Resource Roadmap Show Transcript – PT – Episode 03

Shweta Subramani 0:03
Hello and welcome everyone to the Therapy Insights Resource Roadmap Show where we learn how to use the resources inside the Access Pass. If you’re subscribed to our resource library, you have instant access to all of the resources that we’re going to be talking about today. If you’re not a member, you can get started today by heading to If you’re listening to this episode, on a podcast or watching this video on YouTube, and you want official CEU credit, head to and click on CEUs. Fill out the form for the PT resource roadmap Show, episode number three to get your certificate of completion. I’m your host Shweta. We also have our therapy insights, writers Ross and Troy with us today. Hey, everyone.

Troy Adam 0:53
Yeah. Hey, guys.

Troy Adam 0:54
Thanks for having us again.

Shweta Subramani 0:56
Cool. So really quick, since this course being offered for CEUs, we do need to verbalize our disclosures, all of us here are being paid by therapy insights to run the show. So let’s get started. We have a great lineup of resources again this month from Should I Get a Meniscectomy?, Minimizing the Concurrent Training Interference Effect, High Intensity Gait Training After a Neurologic Condition, How to Perform Ocular Motor Examination, and What is Heterotopic Ossification? The first resource that we’re going to dive into is high intensity gait training by Troy. Troy, since you wrote this piece, I’ll let you talk about it a little bit. Tell us about this.

Troy Adam 1:40
Yeah, absolutely. So this, this resource is is really comes from a Yeah, from some recommendations that were made. And I don’t know, I can’t see it up on my on my screen. Just get that up. But yeah, it was

Megan Berg 1:56
Sorry everybody let me get this going here, then. I thought maybe I could leave my YouTube display that but I can’t. Oh, here we go.

Troy Adam 2:08
All right, perfect. Yeah. So it’s really based on a CPG that came out clinical practice guideline that came out, I think, in 2020. And really, this is meant to provide physical therapists with the ability to, to kind of quickly and accurately record gait training, performance measures, as well as target heart rate zones for their patients with neurologic impairment. So a lot of this is, is really pretty, you know, pretty basic stuff that you should have some exposure to already. But the nice thing about this sheet is, the ones that I find that are the most helpful are the ones that I can grab. And I can put right into my documentation and scan right in. So as I’m documenting in my own files, I’m saying, hey, refer back to, you know, to our scan sheet on our intake forms and subsequent plans of care and things like that. So what this is meant to do is, is get therapists on the right track when it comes to treating folks with gait impairments and neurologic conditions. So specifically, in step one, we talk about just determining ultimately max heart rate, which one of the kind of classic, most known equations for that is there’s 220 minus your age is is how we calculate max heart rate. And then we’re looking for a specific aerobic threshold that we’re going to prescribe as their best. Ideally, that normally sits somewhere between 60 and 80% of max heart rate. So you take that to 20 times the age or minus age and then multiply that by either point six and point eight. And we we’d run into our kind of target heart rate. Now, step two with this is, okay, a lot of our patients with neurologic conditions, maybe have some complications or other comorbidities that are associated. So I think it’s up to our discretion in our own clinical reasoning on what’s maybe reasonable where to start out within that range. And then how can we increase the intensity if we can’t maybe increase their gait speed? So right, so classically, you’re training somebody that doesn’t have a movement pathology or motor control deficits? You know, we want to increase the intensity, we increase the speed we increase the incline, if that’s not available, so to kind of gives you some ideas of ways that we can increase intensity in ways that other researchers have done in this clinical practice guideline in the past to work towards getting that target heart rate up a little bit higher into that kind of aerobic threshold where we’re seeing the most benefits for individuals. Step three, right is just perform or is just recording performance. So two of the most classic and standard measures that are well documented in for folks with neurologic conditions and and others, are as a six minute walk test and a 10 meter walk test. So a six minute walk test really trying to capture you know, the, the client or the patient’s ability to maybe ambulate in the community and to walk in the community, how far can they go, maybe it’s starting to touch into, what’s their endurance, like, is this six minutes might be challenging that a little bit. And then the 10 meter walk test, more of an assessment really, of gait speed. So we’ll measure that in meters per second. And you can use that to determine fall risk. Or write ideally, we’re improving gait speed, as time goes on through therapy. So use this fill it out is what I have envisioned as, and yeah, scan it into your documentation, come back, pull it back out with, with your patients. It’s one of my favorite things to do. Whenever I’m doing a progress note. And I do a lot of progress notes, because I see folks with with chronic conditions. So I see folks for a long time often and one of my favorite things is progress, no day when I can pull out all of my measures that we took on on day one, or on their last progress note and say, Hey, look at look at this, change these changes that you’ve made, you know, and, and really be able to get some buy in from them, have them understand that their hard work is paying off because come times, you know, folks after stroke, or after spinal cord injury, or, you know, other neurodegenerative conditions, they just live in the grind of the day to day, and it’s helpful to look back. Hey, what were things like two months ago? What were things like three months ago, potentially, to see Oh, actually, yeah, we’re doing good work here. So yeah, so that’s, that’s my hope with this one. I hope you guys find it useful.

Ross Eckstein 7:07
I was gonna say true. I actually have been using this principle in practice, since I read your piece here for the last month or so I have a gal with TBI who’s had her TBI for about 15 years and making any progress at all on a six minute walk test is is hard with her. And I’ve been working with her for a long time. And I’ve been using this for about a month with her and she improved a good 50 meters. I don’t remember what the mcid or MDC is. But for her that was huge. It really, it really does work. And it’s, it is a pretty nice piece yeah.

Troy Adam 7:47
I know it actually Shweta as we as we move on to this next piece, maybe that’s a good time to do it. It kind of talking about the the article that supports some of this, right that we have a little bit of a theme here in this resource. And then the next article that’s coming up about high intensity gait training, and, yeah, and improving outcomes. And it’s, it’s honestly, it’s a little counterintuitive, right? I think as movement specialists, we’re like, okay, hey, let’s fix the, you know, let’s fix the technique and the mechanics and, and, you know, let’s, you know, avoid this circumduction, or all of these things that we learned in school, and then come to find out, guess what, just getting some hard work done really pays dividends. So, yeah, I’ll talk more about it.

Ross Eckstein 8:36
Its motivating to the patient too. Atleast, I found that as well.

Troy Adam 8:41
Yeah, great. Great.

Shweta Subramani 8:43
My question to you. I mean, this is not particularly to you, Troy, but just in general, just something that I’m throwing out there. Like, would you consider adding cognitive tasks to step two? At all?

Troy Adam 8:59
You know, that’s a good question. I think if your goal it depends on what’s your what’s your, what your goals are, right? So I think you add cognitive tasks. I can’t imagine where I would be quite surprised if you’re going to improve, improve 10 meter walk test data, or even six minute walk test data. Now, are you going to improve their ability to potentially participate in the community go grocery shopping, or something like that? Absolutely. Right. I think that makes good sense. Adding that, that cognitive tasks to the to the activity, I think, makes it a little bit more, a little more functional, a little, you know, take it out of a closed environment and put it more in an open environment, especially for somebody like Ross’s patient that he mentions as traumatic brain injury. Now, there’s probably some deficits there. But if we’re if we’re really if we’re just looking about kind of improving gait speed and gait tolerance, you know, I guess I can’t say for sure, but but it wouldn’t be on the top of my list as opposed to just increasing things that are going to cost, you know, energy. So.

Shweta Subramani 10:12
Got you. Cool. Well, thank you for that nice one page handout. And like you said, like most of your resources are very compact in terms of like how we can take that and fill it out in the clinic and send it to a physician or you know, how we can track progress. So I really love that about your resources just kind of wanted to tell you that. Great, well thanks. We will move on to the article that you were mentioning, which is related to this particular resource. It’s the improving spatial temporal gait asymmetry has limited functional benefit for individuals post stroke. So I’ll let you talk about it Troy.

Troy Adam 10:56
Yeah, great. So so this is one of many articles, excuse me that this original CPG that I was talking about, has kind of looked at and that, you know, APTA’s neurologic section would recommend for kind of literature review and reading. And really what it what it talks about is pretty much what we were just what we were just mentioning this, this previous concept, or maybe misnomer, or misunderstanding of a lot of therapists is, is that we really look for symmetry, and we really are trying to improve mechanics, with gait, especially after stroke with someone with a Hemiparetic gait. It’s it’s often, you know, it’s it’s easy to see, it’s easy to recognize, and it’s something that often we go after right away. And I’m not saying that there is no value in that. But what this what this article really suggested is, I think they had, you know, maybe upwards of about 50 subjects, they put them in, or they all the individuals after stroke, I believe they were more on the chronic stroke side as opposed to an acute stroke. So this is somebody in a six months post, post stroke. And so in an outpatient setting, and they looked at gait symmetry, and they measured it really with a stride length, or single single step length, as well as stance time, for limb. And they found that, that when they did try to train these asymmetries, and what they did was they would they put them on 18 different sessions. And they, on a split track treadmill that can help to modify gait and stance times because the treadmill track is moving at different speeds. So they kind of normalized that to the to the patient tried to train them in that environment, and then looked at these outcome measures after the fact. So they were really trying to measure or they were assessing changes in gait speed, in balance, in energy requirements, and overall activity levels outside of therapy. So they had, you know, activity monitors on them as well, and a variety of different outcome measures that assessed these, these pieces. And really, they found pretty limited effect from those that had trained on gait asymmetries, or these different kinds of spatial temporal gait patterns to improvements in their outcome measures that they were hoping now. So some trained gait asymmetries, and some didn’t. They did find, though that, guess what, a lot of people’s six minute walk test improved. So it kind of getting back again to this other point of pain, just getting the job done and working on on gait in general and in getting the intensity up, does show improvements. The other catch to that was they didn’t notice that despite changes and improvements in six minute walk test for both both groups, they didn’t really notice that it altered their activity outside of therapy. So the next question would really be, you know, and we have it on the bottom here how much training and improvement needs to occur before we affect the lives of our patients. So right there’s often MCD data and MCIDs are minimally clinically important difference and in detectable change that we should be thinking about and paying attention to because in this case, despite their their significant improvements in some of their measures, they didn’t actually the subjects didn’t actually participate in any more physical activity outside of the sessions. So, yeah.

Shweta Subramani 15:06
Great. Thank you for sharing that.

Troy Adam 15:09
Yeah, absolutely.

Shweta Subramani 15:09
Moving on to our next resource. Our next resource is a nice one page handout on, should I get a meniscectomy? Since this was put on by Ross, we’ll have Ross talk about it. Off to you Ross.

Ross Eckstein 15:28
Yeah so, with this piece, in our clinic, we see a lot of people who have meniscus tears and a lot of them. A lot of people in the United States in general actually are treated with meniscectomy. Still, it’s one of the most common orthopedic surgeries. And it’s, there actually isn’t great evidence to support meniscectomy is and so this is supposed to be kind of an educational handout that can be useful for somebody who has a meniscus tear or something where they can really make an informed decision if they decide to go through with surgery. And so, a lot of times in therapy, we get to see people with meniscus issues before they talk to a surgeon. And this is kind of a nice handout that you can give to them so that they can kind of make an informed decision with their health care. So it kind of outlines what the meniscus is, what a mastectomy is. And then kind of goes through some of the evidence surrounding meniscectomy. So it talks about degenerative meniscus tears, which is what we see more commonly, typically in physical therapy. And it talks about how there was a pretty well designed randomized controlled trial that found that exercise based therapy was non inferior compared to partial meniscectomy, within the first two years or five year follow up. And most trials tend to incorporate some sort of strengthening exercises for the quad, hamstring and hip muscles as well as aerobic exercise. And it talks a little bit about how the rate of meniscectomy, has not really changed over the years, it’s really stayed pretty constant, especially in the United States. And one thing I touched on a little bit is, a lot of times people think they have to get surgery to prevent osteoarthritis, or to prevent further joint damage. And if anything, the research, depending on what study you read is either neutral, or it favors exercise therapy, there was one study that actually found a five times higher rate of total knee replacement and people who had meniscectomy knees compared to people who did not and and I’d say anecdotally, in PT, I see a lot of people who come in years after having a meniscectomy with pretty severe knee OA. And so I’d say that that’s important for people to know as well. And then I get into kind of the difference, different types of meniscus tears. So conventional wisdom has always been like, if it’s a bucket handle tear, or if there’s a flap in the joint or something those need to be treated surgically, or if whereas if it’s more simple tear or something where you can have the hoop stresses that we like, and maybe then you won’t need to have a meniscectomy. But it’s interesting, because there’s some research where they’ve actually, like, there’s one survey based study where they took almost 200 orthopedic surgeons, and they presented them with these cases. And they said, okay, which of these needs surgery, which needs exercise, and they tried to see how accurate they were. And they were about as accurate as a coin toss if you’re going off of the imaging characteristics of the missed minutes of the meniscus. So there’s really there’s not really a good argument to be made there that certain types of tear should be treated with surgery quickly. So you can make the argument that maybe exercise should be the first choice for everybody for a while. And what’s interesting is a lot of studies will actually say, Oh, well, if it’s a locked knee, we didn’t include those people in the study, because those ones obviously need surgery. And so I was thinking about it, it’s like really well, what’s our evidence for that? And I tried to find research actually looking at people who have locked knees to see okay, do these people need meniscectomy and I only found one study, there’s a well done placebo controlled trial where basically, they took people with obstructive complaints or locked knees, half of them got a placebo surgery, half of them got a real surgery, and there’s no difference in outcomes between the groups. And so you might even be able to make the argument that even for people with locked knees, that maybe they could try exercise first, but one thing to keep in mind is that these, unfortunately, people with locked knees, whether they’re treated conservatively or with surgery, they tend to have worse outcomes in general. And so it could be that perhaps some of these people are kind of depending on whether there’s comorbid arthritis or something they might be needing a different treatment. All together like a total knee. And I touched on traumatic meniscus tears, there’s less research surrounding those. But from what I did find repair might be the preferred treatment if it’s a young patient or if it’s in an area with good blood supply. So the periphery of the meniscus, those can be repaired and then there’s a good argument to be made that made you avoid surgery altogether if if it’s not a good case for repair even in traumatic cases. So yeah, that’s pretty much that piece.

Shweta Subramani 20:39
Ross, did you find anything related to like specific age groups, as far as the studies were concerned?

Ross Eckstein 20:44
Most most of these studies were done in older individuals, just because older individuals tend to be the people who have the degenerative meniscus tears. And that’s where really most of the research is done. But and this isn’t something I really got into with this piece. But there are a lot of asymptomatic meniscus tears. So it could be that even younger people have more meniscus tears than we think and that they’re just asymptomatic and the knee doesn’t start to hurt till later. And then that’s when we start to pay attention to it more. But yeah, that’s I’d say that most of this research is probably people aged like 50 to 70 or something like that.

Shweta Subramani 21:21
Okay, I was curious as to whether I mean, like, are they looking at age? And are they also looking at activity level of that person in terms of whether they’re recommending surgery or not? Or like

Ross Eckstein 21:34
That was one, I believe that survey based study I was telling you about? I believe that the surgeons were also given that information as well. And then there’s another trial that I’ll talk about, and I think they may have gotten into age with that one, too. I can’t remember for sure. But I know that the one with the survey based study I they had that information as well. They had imaging, locking characteristics of tear characteristics, I believe for that one. Yeah. Okay.

Troy Adam 22:04
Yeah, Ross. So I really liked this one, I think I feel like, I don’t know, I get this question all the time, actually, you know, and it’s often one that’s, you know, somebody’s asking me at the gym, or, you know, like, even outside of PT or family or whatever, right? Like, this is just one that comes up a lot for whatever reason, I really like how you lay out the evidence and in allow people to kind of make an educated decision on what they what they want, based on on what your your kind of findings have been through the literature. So I think this is an excellent, thanks for doing it.

Ross Eckstein 22:42
Yeah, thank you. Yeah.

Shweta Subramani 22:44
And then were there any in particular that talked about like, prehab?

Ross Eckstein 22:50
Umm not that I saw? Well, a lot of these studies. So one that I’ll talk about the one of the studies, that is one of the research article reviews that I did they, it was an analysis of the escape trial. And in that study, they basically had people start with PT, and then they were trying to see which ones ended up needing surgery later. And so in a sense, I guess you could call that prehab. They’re, they’re doing exercise with the hope that they don’t need to have surgery and then go into some of them and go into surgery and some don’t. But yeah, that’s a good question. As far as whether outcomes are improved with prehab versus not, that wasn’t something I got into quite as much with this.

Shweta Subramani 23:32
Maybe the reason I ask is because like, even with prehab, and not just after, like, you know, something like a meniscectomy but even like a total hip or a total knee, I feel like it has better outcomes, but it’s not being I mean, patients are not really being educated as much about prehab as they need to be, because if you like, I mean, the evidence speaks to as far as that is concerned, because I haven’t researched too much into that. But then I know that there have been people with like good outcomes compared to their counterparts, and they’ve had prehab. I mean, at least contribute to their prognosis. And but still pretty. Cool.

Ross Eckstein 24:15
Right? Right. It seems like it’d be common sense that the prehab would be helpful, and I would definitely encourage patients that they are going to go through with meniscectomy that they should do prehab. And in the back of my mind, I’d be thinking maybe you’ll actually just feel better. I need the surgery, you know, but it seems like it’s common sense. But I didn’t really look into the research on that idea. Interesting to do that. Yeah.

Shweta Subramani 24:36
Cool. Well, since you were mentioning about the article that is tied to this particular resource, I will let you talk about that. So coming up, is our the article in patients eligible for meniscus surgery, who first received physical therapy multivariable prognostic models cannot predict who will eventually undergo surgery. And I’ll let Ross talk about it.

Ross Eckstein 25:04
Yeah, so this was the one I was mentioning. It was kind of piggybacked off of the escape trial. So it was, I think that most patients in that study started with exercise, and some went on to have surgery. And so there was an expert panel of pts and orthopedic surgeons, I think there’s 10 to 20 of them. And they looked at different factors. So they looked at age, sex Kellgren lawrence scores for osteoarthritis with X rays, tear characteristics with MRI, and they looked at all these things, and they said, Okay, who are at the very beginning of the study, which of these patients is going to end up needing a meniscectomy and essentially, what they found, they did say that socioeconomic status was weakly associated. So people with a lower socio economic status were slightly more likely, I think, to end up with the meniscectomy. But it was such a weak Association, they they said, they couldn’t really say it was significant enough to even pay attention to and so their bottom line conclusion was, there’s no factor that anyone can identify at this point based on this study, that can predict who’s going to end up needing surgery versus not. And so it kind of just reinforces what I was saying with the last piece where it’s like, probably everybody should just try exercise therapy. And I tell most of my patients, you know, it’s like, at least six weeks, but preferably more like eight to 12, you know, because there’s a good chance, maybe you won’t, won’t end up needing surgery for that. So. And then something else that was interesting is that the study, this is one of the studies that just automatically excluded people with locked knees. And as we talked about before, like, a lot of it seems like a lot of these research studies make that kind of assumption. It’s like, oh, yeah, they’ve got a locked knee, they are a surgical candidate exclude, them. And maybe they don’t really need to be doing that. So yeah, that was, I guess, the summary for that.

Shweta Subramani 27:11
Again, like in this, did they consider age, activity? And did they mention anything about

Ross Eckstein 27:17
BMI as well I believe. Sorry, go ahead.

Shweta Subramani 27:19
I was just asking if they mentioned anything about, you know, what, kind of like, what specific rehab rehab did they go through, like their exercise? Or whatever?

Ross Eckstein 27:32
That’s a That’s a good question. I would have to read the study. Again, since this was kind of a piggyback analysis of the escape trail, I didn’t really get into what specific exercises were done. I can say that most. Most studies I read where they do rehab for these sorts of issues, it’s pretty generic stuff, or it’s like cycling, walking, and then strengthening exercises, things like squats, you know, nothing incredibly fancy is most of these but I can quickly refer to the escape trial. I’m not sure exactly what their protocol was. I do know that I think they were in twice a week for those either six or eight weeks, something like that of supervised therapy. And I think the sessions were about 30 minutes a session. I mean, but I think that’s what I remember anyway. Yeah.

Shweta Subramani 28:23
I understand like, but I personally feel that if they are a little more specific in terms of like their inclusion criteria, and the protocol that they use, then it might be a better predictor of okay, like, how much did that influence their outcomes?

Ross Eckstein 28:42
Yeah. Yeah, I could. I think that makes sense that maybe, if you were more well, and I guess that’s partially what they’re trying to determine, I guess it’s like, you know, what factors are associated? And really, they couldn’t find any in particular, you know, and maybe future research will find something different. That’s definitely possible. So

Shweta Subramani 29:08
Cool. Thanks. We’ll move on to our next resource. So our next resource is a one page neat handout with some very nice columns, tabular columns. And this is about how to perform an ocular motor examination. And Troy is the one who wrote this resource. I will let try talk about it. Troy, can you tell us a little bit about this?

Troy Adam 29:37
Yeah, absolutely. So yeah, so this this document is meant as a clinician resource, something to have with you, kind of by your side as you’re going through an initial examination, or you’re getting ready to for somebody that you expect some sort of ocular motor dysfunction. So yeah, like I mentioned, we have a variety of tests that are kind of appropriate to be going through that are part of an ocular motor examination, how I instruct the patient on performance of that measure, and then based on the findings, kind of what potential associated pathologies might be, might be likely. So really we’re looking at peripheral nerve lesions or central nerve lesions. So in general, my ocular motor examination and and I think most would include kind of the following thing. So you’re looking for spontaneous nystagmus. This is, this is you know, nystagmus right is more or less movement, fast phase movement of the eyes, spontaneous nystagmus is, is, that’s pretty significant, it’s often something that you won’t pick up in room light. So it is something where ideally, you either have some occulography goggles, or you have what are called Frenzel lenses, which are kind of like these clown, clown house kind of lenses that don’t allow your your eyes to fixate, because naturally, our eyes will fixate on anything, they’re they’re actually required to we cannot fixate, and that can sometimes suppress this nystagmus that we see. But you’re looking for just nystagmus at rest, depending on the look or on the direction, and the severity of that we can make some determinations about whether it’s peripheral or central lesion, visuals, field assessment, I think this is one that commonly people do. Or at least they’re, maybe maybe they don’t actually measure, but they’re at least aware of. So this is somebody that I think of, you know, post stroke is probably the most common thing, I think that people are like, oh, yeah, you know, they can’t see out of their, you know, out of there, they can’t see to the left or something like that. So what this talks about is how I assess visual field. So I’m sitting right in front of them I bring in from the periphery is my finger, is using really myself in my own vision as a guide to when they can begin to see movement of my finger or coming to into vision. So I’m looking for visual field cuts. Normally, normally, those come on one side, most likely, right? That’s, that’s that kind of classic CVA type symptom of somebody either, you know, with a posterior cerebellar, or middle cerebellar artery occlusion or hemorrhage will have, but it talks about what happens if we have vision loss on both sides, or have just one of one eye and what what those types of things can mean smooth pursuits is another thing that’s, that’s vital. So what you’re looking for here, this is the classic doctor’s office test, right, you’re going to point your pain or the tip of your finger you don’t want you do want them to focus on it, I find that often people will just stick their finger kind of straight up like this, you really want them to try to focus on the tip. So kind of pointing pointing directly at them either with pen or your finger is most helpful. And then you’re gonna go through a standard each pattern so that way, we can really check all of the different nerves that are responsible for. For eye movement and the eye muscles. What I’m looking for is what’s called saccadic intrusion, which means, you know, the inability to track that for a moment, and then it catches up or things like that. Saccadic intrusions are often associated with peripheral lesions, and then just the inability to track or inability to see, right, we might be looking at more of a central reason, gaze evoked nystagmus this is one that I do think is not as well understood. Or not as done is frequently but gaze evoked nystagmus you’re gonna have your your patient or whoever you’re testing, move their eyes out to the edges of their vision. Now, I see a lot of people, a lot of students or other clinicians that will bring that that point all the way out to the peripheries of their vision. And it’s not uncommon to actually have some the stag miss out the very edge of your vision, even in a normal healthy person. So if you take them way out there to that to that edge, that’s you know, you might give yourself a false positive, so you’ve let them come back in just a little bit. And again, you’re looking for persistent nystagmus and you’re looking for the direction of that nystagmus to kind of help guide you in terms of your of your diagnosis. Sometimes you’ll see you know someone with known central nervous system pathology, someone with TBI, you know, if you take them way out on that on the edges of their vision, they’ll just have non fatiguing nystagmus that lasts for quite a long time. Vergence, this this is a test where we’re really just looking at abducens to see, can they can they, you know, have the eyes converge. findings on this suggests, you know, 15 centimeters, you should be able to see, without losing the ability to verge the eyes together, you’ll find other outcome measures that want those numbers significantly lower than that the boms comes to mind for somebody post concussive or something like that, where we want those, we want those down to maybe two, three centimeters away from the nose. So 15 seems like pretty, pretty substantial. Saccades, so saccades, this is another thing that I feel like isn’t you know, if you’re don’t do this a lot, you get this saccades and nystagmus confused, or I find that that’s something that’s that people struggle with. But but saccades is the I mean, I’ll have my patient look at my nose, and then look at my finger. So they’re quickly shooting back and forth between between looking at my nose quickly and looking at my finger quickly. I often you’ll want to say finger, nose, finger nose. So just like if you were doing a sensory assessment on somebody, you don’t want to be really predictable. Because they can start to kind of accommodate to that. So you’re looking for is there a delay in in the time that it takes for that to start? And most likely what you would see as an overshooting and overshooting of one, and then coming back. So right so if I if my finger out here on one side, and I say finger and they look over here, they overshoot and come right back to it. I’m not too concerned, that’s also not that abnormal. Or I guess there are folks without impairment that will do that. What you’re really looking for is they they’re their eyes are fixated on nose, you say finger, they overshoot their eyes, they overshoot on the way back, maybe they overshoot again. And then they settle in. So it’s this kind of zigzag closing in pattern on. Yeah, on the on the fixed target. And then the last thing that I like to assess is pupillary light reflex. So this one again, we’re looking at what’s the function of both the the nerves that are responsible for sensing light and the motor response, right, you should see pupil dilation, pupil constriction in both sides, as you’re as you’re doing that. But yeah, so these are the tests that I think kind of include, or go into my standard ocular motor exam. As I’m screening somebody maybe with dizziness, that’s, that’s going to come out of nowhere or something like that, that’s not positional. I’m going to go through all of these types of things to figure out. But I think if I think they need follow up somewhere, so

Shweta Subramani 37:58
Oh, I think this is pretty neat. And the way you’ve like, put in, like, what are the findings with it, and what could be the associated pathology in like, one page is like a great reference. I was gonna say that this. I know, I’m, we’re gonna be talking about our case later on. But I feel like in a way, this is a good start for that case, because like when you are in the initial stages of doing about, like, vestibular examination, and you’re still kind of trying to differentiate and and screen and narrow down as to what treatment, we’re going to go forward with this patient. oculomotor examination is very important in those stages, the early stages before we get into, really get into testing. So I think that this works are great as a reference to use in situations like that.

Troy Adam 38:51
Yeah, no, absolutely. Right. So in you know, it doesn’t go into, you know, the specifics of, you know, what is the central nervous nervous system lesion mean, or what, what all are the pathologies that could that could include right or same thing with a peripheral lesion, but it helps me to go through and be like, Oh, wow, okay, this is funky. Right. Let me make sure that we’re doing our due diligence and either getting you in for an MRI or back to primary care, or Oh, actually, this finding is normal for the fact that you have Vestibular neuritis, and I don’t need to be quite as concerned as as I maybe was, or something like that. So hopefully you can find this as a helpful resource. And maybe even just a checklist as you’re kind of going through like, oh, wait, yeah, I need to come back. And I want to check this. This other piece too, as I’m working through my differentials here. So

Shweta Subramani 39:46
Absolutely. This is definitely something that I’m going to be able to take into the clinic right away. So.

Troy Adam 39:51
yeah, great.

Shweta Subramani 39:53
Cool. Ok we’ll move on to our next resource. This is a two page handout on minimizing the concurrent interference, sorry, concurrent training interference effect and I’m gonna let Ross talk about this piece. Ross, can you tell us a little bit more about this?

Ross Eckstein 40:11
Yeah, so this was designed as more of a resource for clinicians. But some patients might also think that it’s interesting. So it kind of goes through some of the evidence for the concurrent training effect, and talks about how to minimize it as best as you can. So the concurrent training effect is essentially, when you train for aerobic exercise, and for strength and power adaptations, they have kind of competing effects and power can be blunted by aerobic exercise in particular. And so this would be very relevant for either athletes looking to return to play, or for older adults who are looking to enhance function and reduce risk of falling. It’s not something I got into very much with this. But I’ve done other presentations, like when I was in PT, school, things like that, talking about the importance of muscle power for fall risk reduction and for function, and it’s actually much more. So power being your ability to exert force, either with a light or heavy load quickly, whereas strength is your just force or slow speed, force. And power is much more strongly correlated with function, functional activities, like stair climbing, things like that. And so depending on your patients, it can be important to try to minimize this effects. But most people can benefit from both not only for functional benefits, but also for health benefits. So this piece kind of outlines ways that you can still try to get the best of both worlds and hopefully minimize that concurrent training effect. And so this interference interference effect, if you’re talking about muscle power, specifically, it can occur doesn’t matter what your training status is, you could be trained, untrained, older, doesn’t matter if you’re talking about muscle power, aerobic exercise can interfere with power development, if you’re talking about strength. Interestingly, it’s more just highly trained athletes that have strength, impaired by endurance training. But in PT, we care probably more about power anyway. So I think that anybody who needs to enhance muscle power could benefit from some of this knowledge. So it talks about same session training. So it talks about, if you’re the best is really to avoid doing your strength and aerobics in the same session. So when you’re prescribing your home exercise program, if you can tell people to alternate days or something like that, between doing their their strength power work and their endurance work, you will have better adaptations with that. And then, if you do need to perform them in the same session, it’s better to do strength and power exercise first, though, it’s still blunted. So there’s two theories as to why there is this interference effect. One is just that the fatigue from aerobic exercise interferes with power development. There’s probably some truth to that. But it’s interesting, there’s, there was one study, and this was in rugby players, but they had one group do aerobic training right after they did their power training. One group did it six hours later, and one group did it 24 hours later. And the group that did their aerobic training right after power training still had blunted power adaptations. So it has to be at least partially explained by things going on at the molecular level, like signaling pathways and things like that. So let’s see, it talked a little bit about Oh, and one thing that I touched on that was kind of a sidebar, but is a study that I thought was interesting is they there was one trial was looking at women with type two diabetes, and they were looking at health outcomes. So things like insulin sensitivity, and fat mass reduction reduction. And they actually found that for women with type two diabetes, separating the high intensity interval training and strength training in separate days actually had better fat mass reduction and insulin resistance adaptations compared to doing them both in the same session. So there’s less research out there on that, but it’s interesting that there’s potentially even even some health benefits to separating them out if you can. So, I talk a little bit about duration and frequency. There’s one meta analysis is a little older was done in 2012. But they did a pretty good job of looking at the dose response relationship, and they found that the interference effect was lowest if you had short training sessions 20 to 30 minutes for low frequencies less than three days per week. If you’re looking for power to be your desired adaptation, there’s some research looking at volume you There’s one study where they, this is, again, athletes, but they took athletes and what some of them did a ratio of one to one strength to endurance. And then one did three to one. And then another did just strength. The group that did just strength training had the best power adaptations, the three to one ratio group also had impaired power adaptations. But the one the one group had the worst power adaptations. So even at a three to one ratio, you can still expect some blunting of power adaptations. And then it goes into intensity. There’s less, there’s some conflicting evidence with that it looks like if you equate work, so you can do more work in a short period of time if you’re doing high intensity exercise. But if you equate work, it doesn’t seem to make a huge difference one way or another. If work is not equated high intensity exercise, aerobic exercise might be more likely to interfere with power adaptations, because you do more volume, which is, is associated with blunting the power development. And then modality. There’s a lot of conflicting evidence, and we don’t really know, one of the newer meta- analysis that I read said that it doesn’t really seem to matter what type of aerobic training you do, it all kind of interferes with the power development. So yeah, that was that piece.

Shweta Subramani 46:31
Oh, so, Ross, if I’m understanding this, right, in terms of your takeaway, you’re saying that, like, we wouldn’t attempt so much of an aerobic training and power training, like in the same session, right?

Ross Eckstein 46:42
Yeah. So it might depend on your patience. But definitely, if you’re looking for optimal power development, and I’m not saying that you can’t develop power at all, with concurrent training, you can. But if you’re trying to do optimally, if you can separate out your trainings, either on two alternate days, or even waiting six hours like that other studies show that even waiting six hours was a little bit better than doing them right together. That that is better. And so in PT, sometimes we’re limited because we have to address multiple things in one session. But when you’re prescribing the HOME program, especially say you have a woman with osteoporosis, and a recent history of falling for that person, power is probably the adaptation other than balanced training, that’s the adaptation that you need. So for that person, I would be doing everything I could probably to try to minimize that. So I’d probably not be doing endurance training in session at all with that person, unless they really needed it would probably be more just the balanced training and power training, and maybe stuff for bone density. So yeah, so I’d say it depends on your patients, of course, but But ideally, yeah, you want to separate it out the aerobic and power sessions, if you can,

Shweta Subramani 47:55
like even if we were to incorporate, like power training into like most of the session, if we could do like aerobic training just for like, maybe a warm up or cool down that still work? Well. Yeah. And

Ross Eckstein 48:07
so aerobic, and that’s a good a good point. So if you’re talking to warm up, you know, sometimes we throw people on a bike for five minutes. That’s one thing that was talked about, you know, with that meta analysis, where it’s like, if you can do less than 30 20 30 minute sessions for a low frequency, you’re less likely to have interference. And so I’d say that there’s a difference between what we do gentle cycling on the bike, for most people isn’t really aerobic, you know, like five minutes on the bike and get a lot of people might be warming up their legs a little bit, but I’m sure their heart rate is probably not going over 60% Max. So it’s like, I’d say that there is a difference between a warm up and to aerobic training as well. That’s a good question.

Shweta Subramani 48:47
Yeah. Thanks. Well, we’ll move on to our next resource. This is what is heterotopic ossification and this was written by Troy, I’ll let Troy talk about it.

Troy Adam 49:03
Yeah, great. So heterotopic ossification, this is something that not a lot of people talk about, but can be really a big problem. It’s most so ultimately, what it is it’s abnormal bone growth. That’s often happening, extracellular around joints. Most commonly, in terms of why this happens, they don’t have actually that great of an understanding of it. But those that are at risk are often those that have had spinal cord injury or amputation. And in our in general, our younger individuals, so they you know, maybe you’ve acquired a spinal cord injury through some sort of traumatic means and you have subsequent fractures or yeah, injuries along with that. These types of problems can go either or undiagnosed or, or even diagnosed, but but not with a lot of ability to kind of treat and manage, it’s unfortunately not something that we can really get rid of, necessarily. So managing it can be can be challenging, and it can often cause a lot of dysfunction for individuals. So, limits often passive range of motion is what you would expect. You’re going to see this on radiographs. In terms of treatment, right you there are some medications that can pretty much prevent or inhibit bone, bone development and bone growth. However, you’re also working with someone, like I said, often after a spinal cord injury that needs as much, you know, that just by having that injury is almost guaranteed to be osteoporotic, over the course of you know, 12 months or maybe even less. So some of the dosing of those medications can be can be pretty challenging. What you see with it, it’s often pain and swelling in the location, wherever that is, that’s well after the injury occurred. So this this, like I said, it doesn’t go away. So it might be somebody that has HMO is what it’s often referred to as much, much longer years after a fracture years after injury. Yeah, which can be tough. Yeah, but like I said, radiographic CT scans, MRIs are used to identify this, it’s graded on a scale between one and four. So I’m talking about a more severe type of case. But you could have grade one, which is just small pieces of bone, grae 2 grade two is pretty much getting larger and getting closer together in terms of that abnormal bone growth. What it looks like on imaging, I find is kind of more cloudy, more diffuse looks like you know, non nonspecific bone growth in in an area. So this isn’t necessarily, you know, this isn’t like an osteophyte or something like that, that’s, that’s forming just near the bone. This can be this can be six, eight centimeters away from, from the joint or from the area that was originally injured. Yeah, so in terms of managing this, you know, some gentle range of motion is appropriate, but you often don’t want to push into, you don’t want to cause an inflammatory response here. So if you’re aggravating it, there’s potential that you’re going to be causing more problem. But working up to the, to the extent of the range of motion that they have would also be important to make sure that you maintain, yeah, maintain that passive range that that is available to them. Yeah, I think that’s that’s pretty much it.

Shweta Subramani 53:12
Troy, in the like in the treatments you have mentioned that there is like, limited options available? I mean, there’s nothing that can be like an invasive procedure to really, you know.

Troy Adam 53:33
I mean, I honestly know, it’s embedded within the muscular tissue. So I mean, it would be. Yeah, it’s, it’s, it’s diffuse, it is not uniform, and it’s not. Yeah, it’s not like something that can can be removed without, honestly without just exercising a ton of tissue, which, which, yeah, what would the I mean, the other catch is surgery is often one of the risk factors associated with this. So trauma is is what will potentially set you up for this. And, you know, to go in and try to excise this would potentially just lead to worse impairment.

Shweta Subramani 54:17
Right. Thank you. Thank you for sharing that. Yeah. As always, we wrap up try to wrap up our show with a case study. The case study for this month is I’m going to try and talk about this in using the ICF model. So this was a patient of mine. It’s a 50 year old female with right posterior canal BPPV or Benign Paroxysmal Positional Vertigo. She, she lives with her spouse and two daughters actually. And she works as a professor at a university. And she is very active for her age, she was wanting to further her education was kind of going through her PhD process. And in the process of like, working on her dissertation, spending a lot of time on her laptop, she ended up having neck pains. And she also had COVID. And post COVID was when she started noticing more dizzy symptoms more being more off balance and more neck pain. So she, she consulted like a lot of specialists in trying to really find the answer for what her situation was, and like trying also trying to find some sort of treatment, but then she wasn’t really very successful. So like, the frustration that was associated with talking to so many specialists and going to so many appointments, trying to get her PhD done at the same time and teaching. It was a lot of pressure for her. And there was also a lot of anxiety that was setting in in terms of like, why am I not finding an answer for my situation. And even though this patient was kind of educated, like she had a brother in law, who was also a physical therapist and talking to him and trying to figure out like, Okay, how did her symptoms relate to possibly Vertigo at that time, and she was not entirely diagnosed. And you know, just her brother in law educating her about the maneuvers and her getting into the positions and really feeling dizzy, like it’s, it’s very, very sensitive for these patients. They just don’t want to be in that position. I personally have tried, like, using the Dix Hall pike and even like Epleys, on family members, and they just don’t want to feel that feeling when they’re really into the positions. So she just never really wanted to try therapy at all, just because of that anxiety, mean, the anxiety that had set in from not getting an answer and the anxiety that was associated with like getting into the position. So it was a lot to like, even educate her and try like modification of maneuvers and then get her solely accustomed to doing the whole manner. And there it made a huge difference, not just in like, how, like she went through the whole treatment, but also like how her anxiety symptoms kind of calmed down and how her personality, like opened up a little bit more and how she felt like all the stress had been relieved and things like that. So that was quite a life changing experience, not just for her, but also for me as a therapist. So that’s why I kind of wanted to talk a little bit about this case study coming to like BPPV in general, the resource that I use for this patient, which was the most basic one when we first started with the gaze stabilization progression, where we’re using the VOR exercises, which is basically your vestibular ocular reflex reflex. Sorry. So the most basic ones are the VOR 1 and the VOR 2 where, you have the patient hold their thumb, or sometimes they can even hold like a pen or a code, depending upon how much they are able to stabilize their gaze on something as narrow or something wider and then gradually get comfortable and progress into something narrower. And the VOR one is basically trying to rotate their head in the horizontal plane. And still, fixating their gaze on the thumb or the pen or the object that they’re holding out. And VOR 2 is basically you’re trying to, again fixate their gaze and trying to move, rotate their head from right to left. Sorry, I might be. So this is basically like a progression of the VOR 1. And here you want to like not just do that in like horizontal but also like in a vertical position, movement and where they’re trying to like move the object and the head together and see if they’re able to maintain that position. So the reason why I picked this resource is because like I said, like early on when you want to introduce something that’s most basic with patients like these, for them to really get comfortable on gradually progressing to more intense activities which might trigger their symptoms. It’s easier to start with something minimal to at least get them to feel comfortable with their exercise program and maybe even more to try it especially for someone who might have like, really high anxiety like this patient had. We also have like a great course, which was actually like our very first therapy insights, continuing education course by Helena Esmonde, where she talks about strategies for decreasing Visual vertigo in patients with visual motion sensitivity, post concussion syndrome and pppd. The next resource, this was recommended by Ross, which was the Epley maneuver. I’ll let Ross talk about it a little bit.

Ross Eckstein 1:00:34
As a orthopedic PT every once in a while we get vertigo and BPPV. But because it’s not something that I’m seeing day in and day out, I like handouts like this as a reference for me, I’d say the Epley, especially for someone with right posterior canal BPPV is typically what I try first and in this patient became comfortable enough. And if she felt ready to try it, maybe after working on the gaze stabilization for a while, this would probably be what I tried first. And so this is a nice resource that Troy made, where they kind of goes through the different positions and that you go through for right posterior canal BPPV. And it’s also useful as a handout that you can send home with them. Sometimes patients do need to repeat this at home as part of a home program as well. And it’s very straightforward and easy for anybody to figure out how to use it. And it’s also I was gonna say that Epley maneuver, if I remember, right, I’ve read that it’s like over three treatments is like 80% effective, where it’s like almost curative, you know, so it’s like, if you can get them doing this, then then that’s great.

Shweta Subramani 1:01:52
Yeah, absolutely, I so the thing is, like, even with the manuvers, like, like I said, like, if we were to, like completely related to this specific case, we need to talk about like, not just what the patient is coming in with, but like, if they have associated neck pain as well, then you’re doing that, are we able to do modifications for this patient like.

Ross Eckstein 1:02:15
and doing that screening that Troy had mentioned, you know, the the other piece that Troy had, you know, where it’s like, if you can do some screening, and make sure there’s not a vertebral artery problem first, you know, the neck pain with it. And so, you know, you definitely want to make sure that you’ve really nailed in on your diagnosis and, and that the neck pain, you know, that they could take this as well, they had the range of motion to do it. That would also be critical before you went into it. That’s a good point.

Shweta Subramani 1:02:41
Absolutely. And Troy shared a resource for this case study as well. So Troy’s resource was cupulolithiasis and the semont liberatory maneuver. So I will let Troy talk about that.

Troy Adam 1:02:55
Yeah, yeah, absolutely. And I’ll chime in a little bit too on on some of the other ones. I mean, thinking of this patient that does have kind of extreme anxiety that you mentioned. So one of the things that if I you know, if I if I put somebody back in Dix Hall pike and right, the classic thing that we would expect to see here is right torsion, right? And an up beating nystagmus, I would that would tell us, you know, okay, hey, this, this looks like a right sided posterior canal. BPPV. Honestly, I get super excited, because it like Ross said, this, doing this stuff to get people better so fast. And it’s just one of those things where it’s like, people can come in really high level of impairment, and they leave feeling a lot better. But you’re right, they get anxious, because guess what, when you put them back in that position, it was uncomfortable. And really, when I when I, when I talk with my patients about this, I tell them, hey, the fact that this is uncomfortable, gets me excited, because guess what, that means that we’re on the right track, and you are going to feel so much better when you leave. So like, let’s you know, let’s clench your teeth here for a little bit, there’s gonna be tough, you know, in this is going to be uncomfortable, but guess what, you are going to feel so much better. And I feel so confident that this treatment is going to be really effective for you. So I feel like that often kind of can can give people the option to to get back into some of these provocative positions, right, but we do all sorts of provocative tests as PTs but this is this is definitely one that that people don’t often enjoy. Yeah, so classic right, would be the Epley maneuver. That’s what we do in the United States. If you if you if you if you’re in Europe, right, for the most part, they treat everybody instead of with an Epley, they do what’s called a semont liberatory maneuver. Semont is the name of the person that kind of developed the test. But what this is, is you can use this for cupulolithiasis, which I meant in, in this, what we’re talking about is a canalithiasis meaning there’s, you know this calcium carbonate crystals in one of those canals. In this case you can treat BPPV can can nullify assists with a Semont maneuver or a cupulolithiasis which can also be uncomfortable for folks. That’s, that’s right. If you know, if you put somebody in right sidelying or left sidelying, they’ll have eco geotropic nystagmus leading up towards the, towards the sky for a long period of time, and it won’t go away. What that means is that the cupula inside that canal is heavy. And because of that, it causes this nystagmus. What you do with this is honestly it’s it’s kind of intense, you thought they were anxious before, it’s kind of like it, this is a fast, high velocity. You know, I don’t want to call it a body slam but but it’s intense there, there used to really be taught as a body slamming, in fact, you know, it’d be a pile of pillows on both of this, both sides, we’re finding more so now is it’s actually the velocity of taking someone from one side position and trying to almost fling that that otolith or whatever debris is attached to the cupula off of the cupula and continue on through the posterior canal, and ultimately into into the ampula where we can kind of have our symptoms resolved. But you can treat folks with with posterior canal BPPV with just this if you don’t want to do an Epley. But I don’t know that this one is any more comfortable or makes patients less apprehensive than the others. But you know, you mentioned like three PD for in terms of in that initial resource. That’s another thing that I would be thinking about strongly with, with this patient specifically, just with the anxiety that’s kind of set in that that’s a little bit more classic of that unless it’s just this positional stuff that she’s having anxiety with. But yeah, it’s, it’s it’s an awesome treatment, though, when it when it works, and you can really get people feeling good when they leave. So

Shweta Subramani 1:07:22
Oh, yeah, absolutely. Well, I didn’t try the semont onewith her, but I actually did. So I there’s the sideline test for BPPV, which is very similar to this maneuver, and also Brandt daroff exercises very similar to this except that in brandt daroff you take them into the position, you wait for it to subside and then bring them back up. Just like how we will do in Epley’s, that actually worked out great for this particular patient,

Troy Adam 1:07:50
Oh great

Shweta Subramani 1:07:50
that doing that she felt that okay, she was able to comfortably get into the sideline position versus if she were to do a whole that way, where she had to have even her neck in hyperextension not supported. So I think like, like I said, like, sometimes you might not get hardcore, just the condition, but then we’re working with other factors also. And like, especially anxiety, like psychologically, the impact that it has, it’s hard because when I the first time that this patient showed up to me, like when I tried to do Dix Hall pike testing with her, like she was in tears for a long time, so I had to, like, calm her down. And then she never ever wanted to get back into that. And then to the point where like, and this is again, a patient who is like, you know, like was pretty aware staying on top of things is really trying to find those answers talk to her brother in law, who is already physical therapists and who has told her that hey, you know, this is pretty effective and things like that, and she has even seen that the brother in law, they do the treatment for an investment. So in spite of that, it’s hard because like, I personally haven’t had those symptoms so it’s hard to relate, but then you can empathize and understand that if they really don’t want to get the position that is a lot like losing your whole center of gravity and not knowing where you are in space is a lot for some people to take in so it’s about getting them comfortable like okay, if this doesn’t work for you, we have a modified position we have an alternate maneuver that we can try maybe that worked out great and then lot of education about like okay, are they how the patient is feeling after that and slowly trying to get them comfortable that okay, if you don’t want to try this now wait for a few more sessions we’ll try these exercises which are like your VORs, the most basic exercises and like try to get them comfortable with that and then slowly transition and she got to the point where she was able to tolerate a whole Epley, but it was not it wasn’t even about like, okay, like, no like as far as these maneuvers are concerned like, Okay, if you say that you’re able to do it three or four times in a visit, then definitely that means that I feel a lot better. But for someone who’s like, Okay, I did advance, but that’s all I can tolerate for today has to be like, approached slowly. And you know, build that relationship with them. And then kind of see if, okay, you’re at that point where you can slowly use or have that conversation when we start talking about possibly transitioning into like a full Epley maneuver instead of the modified one and then get the patient comfortable with everything. So I think it was a great learning experience for me too.

Troy Adam 1:10:34
Yeah, well, sounds like it worked great.

Shweta Subramani 1:10:36
Well, that brings us to wrapping up today’s show. So thanks so much, everyone, for hanging out with us. We’ll be back next month with another therapy insights resource roadmap show. Thanks to all you therapists out there making therapy informative and powering and person centered. If you need like, if you want to get instant access to these resources and hundreds more that we have on our website, please go to, all the links are available in the show notes. And if you have any questions about any of these resources, or roadmap show, just reach out, reach us out at support at Be sure to vote for what we create next. Take care see you next time.