sábado, 2 de maio de 2015

The Physical Therapy Assessment and Management of Infants with Congenital Muscular Torticollis. A Survey and a Suggested Assessment Protocol for CMT
Department of Paediatrics, University of Gothenburg, Queen Silvia Children’s Hospital, Gothenburg, SwedenAnna M Öhman*
 
Corresponding Author :Anna Öhman
Department of Physiotherapy, The Queen Silvia Children’s Hospital
Sahlgrenska University Hospital/Östra
SE-416 85 Göteborg, Sweden
Tel: +46-313434732
E-mail: anna.ohman@friskispraktiken.com
 
Received May 09, 2013; Accepted June 28, 2013; Published June 30, 2013




Introduction
 
Congenital muscular torticollis (CMT) is the third most common musculoskeletal abnormality in infants next to hip dysplasia and clubfoot. The reported incidence is 0.4-2.0% [1,2] however a recent study indicates that it might be higher [3]. CMT is a result of shortening or excessive contraction of the sternocleidomastoid (SCM) muscle with limited range of motion (ROM) in both rotation and lateral flexion of the neck and an imbalance of muscle function around the neck [4-6]. Due to the positional preference there is a high risk that infants with CMT develop deformational plagiocephaly [7-9]. The birth history demonstrates an unusually high incidence of difficulties during labour e.g. breech presentation is commonly found [10-14]. There is also a coexistence with hip dysplasia [10,11,14]. Infants with CMT are found to be at risk of delay in achieving motor milestones [15,16].
 
Evidence-based Physical therapy is important for patients because it implies that they will be offered the safest and most effective interventions within the limitations of current knowledge. The expectation is that this will produce the best possible clinical outcome [17]. Physical therapists in general have positive attitudes and beliefs regarding evidence-based practice (EBP) [18,19]. However, the majority of physical therapists indicated that they need to increase the use of evidence in their daily practice [18]. The process of implementing any research outcome begins with awareness [20]. In order to understand to what extent there is a need to improve and implement “new” methods and strategies for assessment and treatment of CMT among physical therapists we need to know more about the current practice. Luxford et al. investigated current physical therapy management and issues in management of infants with CMT in New Zealand (NZ) [21]. They constructed a questionnaire for this purpose. In their survey they found that most physical therapists in NZ used a visual estimate [21], this may reflect a lack of knowledge about measurement tools or a possible reluctance to change. Luxford et al. [21] identified key points such as consideration of the use of international protocols, routine assessments of infants hips and the use of information handouts to parents. The aims of physical therapy treatment for infants with CMT are to prevent/reduce plagiocephaly and to achieve symmetrical head position, ROM and muscle function of the neck. It is also important to be observant on the infant’s motor development. Assessments and treatments are described in several studies [1,5,22,23].
 
The aim of the current study is to obtain knowledge about the existing practice in the physical therapy management of infants with CMT among members of a network for torticollis and also to develop a draft assessment protocol that could be used when examining an infant with CMT. The first author is responsible for the survey.
 
Methods
 
Eighty-nine members of the network for physical therapists working with torticollis were invited to participate in this survey by e-mail contact. Most of the members are from Sweden but a few are from Denmark. Forty physical therapists (45%) chose to participate. With permission from Bernadette Luxford, the NZ questionnaire was used. It was translated to Swedish, however the participants had access to both the English and the Swedish version if they wanted.
 
The questionnaire is anonymous, 10-pages long and comprises 28 questions divided into five sections collecting general and demographic information, information specific to subjective assessment, objective assessment techniques, differential diagnosis and treatment techniques used in the management of CMT [21]. The only difference in the Swedish version is that one assessment tool is added in one of the questions. In addition to the arthrodial protractor another large protractor is some-times used in Sweden [22,24].
 
At the beginning of the questionnaire there is a screening question to ensure that the information is sought from physical therapists that had assessed and/or treated an infant (under two years of age) with CMT within the last year. Descriptive statistic is used for the result.
 
After the survey, a panel of experts developed a draft assessment protocol. The panel consisted of six pediatric physical therapists experienced in the assessment of infants with CMT. The panel members had professional experience of assessment of infants with CMT ranging from 10 to 40 years, with a mean of 18 years.
 
Results
 
Of the 40 physical therapists who replied three had not treated any infant during the last year, therefore the analysis is done on the data from the remaining 37 respondents. Thirty-four physical therapists from twelve districts in Sweden and three physical therapists in Denmark were included; one participant did not indicate which region she was from. All participants were female, and 21 were aged between 30-49 years old. The 37 respondents had worked as physical therapists for median of 20 years (range 5-40 years), in pediatric settings for median of 14 years (range 1-40 years). They assessed/treated in median 13 infants with CMT during a year, range 1-300 infants.
 
Nine sources of referral to physical therapy were identified; the three most common were “child health care centers” (81%), commonly referred to as “well baby clinics”, pediatricians (73%), and “special units for children” (46%). Eighty-four percent of the respondents had an information handout for parents. Sixty-two percent had best practice guidelines for CMT at their place of employment and 16% reported that a guideline was in the process of being developed.
 
When considering the subjective assessment there is a high level of agreement about the information sought (Table 1). With regard to the objective assessment techniques for infants with CMT there is also high agreement about most components (Table 2). For hand asymmetry and postural reactions most respondents answered always or never with remaining 40-50% of answers between the extremes. For assessment of ROM in the infant neck most respondents always used a visual estimate, followed by a large protractor and an arthrodial protractor (Table 3). Factors that limited the accuracy when assessing neck ROM, were the level of distress experienced by the infant and lack of suitable measuring tools at the clinic. The selection of treatment techniques is described in a table (Table 4), provision of handling advice being the most common.
 
Most respondents indicated that they stretched the affected SCM muscle when appropriate (81%). Five respondents did never used passive stretching, three because they claimed that they had never seen infants with a contracted muscle, for one respondent the reason was that the infants was distressed and tense, and another respondent was of the opinion that CMT is the result of a fixation in the cervical spine.
 
The perceived most effective form of intervention by the respondents in the management of CMT was passive stretching, handling advice, facilitation of neck muscle strengthening exercises and facilitation of active cervical ROM (Figure 1). Most (93%) did not perform a passive stretch when the infant resisted the stretch or was upset. About half of the respondents performed stretches regardless of the infant’s age (55%). The stretch was done using a movement direction of rotation toward the affected muscle and a movement direction of lateral flexion away from the affected muscle, 69% used a combination of the two movements. The stretch was held for mode 20 seconds, median 20 seconds, ranges 5-30 seconds. Nearly half of the respondents commented that the stretch was individually adjusted according to the compliance of the infant. Typically three repetitions were made during; median 1-2 sessions on each treatment occasion (range 1-5). The major issues faced by a physical therapist, when providing for the overall management of infants with CMT was a lack of parental compliance, infants age, lack of information from physicians/nurses to parents about handling (tummy time). The panel of experts designed a draft assessment protocol (Appendix).
 
Discussion
 
Forty-five percent chose to participate (42% fulfilled the criteria to continue to answer the questionnaire); this is according to Baruch an acceptable response rate [25]. Of those who spontaneously commented why they chose not to participate in the survey the most common was lack of time. Of the returned questionnaires 93% had treated an infant younger than two years during the last year. For some reason some respondents did not answer all the questions, (missing data). Whether they found the question irrelevant or if they just missed it is unknown. Compared with the survey in New Zealand (NZ) we have more missing data. The respondents seemed to be of a similar opinion based on the answers to most of the questions i.e. most had answered always/often or never/rarely. The results from these studies may be used as a baseline for discussion from which improvements can be achieved both in assessment and treatment.
 
Assessment
 
In general there was consensus with regard to the assessment of new infants with CMT. The majority of the respondents always determine typical head posture/preference, head shape, craniofacial changes, preferred sleeping posture, time in prone/supine, birth order, presence of SMT, palpation of affected muscle, passive and active ROM in neck rotation and lateral flexion, cervical muscle strength, postural asymmetry and gross motor function. This is similar to the Luxford et al. result [21], however it was more common to ask about family and social history in NZ (always 81% in NZ and in the current study 29%).
 
It was more common to evaluate cervical muscle strength in the current study; always/often 100% compared with NZ always/often 76%. Asymmetry in muscle function/strength in the lateral flexor of the neck is mostly observed in infants with CMT and is not observed in healthy infants [22]. It is easy to evaluate muscle imbalance with the muscle function scale (MFS), the MFS is valid and reliable and without any cost [18]. The MFS is developed in Sweden and maybe this is the reason that muscle function/strength are more often assessed in Sweden than in NZ.
 
The majority never or rarely assessed the infants’ hips; also Luxford et al. found that hips were not often assessed. As there is a reported coexistence of CMT and hip dysplasia it is recommended to assess the hips as routine in new infants with CMT [21]. Clinically we know that hand asymmetry is not uncommon for infants with CMT, however this aspect had a broad variation in answers by the responders, with “always” being as common as “never”. It can be important to be able to separate “normal” asymmetry due to CMT from a mild cerebral paresis.
 
Protractors were more commonly used in measurements’ of passive rotation and lateral flexion in the current study than in NZ, however the majority never/rarely used a protractor. To use the correct instruments for measurements should be encouraged as it increases accuracy. The cost for the protractors used in the measurements of infants with CMT is minimal. Why protractors are not used more often is unclear there may be a lack of knowledge, these are not convenient to use, there may be some reluctance to change. ROM in infants is not very easy to assess, as the infants dislike to be held during measurements.
 
Treatment
 
The most common treatments were passive stretch, handling advice, facilitation of neck muscle strength and facilitation of active cervical ROM. This is similar to the result in the survey in NZ. This is not unexpected; however there were five respondents who never used passive stretching, three claimed that they never saw infants with limited passive ROM (PROM). It is not known what values they considered as limited or normal PROM as the question about reference values used was not asked. One did not use passive stretching because the infants were distressed and tense. Another respondent considered it as a fixation in all infants that she had seen. For CMT to be attributable to a fixation is not supported by scientific evidence.
 
In both the current study and in the NZ survey it is clear that passive stretches were mostly adjusted to the compliance of the individual infants. More research about treatment options and effectiveness are needed to achieve best possible evidence-based practice. The respondents also considered handling advice, strength exercises and facilitation of active ROM as important factors for treatment.
 
It is unknown to what extent spontaneous recovery occurs. The only study found which investigated spontaneous recovery is not available for critical review as it is not available in English. However by reading the abstract it is obvious that there were an unusually high prevalence of infants in need of surgery in both the invention group and the control group [26]. This raises questions about the method, assessment, and reference values chosen. More studies are needed to find out more about the extent of spontaneous recovery.
 
In the current study as well as the survey in NZ, handling advices was considered a very important part. The majority of respondents (83%) always or often gave information handouts to parents, (90% had access to information folders), in NZ over a third had no access to information handouts for parents [21]. This difference may be due to that information folders and exercise folders developed at the two main Childrens Hospitals in Sweden being accessible to any professional who wishes to use them. There is no known network about CMT in NZ but information folders are shared in some districts (Luxford personal communication). Information handouts may be a very important in order to achieve the best possible parental compliance. The main concerns in the overall management of infants with CMT were lack of parental compliance and the age of the infant this is similar to the survey in NZ. Age at the start of treatment is shown to have influence on the result [1]. When trying to the panel of experts developed a draft assessment protocol for CMT. An international protocol when assessing infants with CMT would probably be of benefit achieves accuracy. International networking may be a good start.
 
Conclusion
 
In general there was a high degree of consensus between the respondents in the survey about assessment and treatment of newly diagnosed infants with CMT. Visual estimates were most common and the measurement tool most commonly used was the large protractor for measurements of lateral flexion of the neck. Evaluation of cervical muscle strength in the neck was always/often done. The perceived most effective form of intervention by the respondents in the management of CMT was passive stretching, handling advice, facilitation of neck muscle strengthening exercises and facilitation of active cervical ROM. The treatment was adjusted to the compliance of the individual infants. Assessment of hand-and hip asymmetry ought to be encouraged. An international protocol could help to increase accuracy of assessment. More studies are needed to investigate the benefit of different treatment strategies and to what extent spontaneous recovery occurs.
 
Acknowledgements
 
We thank all physical therapists that participated in this study.
 
References
 

























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To Exercise or Not During Pregnancy
Linda E May1*, Erin M Smith2 and Ehssan Zare-Maivan2
1Department of Foundational Sciences and Research, East Carolina University, Greenville, NC, USA
2Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA



Abstract

There is growing evidence that activity during pregnancy is beneficial for mother and baby; however, less than half of pregnant women meet guidelines for exercise during pregnancy.

Objective: In order to improve the health of women and children, we need a better understanding of the barriers to women participating in activities during pregnancy. Therefore, our aim was to determine women’s perceived barriers to physical activity during gestation. We hypothesize that most women either do not know exercise is safe during pregnancy or women do not know what specifically is safe to do during pregnancy.

Methods: A 16-item questionnaire was placed in several Ob/Gyn clinics in the Kansas City area. Respondents were women between 18 and 40 years of age who were pregnant or had recently delivered and had no pregnancy complications.

Results: Respondents varied in age, BMI, marital status, pregnancies, ethnicity, education, healthcare insurance, and annual household income. We were able to analyze data from 201 surveys. Most participants (97%) perceived their health as good to excellent; yet, 50% were overweight or obese. The most common reason given for women choosing not exercise during pregnancy was lack of time, dislike of exercise, unsure why, and not knowing what to do. However, women who did not exercise spent significantly less time than exercisers doing sedentary and daily living activities than women who exercised while pregnant. If women exercised before pregnancy, then they were 4.5 times more likely to continue during pregnancy. If their health care provider talked about exercise during pregnancy, then women were 7.5 times more likely to continue exercise during gestation.

Conclusions: We found that most women are unsure about exercise during pregnancy or do not know what to do during pregnancy. Although most women feel they do not have time to exercise during pregnancy, non-exercisers spent less time doing daily activities compared to exercisers. Most importantly, women were almost 8 times more likely to exercise if this topic was discussed by their obstetric provider. To increase the number of women exercising while pregnant, future studies should aim at efficient ways to discuss and encourage women to follow the recommended guidelines of safe exercises while pregnant.
Keywords

Pregnancy; Physical Activity; Time; Encourage; Instruction; Pre-Conception; Barriers
Introduction 

In the United States, pregnant women are twice as likely to be sedentary than the average adult [1]. Furthermore, when pregnant women choose to be active, their exercise regimen is of shorter duration and is completed with reduced intensity [1]. In many instances, pregnant women believe rest and relaxation is more important than maintaining an active lifestyle [2]. These beliefs are derived from magazines, family, and friends instead of their obstetric provider [2]. In the United States, most pregnant women are far below the recommended guidelines for activity during pregnancy [3].

There is growing evidence that exercise during pregnancy benefits mother, improves labor and delivery, and benefits the health of her child [1,2,4-10]. In an effort to give children the best start in life, the option to exercise during pregnancy should be considered [5,8,9]. Women who exercise during their pregnancy typically have fewer complaints of somatic pain, reduced subcutaneous weight gain, and an enhanced sense of well-being and self-esteem when compared to non-active pregnant females [6]. Additional benefits for the mother and fetus include a reduced risk of gestational diabetes mellitus, hypertension [6], preeclampsia [10], edema, and preterm delivery [7]. Physical activity during pregnancy improves heart health for mother and baby [8,9]; however, less than half of pregnant women meet recommended guidelines for exercise during pregnancy [3].

Previous studies have examined daily activities, such as house chores, childcare, [1,10] but did not ask the women why they chose not to exercise during pregnancy. In addition, we examined the reasons pregnant women abstained from exercise. In order to begin to improve the health of women and children, we need a better understanding of the barriers to women participating in activities during pregnancy. Therefore, our aim was to determine women’s perceived barriers to physical activity during gestation. We hypothesize that most women either do not know exercise is safe during pregnancy or women do not know what specifically is safe to do during pregnancy.
Methodology

Subjects

This was a prospective, cross-sectional study designed to determine women’s perceived barriers to physical activity during gestation. Participants were recruited from obstetric practices in the Kansas City metropolitan area. They were asked to complete the survey questionnaire while waiting for their obstetric visit. All participants had to be pregnant or have recently delivered. This study was approved by the Kansas City University of Medicine and Biosciences Institutional Review Board (IRB) and conducted in accord with current ethical practices. Responses to the survey questionnaire contained no links to personal medical information. All participants gave informed consent prior to study participation.
Survey Questionnaire

This study utilized items from the Pregnancy Physical Activity Questionnaire and the Kansas Behavioral Risk Factor Surveillance System Questionnaire [1]. A preliminary version of the questionnaire was pilot-tested with a small cohort of women to insure questions were clear and easy to answer and to insure the questionnaire could be completed in a short period of time.

The final version of the questionnaire contained sixteen items and required approximately ten minutes to complete. Nine items assessed personal descriptive information: age, height, weight, marital status, number or previous pregnancies, education level, healthcare coverage, annual household income, and ethnicity. The remaining seven items assessed respondents’ perceptions of personal health, interactions with their physicians, exercise prior to and during pregnancy, reasons for not exercising, and daily activities.

In order to determine differences between women who exercised during pregnancy and those who did not, we used the American College of Obstetricians and Gynecologists (ACOG) recommendations of previously sedentary women participating in at least 3 days per week of exercise [4]. Based on responds to the question “Do you participate in exercise at least 3 days of the week,” women were classified as Exercisers or Controls.
Data Collection

Questionnaires were placed in the waiting rooms of participating clinics. A cover letter was attached to each survey to explain the purpose of the study, and that every question was optional and participation would not affect their care at the clinic. The cover letter could be kept by participants and contained contact information for the Principal Investigator and Institutional Review Board office. Participants placed completed questionnaires in a locked drop box located in each waiting room.
Data Analysis

Patient demographic data is reported as means + standard deviations (SD) or as percentages, where appropriate. Data are reported as the frequency of occurrence. Differences between self-reported exercisers and control women were examined using t-tests for continuously scaled variables and chi-square tests for categorical variables. Next, logistic models were used to examine the predictors of participation in activities. In the first model, demographic variables, including gravida, education, insurance, and ethnicity, and provider inquiry were entered as predictors. Gravida was coded as first pregnancy, second pregnancy, or more than two pregnancies. Education was stratified as high school degree or less compared to some college up to graduate degree. Insurance status was stratified as private insurance or Medicaid/no insurance. Ethnicity was dichotomized to be white or non-white. In the second logistic model, we entered whether they exercised prior to pregnancy as predictors. Odds ratios along with their 95% Confidence Intervals (C.I.) were calculated for all independent variables in the models. All analyses, statistical significance was defined as a=0.05. Statistical analyses were performed using PASW software (rel. 17, SPSS Inc., Chicago, IL).
Results

We analyzed 201 completed surveys from women between 18 and 40 years of age with healthy, singleton pregnancies (Table 1).
Participant Demographics

The mean age of the entire sample was 28.2 ± 5.6 years. Mean height was 65.0 ± 2.8 inches and mean pre-pregnancy weight is 158.0 ± 39.5 pounds. There was diversity in the sample as far as education (25.5% some high school/diploma, 28.5% trade school/some college, 46.9% college graduate) and household income (27.6% earn <$35,0000, 38,3% earn between $35,001-75,000, 34.1% earn >$75,001). The modal respondent was a white, employed, insured, married college graduate in her first pregnancy. Additional demographic variables are presented in Table 1. There are no statistical differences between group demographics; although, some sub-group sizes are small (i.e. ethnicity), this further demonstrates the diversity of the population in both groups. There were no significant differences between exercise and control for demographic variables (Table 2).
Participant Daily Activities

Participants reported the average amount of time daily used for sedentary activities such as using a computer, watching TV, reading, and talking on the phone (Table 3). Women that did not exercise during pregnancy spent less time using the computer (p=0.04) and reading (p=0.05) compared to exercisers (Table 3). Participants also reported the average amount of time per day used for physically active daily activities, such as: walking (not exercise), meal preparation, childcare, playing with kids, house chores, shopping, and gardening (Table 3). Women that did not exercise during pregnancy spent less time preparing meals (p=0.06), doing house chores (p=0.03), and shopping for the family (p=0.01) compared to exercisers (Table 3).
Participant Health Status 

Using self-reported height and pre-pregnancy weight, the average pre-pregnancy BMI of participants was 26.2 ± 6.0 (Table 2). Almost all women (96.8%) classified their health as good, very good, or excellent, while the remainder classified their current health as fair or poor. Prior to pregnancy, 54.7% of women exercised at least three times per week, but this declined to 21.4% during pregnancy.
Participant-reported Exercise Inquiry 

More than half (60.7%) of women reported to their obstetric provider discussed with them about exercise during pregnancy. Less than half (40.5%) reported their provider instructing them how to exercise.
Reasons women do not exercise during pregnancy

The most common reason (42.9%) reported for not exercising during pregnancy was lack of time. The next reasons for not exercising were: dislike exercise (16.1%). Not feeling good (tired, sick, pain) 13.1%, don’t know how to exercise 13.0%, not sure 9%, Fear of Exercise 4.5%, and lack of transportation or money 4.5%. There was a significant difference between groups in reasons for not exercising with the control group reporting time (p<0.001), dislike (p=0.007), not sure (p=0.006), and don’t know how to exercise (p=0.02) significantly more often than the exercise group. Logistic regressions indicated that no demographic variables significantly predicted reported behavior (Table 4). Patients who reported exercising prior to their pregnancy were 4.9 times more likely (OR=4.9, 95% CI=1.85-13.07) to exercise at least three times per week during pregnancy (Table 4). Patients who reported their provider talked to them about exercise during pregnancy were 7.5 times more likely (OR=7.5, 95% CI=2.08-27.0) to exercise at least three times per week during pregnancy (Table 4).
Discussion 

We hypothesized that women either do not know exercise is safe during pregnancy or do not know what specifically is safe to do during pregnancy. We found for women that did not exercise while pregnant, the reasons are time, dislike of exercise, unsure, and don’t know how to exercise. Although lack of time and dislike of exercise may not be modifiable during pregnancy, the other two reasons can most likely be modified. For example, the two main predictors of women choosing to exercise during pregnancy are 1) provider talking with them about the benefits and risks of exercise during pregnancy and 2) exercise prior to pregnancy. Based on these findings, we can confirm our hypothesis.

The finding that women reported lack of time as a reason for not exercising during pregnancy is similar to other studies when women reported doing less activities [2,7] and believed that rest, relaxation, and diet are more important than maintaining an active lifestyle [2,11]. Interestingly, these women actually spent significantly less time in sedentary and physically active activities compared to exercisers suggesting they may not be good time managers. Nonetheless, fitness instructors and medical professionals can provide advice on how physical activity during pregnancy can attenuate or alleviate this symptom as well as the (13.1%) feelings of tiredness, sickness, and pain. Similar to other research [12], some women reported either being afraid to exercise or they were not sure why they did not exercise during pregnancy. For women who reported feeling too tired, sick or in pain to exercise, providers can explain how exercise during pregnancy is known to provide more energy, decreased musculoskeletal pain, enhancement of mood, and possibly shorter labor and delivery [5], enhanced sense of wellbeing, and improved sleep [4]. Women that lack transportation and finances to go to a gym, or don’t like exercise can be helped by instructors showing them safe exercises to do at home, checkout videos from library, or find information and instructions online [4,13]. Depending on a woman’s stage within the stages of change model, these factors may not be modifiable, while others can.

This study found that maternal activity prior to pregnancy had a significant impact on maternal activity during pregnancy. This finding is similar to another study in which preconception nutrition modification helped improve pregnancy outcomes relative to during pregnancy behavior modification [14,15]. However, these findings are different based on the study population as well. For example, one study found younger women and women with children were less likely to engage in preconception healthy behaviors [16]. However, women with postgraduate education were more likely to practice preconception care [16]. There should be a focus on educating young preconception women regarding the importance of preconception and during pregnancy exercise [17].

Some women, who do not exercise during pregnancy and report being unsure why they do not exercise or they do not know what to do, may be influenced into a positive behavior change while pregnant. For example, we found provider intervention increased the likelihood of a pregnant patient exercising by almost 8 times. This is similar to other studies related to health care provider intervention as a means to change patient behavior and improve pregnancy outcomes [18-20]. Although a previous study suggests women’s beliefs are derived from magazines, family, and friends [2,21]. A recent study found women are more likely to be active during pregnancy when encouraged by their health care provider [22]. Furthermore, women who had other healthy behaviors (i.e. healthy eating), they were three times more likely to exercise during pregnancy [22].

It is important to mention this study has limitations to consider. First, although we had a diverse participant population, our sample only included 3 large clinics in the greater Kansas City area: 2 in Kansas and 1 in Missouri. An inherent limitation involves the bias of self-reported data. However, our questionnaire was validated and the population data is similar to other studies. Although selection bias is a concern in this type of study design, we tried to minimize this by using a general cover letter not mentioning exercise or activity, but interest in completing a questionnaire for a study; these results may still be generalized. However, in order to verify these results a case control study would be informative.
Conclusion 

Overall we found the most common reason for women not exercising while pregnant is lack of time. In addition to reporting a lack of time, many non-exercisers reported a dislike of exercise. Although, lack of time or interest in exercise is not a new finding and is most likely not modifiable during pregnancy, we found other reasons which might be changed during pregnancy. For example, women also report not exercising during pregnancy due to not knowing how to exercise and being unsure why they should exercise. For women with these reasons, it may be possible to help them choose to exercise. We also found, women were almost 8 times more like to exercise during pregnancy if their obstetric provider discussed this topic with them. Based on these findings, future studies should target increasing the education and awareness of pregnancy women on this topic, such as assessing the effectiveness of different methods to encourage and discuss the current guidelines and instructions for exercise during pregnancy.
Acknowledgements

The authors thank Alan Glaros at Kansas City University of Medicine and Biosciences for his support in formatting the questionnaire, allowing us to use the questionnaire scanner, and running statistical analysis. We are especially grateful to the women who participated in this study.
References























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The Effect of An Exercise-Based Intervention to the Quality of Life of Patients Suffering From Parkinson's Disease: Prospective Study
Natália Mariano Barboza1, Isabela Andrelino de Almeida1, Luana Beatriz Lemes1, Cyntia Letícia Batistetti1, Hevely Beatriz Celestino dos Santos1, Alessander Danna-dos-Santos2* and Suhaila Mahmoud Smaili Santos1
1 Research Group in Neurofunctional Physiotherapy, Universidade Estadual de Londrina/Hospital Universitário, Londrina, PR 86038-440, Brazil


Keywords Parkinson’s disease; Quality of life; Physical therapy; Posture; Balance; Exercise; PDQL Introduction Parkinson's disease (PD) is a complex and progressive neurodegenerative disorder associated to profound impact to thequality of life of its survivors [1]. This impact is mostly driven by the combination of a broad range of motor and non-motor symptoms that interfere negatively with the ability of these individuals to interact with the environment they live in. For example, as the motor impairments progress (tremor, rigidity, bradykinesia, inability to initiate movements, shuffling gait, and postural instability) non-motor symptoms also arise (psychological depression, insomnia, and dementia) contributing to lower levels of social interaction, isolation, and depression [2-4]. As an attempt to increase the quality of life and survival rates of PD patients, during the last decades there has been a considerable growth of interest regarding the development of multi-factorial clinical interventions aiming to improve their motor abilities; including those related postural instability. Postural instability is one of the primary motor symptoms directly related to a reduction in survival rates of PD patients [4]. This relation is primarily founded by the inherently higher risk of falls [2,5,6] fractures [2,5] and mild traumatic brain injuries [7] accompanying postural instability. Therefore, enhancement of body balance is considered one of the key goals of exercise-based treatments for PD. In fact, postural stability is a pre-requisite for the execution of other important actions (such as walking) that will greatly define the level of independence of these patients. Previous studies have investigated the effectiveness of balance exercises and collectively they investigations suggest that balance training indeed reduce the number of falls and improve PD motor symptoms [8-13]. However; the superiority of any of the interventions reported cannot be inferred due to: discrepancies regarding the type of exercises implemented combination of exercise interventions with other therapies, duration, intensity, and the use of different outcome measures [4]. As a result, the current set of guidelines for developing programs of exercise-based interventions is still very broad, and further evidence is necessary to establish the effectiveness of customized programs. Another aspect related to the adverse impact of PD to the quality of life of its survivors is related to the high prevalence of the neuropsychiatric symptoms [14,15]. According to previous reports, neuropsychiatric symptoms can affect up to 65% of the PD patients and anxiety and depression are the most common symptoms to affect this population [16,17]. These same symptoms are especially linked to behavioral changes associated to isolation, reduction of social functions, and consequent worsening levels of quality of life [15]. Therefore, another important aspect of the interventions aiming treatment of PD symptoms relates to the inclusion of patient’s socialization. Specific literature focusing in the effectiveness of exercise-based physical therapy interventions to the non-motor symptoms of PD is scarce, but it is hypothesized that exercises (therapeutical or recreational) have the potential to break the deleterious cycle of a sedentary lifestyle considered as one of the factors related to increasing isolation of PD patients [18]. This study was designed to prospectively investigate the possible changes in the quality of life of PD patients submitted to a customized protocol based on [1] body balance training and [2] group interventions. Our main hypothesis is that this protocol would result in an increase of the levels of quality of life of these patients. We expected that improvements will occur in specific assessments of body mobility (motor symptoms) and social functions. Methods and Material Participants Thirteen adults (five females and eight males, 70.3 ± 5.9 years) participated voluntarily in this study. All participants were recruited from the same health care center (Neurologic Outpatient clinic at the General Hospital of the State University of Londrina, Londrina PR, Brazil). In order to study a group with similar clinical characteristics and developmental stages of PD, only patients complying with the following inclusion criteria were invited to participate: (1) ages above 50 years; (2) confirmed diagnosis of idiopathic PD within one year prior to the study; (3) undergoing similar and standard pharmacological treatment defined by the protocols of their treatment center, (4) PD classification of 1.5-3 accordingly to Hoehn and Yahr scale [19], (5) do not suffer from cardiovascular or musculoskeletal pathologies, (6) do not use any orthotic device associated to aid gait or balance control, (7) do not suffer from dementia (score 24 or higher on Mini-Mental State Examination –MMSE), (8) do not suffer of any other neurological disorders including those of central and peripheral nature. Prior to participation, all patients voluntarily gave their informed consent based on the procedures approved by the Institutional Review Board at The State University of Londrina and conformed to The Declaration of Helsinki (authorization #066/2011 in accordance with the Brazilian National Health Council and its resolution #196/96). Procedures All patients were submitted to a series of clinical assessments prior and after the implementation of the training protocol. Clinical assessments Geriatric depression scale (GDS): This assessment is composed by a 15-item questionnaire in which patients are asked to respond by answering yes or no about how they felt over a 3 weeks period prior to the date of the assessment. With scores ranging from 0-15, scores of 0-4 are considered normal; 5-8 indicate mild depression; 9-11 indicate moderate depression and 12-15 indicate severe depression [20,21]. We used this assessment to analyze the possible effects of the intervention protocol to depression symptoms. Parkinson’s disease quality of life (PDQL): This tool was used to measures the physical and emotional health of our group of patients. This scale is based on a set of 37 items divided into four categories: 1-parkinsonian symptoms (14 items), 2-systemic symptoms (7 items), 3-social functioning (7 items), and 4-emotional functioning (9 items). The scoring system ranges from 1 (Always) to 5 (Never) for each item. An overall score can be derived (185 points), with a higher score indicating better perceived quality of life. The PDQL is recognized for its high internal reliability (R=0.94) and is considered a valid measure of the quality of life of patients with Parkinson's disease [16,17]. Intervention protocol A series of 32 physical therapy group sessions were distributed over a 16 weeks period (2 sessions per week) between the pre- and post-clinical assessment. Each session had duration of 90 minutes and comprised of interventions of increasingly difficult as the weeks progressed. During the 16 weeks, patients were submitted to balance training while standing on stable or unstable surfaces. Two stable surfaces were used, and they were: [1] the floor and [2] a step raised 15cm from the floor. Two unstable surfaces were used and they were: [1] a medium density foam pad (dimensions 65cm x 35cm x 10cm LxWxH) and [2] a 90cm diam. trampoline. The implemented training protocol was based on the execution of dual tasks where patients were required to balance their bodies while executing secondary movements of the trunk, upper extremities, or combined to walking on a simple obstacle course. During exercises performed on the obstacle course, patients were also asked to execute other tasks such as catching or throwing a ball, naming animals and colors provided by the therapist. Changes in the configuration of the body’s base of support were also used as variations of exercises performed on the step, foam pads, and trampoline. More specifically, exercises were performed while keeping either the feet parallel to each other or in tandem position. Distances between the feet were also varied as weeks progressed. Low amplitudes jumps, handling of objects away from the trunk, and changes in body direction were also introduced as part of the progression. A more detailed description of the exercises used in this protocol is provided on Table 1. Ten repetitions were performed for each exercise, and trained personnel were available to provide safety for the patients. Figure 1 shows actual pictures taken of exercises being performed on the foam pad (Panel A), floor (Panel B), trampoline (Panel C), and raised step (Panel D). Data processing Scores obtained from clinical assessments were compiled and analyzed by the IBM SPSS statistics software suite (version 20, IBM® SPSS®). Due to our small sample size (n=13), comparisons of scores obtained before and after the intervention protocol were performed by series of non-parametric tests (Wilcoxon signed-rank test for related data) with levels of significance kept at 5% (α = 0.05) for all analyses performed. A non-parametric approach was taken due to the lower number of observations (n<30) recorded for this prospective study. Results Due to subtle changes observed between some the pre- and postintervention scores, descriptive statistics are presented in two formats: [1] averages and standard deviation (Table 1) and [2] medians and quartiles (Figure 2). In general, all patients tolerated well the interventions implemented. The patients between interventions reported no complaints of fatigue or pain. In fact, patients reported a general positive change in their mood. This change was captured by a sensible decrease in the scores obtained by the Geriatric Depression Scale (GDS) before and after the protocol. Averages and standard deviations across patients for this variable were 5.2 ± 2.54 and 4.3 ± 2.46 prior and after the application of the protocol, respectively. Even though the recorded reduction was relatively small (approximately 0.9 points) our group of patients changed their general status regarding the depression symptoms from mild depression to normal (no-depression). Parkinson’s disease Quality of Life (PDQL) Table 2 describes averages and standard deviations across participants for all four domains of symptoms captured by the PDQL assessment tool. Note the increase in average values for all domains and, consequently, resulting in a higher total score recorded after the protocol (from 126.92 pre-treatment to 139.77 points post-treatment). This overall effect was confirmed by a significant increase in the total scores (p=0.004). Scores recorded from two domains also reached significance, and they were Parkinson’s symptoms (p=0.002) and Social function (p=0.045). Figure 2 shows the box plots of these scores obtained before (white bars) and after (gray bars) the execution of the protocol. It is also important to note that within all four domains we observed a broad range of changes in pre- and post-intervention scores. For example, within the Parkinson’s symptoms domain we observed relative differences in scores ranging from 4.00 to 62.50% (Table 1, % Diff column). This finding indicates that even though the overall effect of the protocol was positive, some symptoms responded more positively to the intervention than others. Discussion This study was designed as a prospective study aiming to provide initial results related to the effectiveness of an exercise-based protocol to the improvement of motor and non-motor symptoms of PD. In general lines, the protocol proposed here promoted enhancement of 30 scores (81% of all 37 possible scores) distributed across all four domains of life quality measured by the PDQL assessment tool. This increase ultimately resulted in a significant improvement of the total scores obtained after the intervention (from 126.92 pre-treatment to 139.77 points post-treatment). This finding allows us to conclude that the protocol was effective to improve the quality of life of our group of patients; confirming our main hypothesis. This finding is in agreement with several previous studies suggesting that the exercise-based balance training indeed improve aspects of life quality of PD patients [22]. For example, Pompeu et al. [22] recently reported that a customized protocol of balance training based on virtual reality (Microsoft Kinect, Microsoft®) was able to improve aspects of quality of life of PD patients (measured by PDQ-39). These authors reported that the positive results produced by their protocol were not restricted to quality of life assessment tools but were able to improve clinical measures such as the 6-minute walk test, balance evaluation system test, and dynamic gait index. In addition, an extensive review made by Tomlinson et al. [23,24] corroborates with these observations by describing improvements in a variety of physical symptoms including walking speed, functional mobility, postural instability, and agility. Collectively, these reports are suggestive of a general positive effect that therapeutical exercises have in the quality of life of these patients. The protocol presented here was elaborated specifically to promote improvements of motor symptoms and increase socialization of PD patients. Our rationale in concentrate our efforts in balance training exercises arises from the principle that body balancing is a prerequirement for the execution tasks that are directly related to the independence of the individual (such as walking, stand-up, sit-down, reach for objects during standing-up). In fact, previous studies have provided evidence that balance exercises can improve balance control on PD patients and therefore reduce the number of falls affecting this population [3,9,25]. For example, Smania et al. [9] reported a significant improvement on postural stability resulting from a series of 21 intervention sessions aiming to decrease the deleterious effect of PD to body balance. This same randomized control trial a large number of PD patients (n=64) where only those submitted to the balance specific interventions were able to improve their postural stability. Other studies have also suggested that the effectiveness of balance-oriented interventions can be enhanced when other training modalities are incorporated to the treatment [3,25]. The neural mechanisms related to this improvement are yet not known. As expected, the majority of the physical symptoms recorded by the PDQL questionnaire suffered a positive effect of our interventions. However, it is evident that some symptoms were more sensitive to the effects of the protocol than others. This observation is corroborated by the large range of relative positive changes recorded between pre- and post-scores across questions (4%-62.50%). One may note that several scores with higher relative changes are not directly related to main features of posture control. For example, symptoms such as shaking of hands, auto-perceived clumsiness, difficult signing your name in public and difficulties writing scored either better or comparatively to those abilities requiring postural stability control such as difficulties walking, difficulties getting up from a chair, and difficulties in doing leisure or sports activities. It is also important to emphasize that some of these larger relative changes in scores were related to improvement of dyskinesia-related symptoms. In fact, we expected an improvement of dyskinesia-related symptoms, but not as pronounced as the results recorded. This finding compel us to interpret that the exercise-based interventions proposed here had its effect to basic neural mechanisms involved to the regulation of human motor actions. This interpretation is corroborated by current evidence indicating that physical activity can attenuate motor impairments related to PD, including dyskinesia [26-30]. Dyskinesia is a complication from dopamine replacement therapy characterized by involuntary movements and lack of coordination. Park et al. [31] studied the effects of dopaminergic replacement to aspects of hand control in PD patients. More specifically, these authors applied the idea of synergies and the framework of the uncontrolled manifold hypothesis to explore the effects of dopamine replacement therapy on finger interaction and coordination in patients with early-stage PD. Their results demonstrated a significant improvement of finger coordination within 24 hours of dopamine replacement withdraws. Accordingly to Heumann et al. [30], the effects induced by dopamine replacement therapy are widespread in the brain, however, the striatum, the most dopamine receptor-rich area, is where the major neurochemical and functional changes that underlie dyskinesia take place. Interventions seeking to ameliorate dyskinesia symptoms include deep brain stimulation [32], pharmacological [30], exercise-based therapies [33], and surgical procedures [34]. Due to its several advantages, exercise-based therapies are currently gaining importance as a primary intervention in early-stages of development of PD. Even though we can cite its relative simplicity and lower costs of implementation as its primary advantages, exercise-based interventions seems to not impact the positive effects of dopamine replacements [30,35,36] and yet have positive cardio-vascular effects [37]. In addition, exercisebased therapies have the potential to counteract depression and anxiety related symptoms [19,38-40]. These neuropsychiatric symptoms are not exclusively present in late stages of PD development and can precede motor symptoms on early development stages [41,42]. Currently, the number of investigations addressing the effectiveness of exercise-based interventions to the control of neuropsychiatric is scarce and, most of the information available is based on investigations of healthy aging patients [10]. Our result revealed improvements on non-motor symptoms, including those of neuropsychiatric origin. The subtle changes to results recorded by the Geriatric Depression Scale reinforce this observation. It is important to emphasize that we can only speculate about the mechanisms of these changes that can originate from; [1] neurophysiological changes induced by the exercises; [2] approximation of other patients suffering from the same condition and exhibiting similar symptoms; or [6] a combination of both factors. Based on our interaction with our patients we are inclined to accept the third hypothesis. During the 16 weeks of implementation of the protocol, we experienced the creation of a certain bond among the patients and a gradual change on the acceptance of their condition. These changes were also perceived regarding their acceptance of physical activity that increased along the 16-weeks of the protocol. Due to the prospective nature of this study, this question remains and we expect to follow-up with studies designed to test this very same hypothesis. Based on these initial results we also expect to extend our investigations by including more patients and neurophysiological measurements to advance our understanding of PD movement disorders. Conclusions We found that the 16-week exercise-based protocol aiming the improvement of body balance control in patients with PD was successful to increase the levels of life quality of the patients studied. References 









































 


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