (week 11), a reassessment was performed with outcome measures as shown in Tables 3 and 4. We discussed changes in performance and reviewed aspects of his HEP to address areas for opportunity with progression. And we discussed safety considerations for his upcoming travel. Lastly, we discussed potential return to PT after his travels to progress his exercise program to further progress his balance, strength, and function.
Results
Postural measure with OWD demonstrated a 42% improvement in normal posture and a 34% improvement
in ‘best’ posture, although still indicative of hyperkyphosis and suggestive for a risk for falls. Lower extremity functional strength measured with the 30-second sit-tostand test showed no change in repetitions and under his AGN (8 -14 reps)9 but he did demonstrate improved form with appropriate stress response with quadricep fatigue rather than back and knee stress. Improvement was seen with both normal and fast gait speed more supportive of community demands. Improved balance was demonstrated throughout conditions but challenge still noted with vestibular inputs (m-CTSIB, condition 4) and a risk for falls due to performance with L tandem and L SLS.
Discussion
According to clinical practice guidelines, the role of exercise in improving BMD in men is lacking; but, despite the limited evidence, recommendations suggest encouraging lifelong fitness and bone health strategies such as those for corresponding women.1 Clinicians benefit from the use of CPG to guide patient intervention but application can be limited when guidance on condition management does not completely address your client presentation due to limited evidence. This OP CPG1 undertook a rigorous approach to determine the best quality CPG to guide exercise intervention. Although the CPG identified6 addressed comprehensive management including exercise intervention, recent updates in 2018 did not prioritize exercise intervention and thus evidence guiding exercise intervention did not extend beyond 2013. More recent clinical trials have begun to demonstrate that high RT and impact exercise18 and multicomponent PRT, balance, and mobility programs16 can improve BMD and bone strength in men. Balance and functional training have also been shown to have a significant impact on reducing falls and fractures.19
Changes in postural measures with targeted spine mobility and extensor strengthening have shown significant change in interventions lasting 6 months7 and thus my client may continue to have potential for further improvement. Improvements in strength often require 6-12 weeks to have measurable changes in older adults. While a significant change was not seen here, improved response and movement control was noted; potentially having an even greater impact on functional tasks. An association of balance confidence and gait speed have implications for fall risk8 suggesting Mr. O’s gait speed may be most appropriate for reducing his fall risk especially with his judgement to include the use of a STC or hiking poles to support his community activity and travel. A significant improvement was seen in R tandem and SLS as compared to the L side. Further intervention may benefit from careful attention to weight distribution and favoring during strengthening and balance exercises. There may also be an association with frontal plane postural alignment impacting weight shift and stability.
During the course of Mr. O’s therapy intervention, he met with the pharmacist who performed a medication review and reconciliation. Adjustments were made to eliminate the extra Vit D supplements taken. He also agreed to discontinue use of the omeprazole and monitor his GERD symptoms, which he indicated had not returned. He had an initial consultation with the osteoporosis specialty clinic and was scheduled to receive IV zoledronic acid (Reclast) for bone health protection.
The most important outcome for this intervention was the one that mattered most to the client – the confidence and ability to re engage in travels. In fact, Mr. O did have successful travels to Alaska with his grandson. Gaining his confidence, he continued with plans to Germany sending a letter and picture back stating how impressed he was in his ability to manage the cobblestone streets with his cane and hiking poles – never sustaining a fall.
References
1. Hartley GW, Roach KE, Nithman RW, et al. Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy. J Geriatr Phys Ther (2001) 2022;44(2):E106-e19 doi: 10.1519/jpt.0000000000000346
2. Kanis JA, McCloskey EV, Johansson H, Oden A, Ström O, Borgström F. Development and use of FRAX in osteoporosis. Osteoporos Int 2010;21 Suppl 2:S407-13 doi: 10.1007/s00198-010-1253-y.
3. Wiyanad A, Chokphukiao P, Suwannarat P, et al. Is the occiput-wall distance valid and reliable to determine the presence of thoracic hyperkyphosis? Musculoskeletal science & practice 2018;38:63-68 doi: 10.1016/j.msksp.2018.09.010
4. Siminoski K, Warshawski RS, Jen H, Lee KC. The accuracy of clinical kyphosis examination for detection of thoracic vertebral fractures: comparison of direct and indirect kyphosis measures. J Musculoskelet Neuronal Interact 2011;11(3):249-56
5. Singer AJ, Sharma A, Deignan C, Borgermans L. Closing the gap in osteoporosis management: the critical role of primary care in bone health. Curr Med Res Opin 2023;39(3):387-98 doi: 10.1080/03007995.2022.2141483
6. Tominaga R, Fukuma S, Yamazaki S, et al. Relationship Between Kyphotic Posture and Falls in Community-Dwelling Men and Women: The Locomotive Syndrome and Health Outcome in Aizu Cohort Study. Spine (Phila Pa 1976) 2016;41(15):1232-38 doi: 10.1097/brs.0000000000001602.
7. Antonelli-Incalzi R, Pedone C, Cesari M, Di Iorio A, Bandinelli S, Ferrucci L. Relationship between the occiput-wall distance and physical performance in the elderly: a cross sectional study. Aging Clin Exper Res 2007;19(3):207-12 doi: 10.1007/bf03324691.
8. Koele MC, Lems WF, Willems HC. The Clinical Relevance of Hyperkyphosis: A Narrative Review. Front Endocrinol (Lausanne) 2020;11:5 doi: 10.3389/fendo.2020.00005.
9. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport 1999;70(2):113-9 doi: 10.1080/02701367.1999.10608028.
10. Fritz S, Lusardi M. White paper: "walking speed: the sixth vital sign". J Geriatr Phys Ther (2001) 2009;32(2):46-9
11. Nithman RW, Vincenzo JL. How steady is the STEADI? Inferential analysis of the CDC fall risk toolkit. Arch Gerontol Geriatr 2019;83:185-94 doi: 10.1016/j.archger.2019.02.018.
12. Lusardi MM, Fritz S, Middleton A, et al. Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Posttest Probability. J Geriatr Phy Ther (2001) 2017;40(1):1-36 doi: 10.1519/jpt.0000000000000099.
13. Giangregorio LM, McGill S, Wark JD, et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporosis international: a journal established as result of cooperation between the European
Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2015;26(3):891-910 doi: 10.1007/s00198014-2881-4.
14. Hughes LC, Galloway RV, Fisher SR. Feasibility of a 4-Week Manual Therapy and Exercise Intervention on Posture and Function in Community-Dwelling Older Adults: A Pilot Study.J Geriatr Phys Ther(2001) 2022;46(3):151-60 doi: 10.1519/jpt.0000000000000360.
15. Kukuljan S, Nowson CA, Sanders KM, et al. Independent and combined effects of calcium-vitamin D3 and exercise on bone structure and strength in older men: an 18-month factorial design randomized controlled trial. J Clin Endocrinol Metab 2011;96(4):955-63 doi: 10.1210/jc.2010-2284.
16. Daly RM, Dalla Via J, Fyfe JJ, Nikander R, Kukuljan S. Effects of exercise frequency and training volume on bone changes following a multi-component exercise intervention in middle aged and older men: Secondary analysis of an 18-month randomized controlled trial. Bone 2021;148:115944 doi: 10.1016/j.bone.2021.115944
17. Harding AT, Weeks BK, Lambert C, Watson SL, Weis LJ, Beck BR. A Comparison of Bone-Targeted Exercise Strategies to Reduce Fracture Risk in Middle-Aged and Older Men with Osteopenia and Osteoporosis: LIFTMOR-M Semi-Randomized Controlled Trial. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 2020;35(8): 1404-14 doi: 10.1002/jbmr.4008
18. Harding AT, Weeks BK, Lambert C, Watson SL, Weis LJ, Beck BR. Effects of supervised high-intensity resistance and impact training or machine-based isometric training on regional bone geometry and strength in middle-aged and older men with low bone mass: The LIFTMOR-M semi-randomised controlled trial. Bone 2020:115362 doi: 10.1016/j.bone.2020.115362Shelene Thomas, PT, DPT, EdD, GCS, FNAP is an Associate Professor of Augustana University, teaching in the areas of Geriatrics and Cardiopulmonary practice.; her research interest focuses on IPE. She is a Fellow in the National Academies of Practice (FNAP). She continues to practice at Reunion Rehabilitation.
19. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019;1(1):Cd012424 doi: 10.1002/14651858. CD012424.pub2
20. Katzman WB, Vittinghoff E, Lin F, et al. Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2017;28(10):2831-41 doi: 10.1007/s00198-017-4109-x
21. Tsang CSL, Lam FMH, Leung JCS, Kwok TCY. Balance Confidence Modulates the Association of Gait Speed With Falls in Older Fallers: A Prospective Cohort Study. J Am Med Dir Assoc 2023;24(12): 2002-08 doi: 10.1016/j.jamda.2023.05.025.
Kathlene Camp, PT, DPT is an Assistant Professor at the University of North Texas Health Science Center in Fort Worth, Texas. She is a Board Certified Specialist in Geriatric Physical Therapy and currently serves as Vice Chair of the APTA Geriatrics Bone Health Special Interest Group. Kathlene provides clinical services within a primary care geriatric specialty practice as part of an interprofessional team. She provides teaching on the topic of mobility, balance, and fall prevention in geriatrics for physician assistant, osteopathic, and medical physician education programs. And she volunteers as a bone health educator for the Bone Health and Osteoporosis Foundation.
Promote Physical Activity after Exercise Interventions in Parkinson’s Disease
by Jessica Watson, PT, DPT and Jennifer Howanitz, PT, DPT
Editor’s Note: This clinical case commentary was part of content for the March 2025 Journal Club. These case studies are intended to demystify the more formal statistics and format of a peer-reviewed article and translate key concepts into clinically usable information. Join us for Journal Club on the third Tuesdays of January, March, June, July, August, October, and November at 8 pm ET to discuss current concepts with a wide range of peers.
Case study presentation based on the research article from Journal of Geriatric Physical Therapy: Martín-Núñez J, Calvache-Mateo A, López-López L, et al. Effects of Exercise-Based Interventions on Physical Activity Levels in Persons with Parkinson's Disease: A Systematic Review with Meta-analysis. J Geriatr Phys Ther. 2023;46(4):207-213. doi:10.1519/JPT.00000000000003731
There is a substantial amount of evidence based literature to support that physical activity leads to improvements in motor and non-motor symptoms of Parkinson’s Disease (PD).1,2 More specifically, there are beneficial effects on physical performance including gait, balance, strength, flexibility, and cardiovascular fitness.1 Despite this abundant research, translating this knowledge into practical, sustained lifestyle changes for individuals with PD presents a formidable challenge. Physical therapists can serve a critical role in the development of effective strategies and interventions to address the complex barriers individuals with PD face in adopting and maintaining an active lifestyle. MartinNunez et al’s meta-analysis shows improvements in physical activity after exercise interventions and supports that physical therapists have an important role in public health and activity promotion.1 This systematic review identified the most frequently used modalities to yield the previously mentioned result included aerobic, balance, and multimodal exercises. This case presentation will outline an individual with Parkinson’s Disease that presents in a physical therapist supervised community fitness program. This community fitness program incorporates all of the previously mentioned exercise interventions and further illustrates how to translate Martin-Nunez et al’s meta-analysis into practice.
Case Presentation
Mr. F, a 71-year-old male was diagnosed with Parkinson’s Disease 5 years ago. He recently endorses an increase in his symptoms including increased tremors, rigidity, and bradykinesia. He also reports increasing difficulty with balance and gait and has a history of
Table 1. Medications
Lisinopril (hypertension)
Levodopa (Parkinson’s Disease)
Vitamin D
Multivitamin
1 fall in the last 12 months. His spouse is not only concerned about his declining mobility but also his disinterest in usual hobbies including boxing in their community gym and going to their grandchildren’s sporting events. Mr. F understands the importance of physical activity but reports he doesn’t enjoy going out anymore and thinks it would be easier on everyone if he just stayed at home. Mr. F’s spouse remembers seeing a flyer at their neurologist’s office for a community high intensity boxing class specifically for those with Parkinson’s. He points out that the class is led by Mr. F’s previous physical therapist, hoping this will help convince him since Mr. F really enjoyed working with him. Previously Mr. F would jump at the chance to give something new a try but with his most recent fall he isn’t sure it would be worth the risk. Mr. F’s spouse manages to convince him to give it a try since it is right next to the community gym he goes to and would be heading there anyway. Medical History and current medications: His history is significant for hypertension, osteopenia, cataracts, depression. His medications are outlined in the table below:
Prior level of Function/Social History
A retired accountant of a private law firm, Mr. F lives with his husband in a 55 and older community with a 1 story home with 1 step and 1 handrail to enter. Recently using a single point cane for ambulation in the community to navigate uneven surfaces, he continues to walk without an assistive device in the home. He had 1 fall in the last 12 months without significant injury. He was referred to physical therapy for focused balance training and completed 16 visits of outpatient physical
therapy over 8 weeks. Following discharge from PT, Mr. F remained fearful of fully resuming his hobbies such as boxing and has not engaged in a regular exercise routine since being discharged 3 months ago. He completes medication management independently. Mr. F reached out, with the encouragement of his spouse, to join the community boxing class. The boxing class is a 60-minute-high intensity session that is twice a week for 12-week increments. Mr. F was evaluated by a PT before and after his involvement in the class.
Examination
Mr. F is classified as Hoehn and Yahr II. Observation of postural and gait assessment yields forward flexed posture, reduced arm swing bilaterally during gait, with decreased stride length, and gait initiation hesitation. Decreased ROM was noted in trunk rotation and hip flexion. Global deficits in LE strength were recorded, particularly in quadriceps, hamstrings, and gastrocnemius MMT. Other findings were: 0.8 m/s gait speed, x5STS of 17 seconds, TUG of 18 seconds, Cog Dual Task TUG 24 seconds, ABC Confidence Scale 65%. Six Minute Walk test of 500 m.
Assessment
A comprehensive examination was conducted after gathering pertinent information from the chart and an interview with Mr. F and his husband. Mr. F presented with generalized lower extremity weakness, impaired functional mobility, impaired balance, impaired gait, and limited community mobility. Increased time to complete the TUG, x5STS and slow gait speed indicate a high risk for falls despite recently being discharged from skilled PT a few months ago. Mr. F demonstrates decreased aerobic capacity and limited cardiovascular fitness. He is deemed appropriate to participate in the community boxing class however with increased guarding and the utilization of a gait belt for more dynamic tasks to ensure safety.
Intervention
A multimodal twice a week, 12-week treatment plan consisting of balance, strengthening, agility, coordination and aerobic exercises. Exercise sessions lasted approximately 60 minutes, including a 10-minute warm up, 30 minutes of boxing drills, 10 minutes of strength and endurance exercises and a 10-minute cool down. The warm-up included multi-planar movements involving ranges of motion used in the subsequent portions of the workout, dynamic stretches, and agility activities. Both the warm-up and boxing portion utilized activities to improve balance, agility, and multi-tasking abilities, including multi-directional stepping, weight shifting, large amplitude movements, functional agility, and cognitive drills. The strength and endurance exercises utilized all major muscle groups involving 10-15 repetitions of each
exercise using equipment such as kettle bells and weighted medicine balls. Boxing drills included jabs, hooks, and uppercuts, coupled with cognitive activities. Participants wore boxing gloves and the only contact made was with sparring mitts worn by the organizers of the class. In the boxing portion as well as the strength and endurance portion, participants engaged in 1:1 ratio of work to rest. The cool-down portion of the workout included walking to gradually decrease heart rate, prevent blood pooling, and improve venous return. The cool-down also incorporated flexibility, specifically static stretching for all major muscle groups, held for 30 seconds, with two repetitions of each exercise completed.3,4
Mr. F wore a gait belt throughout the class and was receiving contact guarding from one of the instructors for more dynamic tasks including balance and agility drills. The first few weeks Mr. F reported feeling very tired and the PT class supervisor noticed he rarely engaged in conversation with the other participants. The class supervisor, knowing Mr. F from working with him in PT, remembered Mr. F as always making conversation even with the strangers in the waiting room. The PT class supervisor met with Mr. F and encouraged him to try attending a support group started by one of the other boxing participants as well as share with his neurologist his lack of interest. He educated Mr. F that PD not only impacts motor function but non-motor aspects like mood, potentially leading to anxiety and depression. Mr. F said he would give the support group a try since it met right after the boxing class in the same building.
Outcome
Mr. F demonstrated improvements in balance, gait, and physical function as reflected by the following post test scores: 1.1 m/s gait speed, x5STS of 14 seconds, TUG of 12 seconds, Cog Dual Task TUG 20 seconds, ABC Confidence Scale 80%. Six Minute Walk test of 700 m. As a result, Mr. F reduced his risk of falls as reflected by his x5STS score (16 seconds in PD discriminates fallers vs. non fallers) and TUG (<13.5 seconds in community dwelling older adults). Additionally, Mr. F also reported feeling more confident in his ability to move in the community and demonstrated more interest in participating in his previous hobbies (as reflected by the ABC confidence scale). Mr. F was able to connect with other individuals diagnosed with PD in a support group he learned about through his participation in the community boxing class and attends these support group meetings twice a month with his spouse. Mr. F reported feeling less fatigue through these boxing classes over the 12 weeks but sometimes still experiences days of not feeling up to socializing with others. Mr. F is planning on bringing this up to his neurologist as he learned from his former PT and other individuals in the support group that there may be other ways to improve his mood and feel more consistently like himself.
Table 2. Static Balance Measures Evaluation and Discharge
Discussion
This case example illustrates how exercise interventions can increase physical activity levels in a person with PD. Client-centered approaches by rehabilitation specialists may ensure continued physical activity. Physical therapists may have an important role in promoting a physically active lifestyle and in the development of secondary prevention interventions through exercise-based interventions in individuals with PD. This example case also touches upon Matin-Nunez et al ‘s commentary on the need for comprehensive strategies that address behavioral and social factors to promote long-term adherence to physical activity and maximize benefits of exercise for this population. There is a significant lack of research on interdisciplinary collaboration in individualized physical activity tailored counseling and the long-term follow up and support for persons with PD. In this case study, Mr. F’s spouse found out about the community program, provided by the PT he had seen previously, through a flyer at the neurologist office 3 months after being discharged from PT. This small detail highlights the significance interdisciplinary communication can play in addressing societal health needs but also prompts us to acknowledge the gaps that exist... What kind of impact would have been made on his quality of life and function if Mr. F found out about this sooner? Physical therapists in all clinical settings can promote continued physical activity after skilled physical therapy services and should consider participating or starting community programs. This is a responsibility to meet the health needs of our society as reflected by Principle 8 of the Code of Ethics for the Physical Therapist “Physical therapists shall participate in efforts to meet the health needs of the people locally, nationally, or globally.”5 How physical therapists will respond to this call to action may look very different based on the unique cultural and geographically aspects that impact each community; we should continue to share our experiences to further support each other in these endeavors.
Matin-Nunez’s review includes a wealth of studies with results showing improvement in physical performance of those with Parkinson’s Disease but what about cognitiveemotional factors such as depression? Depression is a significant non-motor symptom of PD with a prevalence of approximately 38%6. If cognitive-emotional factors like depression can impact quality of life and cause disability, how is continued physical activity addressing these symptoms? We saw in Mr. F ‘s case his spouse reported his disinterest in his usual hobbies and his PT noticing a difference in his behavior (particularly social engagement). This case example highlights a possible scenario that could play out as a consequence of a PT intervening, but future research needs to examine the relationship between physical activity and cognitive-emotional factors and how they impact one another.
References
1. Martín-Núñez J, Calvache-Mateo A, López-López L, et al. Effects of Exercise-Based Interventions on Physical Activity Levels in Persons with Parkinson's Disease: A Systematic Review with Meta-analysis. J Geriatr Phys Ther. 2023;46(4):207-213. doi:10.1519/ JPT.0000000000000373
2. Osborne, JA, Botkin R, Colon-Semenza C et al. Physical therapist management of Parkinson disease: a clinical practice guideline from the American Physical Therapy Association. Phys Ther. 2022;102(4):pzab302. doi: 10.1093/ptj/pzac098]
3. El Hayek M, Lobo Jofili Lopes JLM, LeLaurin JH, et al. Type, Timing, Frequency, and Durability of Outcome of Physical Therapy for Parkinson Disease: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(7):e2324860. Published 2023 Jul 3. doi:10.1001/ jamanetworkopen.2023.24860
4. Ramos L, Watson J, Macalintal R, Ellis C. High-intensity exercise in community-based boxing improves functional limitations in individuals with Parkinson’s disease. Int J of Exerc Sci. 2024;17(3):1493 - 1503. Doi: https://doi.org/10.70252/IHKW5009 5. American Physical Therapy Association. Code of Ethics for the Physical Therapist. APTA.ORG. 2020. Accessed November 10, 2024. Code of Ethics for the Physical Therapist | APTA
6. Shengri C, Chunchen X, Shun Z, et al. Prevalence and clinical aspects of depression in Parkinson’s disease: A systematic review and meta-analysis of 129 studies. Neurosci Biobehav Rev. 2022; 141. https://doi.org/10.1016/j.neubiorev.2022.104749.
Jennifer Howanitz PT, DPT, GCS
Dr. Howanitz is an assistant professor and Director of Clinical Education in the DeSales University Doctor of Physical Therapy program. She earned her Bachelor of Health Sciences and Master of Physical Therapy from St. Joseph’s University (formally the Philadelphia College of Pharmacy and Science). She went on to earn her transitional Doctorate in Physical Therapy from Arcadia University. She has over 25 years of clinical experience, including practice in acute care, sub-acute rehabilitation, long-term care, home care, and inpatient and outpatient oncology rehabilitation. She currently practices in inpatient acute care. She is a Board Certified Geriatric Clinical Specialist by the ABPTS. She is a member of the APTA Academies of Education, Geriatrics, and Oncology and is currently serving as ELC Co-Chair for the APTA Academy of Education. Her expertise includes rehabilitating older adults with neurocognitive disorders and adults with oncologic diagnoses. Dr. Howanitz has presented research at multiple national conventions on the topic of rehabilitation of patients with neurocognitive impairment. She has performed numerous continuing education courses for physical therapists and other healthcare professionals on the rehabilitative management of patients’ geriatric rehabilitation needs. She has authored and co-authored several articles on neurocognitive impairment’s role in the rehabilitative process.
Jessica S. Watson, PT, DPT is an Assistant Professor for the Doctor of Physical Therapy program. She is an APTA board-certified geriatric clinical specialist and a credentialed clinical instructor. She earned her Doctorate in Physical Therapy from DeSales University in 2018 after she earned her BS in Sport and Exercise Science from DeSales University in 2015. Jessica has diverse clinical experience in the acute and acute care rehabilitation settings throughout her career. She has worked for multiple established health networks, including Kessler Institute for Rehabilitation, and continues to practice clinically for St. Luke’s Health Network in their acute rehabilitation center. Dr. Watson values evidence-based practice as reflected through her continued work in research. She has presented peer-reviewed posters and platform presentations at both the local and national level as well as recently published this year in the International Journal of Exercise Science: “High-Intensity Exercise in CommunityBased Boxing Improves Functional Limitations in Individuals with Parkinson’s Disease.” She has been an APTA member throughout her career and currently is a member of the Acute Care and Geriatrics sections. She is an active member of the APTA and serves as the Treasurer of the Northeast District of APTA Pennsylvania. She serves as Faculty Liaison of the DeSales Community Wellness and Physical Therapy Pro Bono Clinic. Through this pro bono clinic she supervises a student run, faculty mentored free community boxing classes for those with Parkinson’s.
Congratulations to Another Cohort of APTA-Geriatrics Credentialed Balance & Falls Prevention Professionals!
Congratulations to the following physical therapists for achieving their Credential as a Balance & Falls Prevention Professional in 2024! And a special thanks to Providence Health System (Portland, OR) for hosting everyone!
Alyssa Burns, Jamie Caulley, Brittany Dillahunty, Sara Duran, Molly Fauske, Rebecca Flores, Valier Franck, Shilpa Gaikwad, Melissa Gerard, Matthew Gordon, Kim Groleau, Deb Gulbrandson, Jenn Haunold, Deborah Jones, Ashwini Kulkarni, Ashlee Lane, Marshall Lieber, Holly Lookabaugh-Deur, Christian Miranda Aguirre, Annessa Morey, Michele Myers, Lucia Paciotti, Tim Pazier, Venkatesan Rajagopal, Claudia Segura, Priti Shah, Patima Silsupadol, Megan Smith, Bethany Spillane, Shweta Subramani, Joshua Thompson, Kristen Triquet, Ari Witkin, Jessica Yeadon
