Department of Physical Therapy Articles

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Health Behavior Risk Factors Across Age as Predictors of Cardiovascular Disease Diagnosis
(2009-08) Cardi, Michelle; Munk, Niki; Sanjani, Faika; Kruger, Tina; Schaie, K Warner; Willis, Sherry L
Objectives: The current study examines the prevalence of health risk behaviors and their cumulative effects on cardiovascular disease (CVD) among a sample of adults. Age cohort is also examined to determine the role of age in predicting CVD and risky health behaviors. Method: Medical records of a sample of adults from the Seattle Longitudinal Study categorized into one of four age-group cohorts were examined. Data regarding participants' health risk behaviors were examined individually and cumulatively for predicting later CVD diagnosis. Results: The prevalence of CVD increases with age, obesity, and risky medical checkups. Female risky sleepers are more likely to receive a CVD diagnosis than men who report risky sleep patterns (p < .05). Discussion: A high risk of CVD appears to exist for adults across the life span, and several risky health behaviors also seem to place individuals more at risk for being diagnosed with CVD.
A Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Examination of a Recent Study of Massage and Relaxation Therapy Effectiveness
(2014-05) Elder, William; Munk, Niki
Purpose: This presentation will discuss the pragmatic methodological approach of a recently completed NIH sponsored study of clinical massage therapy (CMT) and progressive muscle relaxation (PMR). While CMT and PMR have demonstrated efficacy for chronic low back pain (CLBP), their effectiveness in the real world of health care practice is only now being evaluated. Pragmatic studies have been recommended by NIH and the Institute of Medicine to address effectiveness questions. Methods: Critical discussion among 2 key study team members and 2 outside reviewers analyzed the study protocol for accordance with pragmatic vs. explanatory characteristics developed in the PRECIS tool by Thorpe et al. (2009). Scores for each of 10 domains were used to create an overall visual representation of the extent to which this study reflects a pragmatic research approach. Results: The visual wagon wheel reflecting the current study's “standing” on the Thorpe model will be presented. The study most strongly reflected a pragmatic approach in the following domains: Eligibility Criteria, Flexibility of Experimental Intervention, Practitioner Expertise, Outcomes, and Participant Compliance. Areas that the current study neutrally reflected a pragmatic approach or reflects more of an explanatory approach included Follow-up Intensity, Analysis of the Primary Outcome, and Practitioner Adherence. Conclusion: To our knowledge, this is the first CAM related research trail that has retrospectively critiqued its study design utilizing the PRECIS tool. CAM investigators may utilize this self-critique and the PRECIS tool to develop study designs and prospectively critique the extent to which pragmatic approaches apply. Audience participants will gain understanding of methodologies and techniques of pragmatic studies.
Case Reports: A Meaningful Way for Massage Practice to Inform Research and Education
(2013-09) Munk, Niki
Practice-induced challenges to massage research and education include those related to disparate training standards, requirements, and expectations across the US, North America, and internationally. These challenges should not overshadow the need for practice to inform research and education, especially in light of the move towards effectiveness research. What remains constantly applicable to massage practitioners of all locations and from all backgrounds are treatment details regarding the techniques used, client/patient characteristics, condition/issue of complaint, provider and client/patient expectations, and outcomes. Case reports provide a venue for this information to be shared across all practitioners, educators, and researchers. While many massage practitioners are not trained in scientific writing, preparing and publishing a case report need not be daunting, especially with writing partners when writing burden can be shared. Writing in isolation can be challenging, even for trained researchers. Perceived practitioner contribution and credit are not reduced when authorship in a manuscript is shared; rather it may be enhanced with an experienced partner.
Adaptation of the CARE Guidelines for Therapeutic Massage and Bodywork Publications: Efforts To Improve the Impact of Case Reports
(2014-09) Munk, Niki; Boulanger, Karen
Case reports provide the foundation of practice-based evidence for therapeutic massage and bodywork (TMB), as well as many other health-related fields. To improve the consistency of information contained in case reports, the CARE (CAse REport) Group developed and published a set of guidelines for the medical community to facilitate systematic data collection (http://www.care-statement.org/#). Because of the differences between the practice of medicine and TMB, modifying some sections of the CARE guidelines is necessary to make them compatible with TMB case reports. Accordingly, the objectives of this article are to present the CARE guidelines, apply each section of the guidelines to TMB practice and reporting with suggested adaptations, and highlight concerns, new ideas, and other resources for potential authors of TMB case reports. The primary sections of the CARE guidelines adapted for TMB case reports are diagnostic assessment, follow-up and outcomes, and therapeutic intervention. Specifically, because diagnosis falls outside of the scope of most TMB practitioners, suggestions are made as to how diagnoses made by other health care providers should be included in the context of a TMB case report. Additionally, two new aspects of the case presentation section are recommended: a) assessment measures, which outline and describe the outcome measures on which the case report will focus, and b) a description of the TMB provider (i.e., scope of practice, practice environment, experience level, training, credentialing, and/or expertise) as part of the intervention description. This article culminates with practical resources for TMB practitioners writing case reports, including a TMB Case Report Template—a single document that TMB practitioners can use to guide his or her process of writing a case report. Once the template is adopted by authors of TMB case reports, future efforts can explore the impact on the quality and quantity of case reports and how they impact TMB practice, research, education and, ultimately, the clients.
Massage Effectiveness for Primary Care Patients with Chronic Low Back Pain and Below Normal SF-36v2 Mental Health Scores: Secondary Analysis
(2014-05) Munk, Niki; Elder, William; Love, Margaret
Purpose: The challenging condition of chronic low back pain (CLBP) is often complicated by negative mental health factors. Non-pharmacological approaches to address CLBP alone and in combination with mental health issues are needed. A recently completed NIH funded study examined the effectiveness of clinical massage therapy (CMT) on functional health outcomes for CLBP patients referred to CMT by their PCP regardless of mental health status save psychosis. CMT was found to have significant and clinically meaningful effectiveness for patients (N=85) in the primary outcomes: Oswestry Disability Index, SF-36v2 mental and physical components and pain domain (in review). The purpose this study's secondary analysis is to determine the extent to which participants that began the study below normal in the SF-36v2 mental health component had clinically meaningful change. Methods: CLBP patients referred by their PCP were assigned to community massage practitioners (CMPs) to receive up to ten, 1-hour CMT sessions over 12-weeks. Individual treatment plans were formulated by study CMPs. Secondary data analyses were conducted examining a subpopulation (n=41) of those beginning the study at below normal (<45) for the SF-36v2 mental health component score. Results: Mean change for those
Integrating the International Classification of Functioning, Disability, and Health Model into Massage Therapy Research, Education, and Practice
(2010-12) Munk, Niki; Harrison, Anne
Without an increase in clearly defined and clinically significant outcomes research in massage therapy (MT), the practice is in jeopardy of remaining on the fringes of accepted and utilized therapeutic care. This reality will slow the integration of MT into routine preventive, rehabilitative, curative, and supportive care. The International Classification of Functioning, Disability, and Health (ICF) developed by the World Health Organization is a comprehensive model of functioning and disability that provides a universal taxonomy of human functioning that is recognized globally. Integration of the ICF model into MT research, education, and practice would provide a foundation for a common language, particularly in regard to examining outcomes of MT. Here, we review the dynamic and respected ICF model as it applies to massage research, outcomes dissemination, education, and practice, with these specific objectives: To describe the specific domains of the ICF model To apply the described ICF domains to current massage practice and research To discuss how integration of the ICF model enhances communication and translation among those within and to those outside the MT field The ICF model is ideal for application to MT interests because it works outside the typical focus on pathology or a specific organ system. Instead, the ICF focuses on impairment or limitations in functioning associated with health conditions. The ICF also highlights and incorporates the complex interactions of environment and personal factors and the impact that those factors exert on the domains of body structure, activity, and participation. This interaction has unique implications for MT practitioners, researchers, and clients/patients. Furthermore, the ICF model provides a framework for classifying outcomes, which is a critical aspect of clinical research.
Massage Therapy Usage and Reported Health in Older Adults Experiencing Persistent Pain
(2011-06) Munk, Niki; Kruger, Tina; Zanjani, Faika
Background: Persistent pain is a frequent complaint among older adults and can greatly decrease quality of life while also contributing to other negative outcomes such as poor health, increased pharmaceutical medication usage, increased rates of depression, and cognitive decline. Objective: The current study (N = 69) examines the potential impact of massage therapy (MT) in older adults (60+ years) with persistent pain, by comparing self-reported health outcome scores among those who have and have not utilized massage therapy in the past year. Design: The current study was derived from a larger study that collected data as part of a one-time, self-report, mail-in survey. Participants: Lexington, Kentucky area adults, 60 and older who reported persistent pain were eligible to participate in the study. Outcome measures: The RAND 36-Item Health Survey was used to determine participant health-related quality of life. Results: The current study demonstrated that for older adults experiencing persistent pain, massage is associated with self-report of less limitation due to physical or emotional issues, better emotional health, more energy/less fatigue, better social functioning, and better overall health. Age, education, cumulative morbidities, number of areas in which participants reported experiencing persistent pain, and number of complementary and alternative medicine options in addition to MT utilized in the past year did not affect the association between receipt of massage and better self-reports in those domains. Conclusions: While many causes of pain for older adults elude cure, further study is warranted that examines MT as an intervention to improve coping in older adults with persistent pain.
Introducing IJTMB’s Trigger Points: Topical Dialogue amongst Therapeutic Massage & Bodywork Practitioners and Educators
(2014) Lowe, Whitney; Munk, Niki; Porcino, Antony
The International Journal of Therapeutic Massage and Bodywork (IJTMB) has as its core a key interest in and mission to develop the practice of therapeutic massage and bodywork by contributing to the field’s body of knowledge. The IJTMB Editorial Board understands that one’s daily practice provides the initial testing ground for the development of practice-based knowledge and, ultimately, expertise. Consequently, this practicebased knowledge and experience provides fertile ground for research ideas that further refine our understanding and come full circle to enhance clinical efficacy. Ultimately, without discourse and knowledge transference, the possibility of growing the body of knowledge for therapeutic massage and bodywork or stimulating research in the field is lost. To facilitate discourse and transference of knowledge within the field of therapeutic massage and bodywork, the IJTMB is launching a new journal component entitled Trigger Points: Topical Dialogue amongst Therapeutic Massage & Bodywork Practitioners and Educators. The purpose of IJTMB’s Trigger Points is to “trigger” the sharing and discussion of knowledge and expertise among therapeutic massage and bodywork practitioners, educators, and researchers about different approaches to treating specific conditions or addressing specific population issues. Each IJTMB issue, starting with this issue, will include a call for responses to the next Trigger Points topic. Publication of the results for each topic will be in the second issue after the initial call for submissions. With your participation, these IJTMB Trigger Points columns will spark dynamic dialogue, perhaps even collaborations, in the therapeutic massage and bodywork field across practitioners, educators, and researchers.
Physical activity when young provides lifelong benefits to cortical bone size and strength in men
(National Academy of Sciences, 2014-04-08) Warden, Stuart J.; Mantila Roosa, Sara M.; Kersh, Mariana E.; Hurd, Andrea L.; Fleisig, Glenn S.; Pandy, Marcus G.; Fuchs, Robyn K.; Department of Physical Therapy, School of Health and Rehabilitation Sciences
The skeleton shows greatest plasticity to physical activity-related mechanical loads during youth but is more at risk for failure during aging. Do the skeletal benefits of physical activity during youth persist with aging? To address this question, we used a uniquely controlled cross-sectional study design in which we compared the throwing-to-nonthrowing arm differences in humeral diaphysis bone properties in professional baseball players at different stages of their careers (n = 103) with dominant-to-nondominant arm differences in controls (n = 94). Throwing-related physical activity introduced extreme loading to the humeral diaphysis and nearly doubled its strength. Once throwing activities ceased, the cortical bone mass, area, and thickness benefits of physical activity during youth were gradually lost because of greater medullary expansion and cortical trabecularization. However, half of the bone size (total cross-sectional area) and one-third of the bone strength (polar moment of inertia) benefits of throwing-related physical activity during youth were maintained lifelong. In players who continued throwing during aging, some cortical bone mass and more strength benefits of the physical activity during youth were maintained as a result of less medullary expansion and cortical trabecularization. These data indicate that the old adage of “use it or lose it” is not entirely applicable to the skeleton and that physical activity during youth should be encouraged for lifelong bone health, with the focus being optimization of bone size and strength rather than the current paradigm of increasing mass. The data also indicate that physical activity should be encouraged during aging to reduce skeletal structural decay.
Cell Mechanosensitivity to Extremely Low Magnitude Signals is Enabled by a LINCed Nucleus
(Wiley, 2015-06) Uzer, Gunes; Thompson, William R.; Sen, Buer; Xie, Zhihui; Yen, Sherwin S.; Miller, Sean; Bas, Guniz; Styner, Maya; Rubin, Clinton T.; Judex, Stefan; Burridge, Keith; Rubin, Janet; Physical Therapy, School of Health and Rehabilitation Sciences
A cell's ability to recognize and adapt to the physical environment is central to its survival and function, but how mechanical cues are perceived and transduced into intracellular signals remains unclear. In mesenchymal stem cells (MSCs), high-magnitude substrate strain (HMS, ≥2%) effectively suppresses adipogenesis via induction of focal adhesion (FA) kinase (FAK)/mTORC2/Akt signaling generated at FAs. Physiologic systems also rely on a persistent barrage of low-level signals to regulate behavior. Exposing MSC to extremely low-magnitude mechanical signals (LMS) suppresses adipocyte formation despite the virtual absence of substrate strain (<0.001%), suggesting that LMS-induced dynamic accelerations can generate force within the cell. Here, we show that MSC response to LMS is enabled through mechanical coupling between the cytoskeleton and the nucleus, in turn activating FAK and Akt signaling followed by FAK-dependent induction of RhoA. While LMS and HMS synergistically regulated FAK activity at the FAs, LMS-induced actin remodeling was concentrated at the perinuclear domain. Preventing nuclear-actin cytoskeleton mechanocoupling by disrupting linker of nucleoskeleton and cytoskeleton (LINC) complexes inhibited these LMS-induced signals as well as prevented LMS repression of adipogenic differentiation, highlighting that LINC connections are critical for sensing LMS. In contrast, FAK activation by HMS was unaffected by LINC decoupling, consistent with signal initiation at the FA mechanosome. These results indicate that the MSC responds to its dynamic physical environment not only with "outside-in" signaling initiated by substrate strain, but vibratory signals enacted through the LINC complex enable matrix independent "inside-inside" signaling.

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