Beyond 3 Sets of 10PAMELA BARTLO, PT, DPT, CCSPATRICIA NOWAKOWSKI, PT, PHD, GCS, CEEAARONALD WHITE, PT, DPT, OCS

Learning Objectives• Describe the physiology behind decisions of parameters of

exercise.

• Understand the barriers to individualized care vs. protocols.

• Detail standardized tests that may be used to formulate individual exercise programs.

• Explain and apply options for individualization of exercise for patients with several co-morbidities and apply those concepts to common patient case scenarios in a variety of settings.

Schedule

• Introduction.

• Physiology behind exercise program parameters.

• Barriers to individualized care and the effect of protocols.

• Discussion of standardized tests for exercise prescription.

• Intervention ideas and case studies for Cardiovascular and

Pulmonary, Homecare, and Outpatient Orthopedic patients.

• Open discussion and questions.

Introduction• Collectively:• D’Youville College, Buffalo, NY - About 60 students per cohort in DPT

program

• Over 60 yrs experience as PTs and 35 as educators

• Individually:• Pam - has been a CCS since 2005, has numerous publications and

presentations in the area of cardiovascular and pulmonary PT, as well as exercise for adults with intellectual disabilities. She has been a Clinical Associate Professor since 2004 and worked per diem in an out patient cardiopulmonary rehab setting since 2011.

• Ron – has been an OCS since 2007. He has owned a private physical therapist orthopedic clinic since 1997 and he has been a full time Clinical Assistant Professor since 2012.

• Pat – has been a GCS and CEEAA since 2015. She has worked per diem in Home Health for several years. She has been the DCE and a Full time Associate Professor since 2000.

3 Sets of 10History, Physiology, and MorePAMELA BARTLO, PT, DPT, CCS

3 SETS of 10 – The History

• 1945 - Army physician, Dr. Thomas L. DeLorme experimented with a new rehabilitation technique.

• DeLorme used strength training after an illness as a child

• He reasoned that heavy training could help injured servicemen.

• DeLorme's protocol: multiple sets of resistance ex - pts lifted their 10-rep max.

• He worked on the protocol and by 1948 – it was 3 progressively heavier sets of 10 reps

• Called it "Progressive Resistance Exercise."

3 SETS of 10!!!! – The Physiology• 3 sets of 10 uses a 10 rep max and repeats it 3 times.

Attempts to build muscle tissue by microtears during fatigue

• Lower reps/Higher weight 1-3

• Point is to fatigue muscle at high weight

• Change the protein phosphorylation (muscle protein synthesis) response of the muscle fiber Create a hypertrophic effect which leads to increased muscle fiber number and size

Low Weight/ High Reps - Physiology

• Higher reps/lower weight 2,4

• Point is to change muscle protein phosphorylation, but without full fatigue of muscle

• Creates increased muscle fiber number and size to a degree, but less hypertrophy than high weight

•Is one superior to the other?????

Protocols• Established to: guide care, provide standardized treatment,

encourage quickest/most efficient recovery, eliminate use of poor techniques, etc.

• True protocol

• NO room for individualization

• Patient can’t meet protocol – they FALL off the protocol and get a different treatment

• Realistic protocol – establishes “guidelines” and allows for individualization as needed

Barriers to Individualized careAffect of ProtocolsRONALD WHITE, PT, DPT, OCS

What are Barriers to Individualized Care• Protocols

• Co-morbidities

• Reimbursement Rates

• Static care plans that exclude patient input

• Ineffective communication strategies

• Lacking team approach

• Time

Protocols• Who has written the protocol?

• Do we only do exactly what is on the protocol?

• Does this limit our professional conversation with MD’s

Protocols Con’t

• Example: RTC Repair (protocol states ROM only no strengthening)

• Soft Tissue Mobilization?

• Scapular Mobilization?

• Scar Tissue Management?

• Lower Trapezius Activation?

• Core Strengthening?

Co-Morbidities

• Fear of Progressive exercises due to lack of knowledge about diagnosis.

• Reduced intensity to an ineffective level

• Patient-Centered vs. disease-oriented

• Educate patients on exercise and their conditions

How do Co-morbidities Affect Rehab? • HTN/MI/Cardiac: Need to monitor vitals, attention to

meds

• Depression: Prevalent following surgery: look for signs

• DM: Wound healing/ Balance/Proprioception issues/Sensation/ Glycemic control

• Arthritis: Joints other than the surgically replaced can

affect progress.

• COPD /Emphysema /Asthma: Need to monitor vitals, may require more frequent rest

Reimbursement Rates

• Low rates force PT’s to see multiple patients at one time

• Decreased manual techniques due to lack of time

• Decreased individual/specific exercises

Static Care Plans That Exclude Patient Input• Culture

• Individual and Meaningful Goals

• Patient Resources

Ineffective Communication Strategies• Motivation

• Clarification

• Learning Style

Lacking Team Approach

Clinician

Interdisciplinary Collaboration

Patient

Time

• High co-pays

• Work schedules

• Family responsibilities

• Transportation

Standardized Tests for Exercise PrescriptionPATRICIA NOWAKOWSKI, PT, PHD, GCS, CEEAA

Aerobic Capacity• 2 Minute Walk Test

• 6 Minute Walk Test

• Graded Stress Test

• 2 Minute Step Test

Balance Tests

• Functional Reach

• One Leg Stance Test (OLST)

• Four Square Step Test

• Sitting Balance Scale

Gait and Locomotion Tests

• Dynamic Gait Index

• Gait Speed

• Tandem Walk

• Timed Up and Go (TUG)

Muscle Performance Tests

• Single Step Test

• Sit to Stand Test ( 30 second)

• Sit to Stand Test (5 repetition)

• Getting Up from the Floor

Intervention Ideas and Case Studies –Cardiovascular and Pulmonary PatientsPAMELA BARTLO, PT, DPT, CCS

HTN, CAD, MI, PTCA, CABG, AICD Pacemaker

• History to guide ex:

• Before heart issue

• Since diagnosis, MI, or surgery

• Likes/Dislikes and Goals

• Adjust duration and intensity of each piece of equipment

• Don’t fall into trap of your facility’s standard

• Weights – based on ability and time from event

• Use standardized tests

• Use VITAL SIGNS including 4th Vital Sign – RPE5

Additional Individualized Exercises• Tai Chi – very effective 6,7

• Swimming – needs to be ok’ed by MD first

• Watch depth and temp of water

• Therapy Ball exercises

• Yoga 8,9

• Others that the person may want to do

CHF, LVAD, Transplant

• Should be 100% individualized10,11

• Use VITALS to guide your prescription

• Lighter weight/more reps

• Longer duration/lower intensity as able for aerobic

• Or do intervals at low to moderate intensity in beginning

COPD, IPF, CF, Lung Surgery or Transplant• All individualized12

• Definitely use intervals with rest

• Try therapy ball and Tai Chi for breathing and thoracic mobility techniques

• A lot of emerging research in yoga for pulmonary conditions due to the breathing component 13-16

Smart Technology to Help Us (Apps)• Human move 30 min or more: tracks outdoor walking until

you hit 30 min, doesn’t count indoors• Accupedo: accurate pedometer to track walking • Fitocracy: turns workouts into video game like experience• Fitbit: pedometer, also monitors calories burned, food eaten,

and hours you sleep • My Fitness Pal: calorie counter, but you also put in exercise so

may be good for someone who’s main exercise motivator is weight loss as main motivator for ex

• Map my run/walk/hike: You get the app for the activity you are doing (walking, running, etc.) App uses GPS to track distance, speed, time, etc.

• Gorilla workout – app gives you an ex program to do at home

Case Study –Alessandro FloresACROSS THE CONTINUUM OF CAREACUTE CARE

Alessandro Flores

• Alessandro is a 58 y/o man. He was admitted to the hospital 2 days for TKA. He underwent uncomplicated TKA yesterday.

• PMH: HTN, MI in 2009, PTCA 2009, OA bilateral knee, DM.

• Social History: Lives with his wife in a 2 story house. He works full time as an accountant for a Dentist practice.

• Interests: playing golf and pickle ball

Alessandro – PT Care

• Why individualize the care of a TKA patient?

• Co-Morbidities, especially Cardiac and Pulmonary impact outcomes 17, 18

• Historically more intensive PT for TKA and THA was started too late and too little after surgery (i.e. 2-4 weeks)19

• Research shows impairments in quads from not rehabbing enough can cause other compensations and knee conditions 20-22

• Individualizing gait exercises focusing on symmetry training had greater knee extension in mid-stance and improved symmetry during gait versus just exercise alone. 23

• A High Intensity program led to better short and long term strength and functional outcomes compared to lower intensity programs. 24

TKA Rehab Recommendations

•Fast Tracking

•Early initiation

•High Intensity(HI) Rehab

• How to individualize acute care?

• VITAL SIGNS – use them to guide how much to push pt

• Use EKG if you have it. DON’T be afraid of EKG

• Give frequent rests due to aerobic demands

• Watch breath holding due to exertion or pain

• Early mobility and progressive enough

• Don’t forget an endurance goal!

Alessandro – Acute Care

Case Study –Mary BianchiACROSS THE CONTINUUM OF CAREACUTE CARE

Mary Bianchi

• Mary is a 75 y/o woman. She underwent an L4 spine decompression surgery yesterday.

• PMH: Multi-level lumbar spinal stenosis, HTN, venous insufficiency, and Fibromyalgia.

• Social History: Lives alone in a 3rd floor apartment with an elevator. She works part-time at a florist’s helping with arrangements and customer service.

• Interests: bowling and playing cards with friends.

Mary – PT Care

• Why individualize the care of this patient?

• Increased age (> 65 y/o) led to increase in all complications and D/C to someplace other than home.25

• Cardiac and pulmonary complications somewhat commonly arise after spinal surgery. 26

• Pulmonary embolism

• MI

Mary – Acute Care• How to individualize acute care?

• VITAL SIGNS – use them to guide how much to push pt• More importantly to watch for abnormal responses

• Use EKG if you have it. DON’T be afraid of EKG

• Watch for signs of O2 difficulties due to exertion (smoking hx)

• Watch for signs of DVT/PE

• Watch breath holding due to exertion or pain

• Don’t forget an endurance goal!

Intervention Ideas and Case Studies –Homecare PatientsPATRICIA NOWAKOWSKI, PT, PHD, GCS, CEEAA

Diabetes• Aerobic exercise and resistance exercise improve

glycemic control in T2DM.27

• Incorporating Tai Chi in program demonstrates: Improvements in QoL for people with elevate blood glucose.28

Diabetes• Continuous high intensity endurance exercises are

equally effective as continuous low intensity endurance exercises to improve glycemic control.29

• High intensity versus low intensity strength training results in greater improvements in strengthening but no difference in muscle mass or glycemic control with T2DM.30

LESS SIT, MORE FIT

Increasing Medical Safety of Exercise in T2DM

• Hyperglycemia

• Hypoglycemia

• Retinopathy

• Nephropathy

• Peripheral Neuropathy

• Autonomic Neuropathy

Fibromyalgia• Aerobic exercise has been shown to decrease pain, fatigue

and depression and improve health related quality of life (HRQOL).31,32

• Strength training associated with large improvements in global health and physical function.31

• Combination of strength, aerobic and or flexibility exercise demonstrates improvements in pain and physical function.31

Fibromyalgia• Low to moderate intensity but not low intensity aerobic

exercise reduced pain.33

• “Start low and go slow approach”

• Begin strengthening programs with lower resistance levels than age predicted norms.34

• Increase intensity by 10% after 2 weeks of exercise without exacerbating symptoms.34

Additional Interventions for Fibromyalgia

• Nordic walkers-improvements in 6 min walk test, FIQ physical scores and reduced HRs during submax cycle ergometer compared to controls.35

• Yoga, Tai Chi and Breathing exercises -improvements in symptoms, SF-36 and FIQ components. 31,36

• Improvements in balance and SF-36 global score noted using Whole Body Vibration.31

• Aquatic- pain reduction.31

Factors Affecting Response to Exercise

• Symptoms (variety, severity, and duration)

• Physical fitness levels

• Psychological characteristics

• Preference for types of exercise

Case Study –Alessandro FloresACROSS THE CONTINUUM OF CAREIN-HOME CARE

Why Individualize the HomeCare of TKA Rehabilitation?

Remember:

No 2 Patients are alike

Individualized Rehab in Home Care

• Prior Level of Function

• Personal goals /expectations

• Family / Social Support / Pets

• Home environment /Available space / Stairs

• Co-morbidities / Medications

• Vigilant for signs of Infection, DVT

• Incision Care / Edema Management

Individualized Rehab in Home Care• Incision Care / Edema Management

• Full PROM Knee Extension / Quad control

• Strengthen proximal and distal musculature

• Don’t forget other limb

• Monitor VITALS: RPE, Talk Test

• Safe and efficient Transfer and Gait Training

• Interdisciplinary collaboration

Case Study –Mary BianchiACROSS THE CONTINUUM OF CAREIN-HOME CARE

Mary – Homecare• How to individualize homecare?

• Vitals- pre and post ex; R vs. L, if vascular component present compare UE ipsilateral pulse to LE ipsilateral pulse

• Co-morbidities: DM, vascular insufficiency. Differentiate symptoms of neurogenic versus vascular claudication. Monitor

• Monitor signs of infection, DVT, PE

Mary-Homecare

• Medications & Exercise

• Glycemic Control

• Patient Knowledge of ABCs

• Education on bending, lifting and twisting restrictions

• Promote movement within limitations

• Incorporate fun and value in ex program

Post Surgical Management• General aerobic fitness work

• LE Stretching

• Stability exercises

• Strengthening & endurance training for back, abdominal and leg muscles

• Ergonomic training

Post Surgical Management Cont’d• Education on restrictions

• Cognitive Behavioral Training (CBT)

• Assess Fear Avoidance Behavior

Additional Interventions for Chronic LBP• Yoga

• Significant reductions in functional disability and pain intensity compared to control group at 24 weeks in patients with low back pain.37

• Improved back function at 3, 6, and 12 months and higher pain self-efficacy scores at 3 and 6 months but not at 12 months.38

• Physical and psychological benefits with a variety of musculoskeletal disorders.39

Additional Interventions

• Tai Chi / GiGong

• Improve balance40

• decrease risk of falls41

• Stress management / immune support40

• Modified complementary approaches

Intervention Ideas and Case Studies –Orthopedic PatientsRONALD WHITE, PT, DPT, OCS

Case Study –Alessandro FloresACROSS THE CONTINUUM OF CAREOUTPATIENT CARE

Rehabilitation of the TKR in an Orthopedic Setting

• What Does the Research Say?

• 80-90% of Patients objectives are successfully met. 42-45

• Failure to meet patient expectations is one of the major cause for dissatisfaction after surgery. 44,46

• Patients who are under 60 are at higher risk of post op pain compared to older adults. 47

• Woman are 45% more likely to report moderate to severe pain 2 years post op. 47

• Depression plays a major factor in outcomes. 48

• Social support is related to earlier success. 49

Evaluation

• Important not to think of this as “Just a Total Knee”

• Good sound history (pre-surgery level- both functional and measurable, co-morbidities, realistic goals, motivation)

• Copy of Surgical Report

• Vitals

• Asses wound/Scar mobility, Assess core, upper body strength, static and dynamic balance

“Cook Book Exercises”• Heel slides

• SAQ, LAQ, SLR’s

• Heel Raises

• Gait and Stair Progression

Important “Overlooked” Activities

• Incision and Scar Mobility

• Pre condition i.e.. Varus/Valgus Deformity: How will this affect post operative care?

• Lower Extremity Swelling: Post surgical vs. Circulation

• Other LE joint issues

• Core Strength

Treatment

• Difficult to follow “Protocol”, All patient’s treated individually.

• Patient Goals and “Realistic” post activities should drive treatment.

• Scar Mobility

• Early Gait Training- ambulating with a good gait pattern is far more important than progressing a device too early.

Treatment Con’t

• Looking at deficits throughout the entire body, the patient has probably ambulated with a compensatory gait pattern for a long period of time and this certainly has effected other extremities/spine.

• Balance/Proprioception

• Higher Level functional activity level specific activities

Case Study –Mary BianchiACROSS THE CONTINUUM OF CAREOUTPATIENT CARE

Rehabilitation of the Lumbar Fusion Patient in the Outpatient Physical Therapy Setting

• What are the facts? Complications that affect Therapy?

• 60-70% state pain is improved

• 80% satisfied

• Complications: Infection, Blood loss, Nerve injury, Lack of solid fusion

• Rates of sx depends on zip code? • Bangor, Maine 9.2/100,000

• Bradenton, Florida 127.5/100,000

Physical Therapy Evaluation

• Good sound history (pre-surgery level- both functional and measurable, co-morbidities, realistic goals, motivation)

• Copy of Surgical Report

• Vitals

• Asses wound/Scar mobility, Assess core, upper body strength, static and dynamic balance

• Assess gait and posture

• Look for signs of depression

Education

• Educate patient on surgical procedure

• Realistic expectations/ Goals

• Importance of exercise / Address fear of exercise

• Pain management

• Daily activity modification

• Importance of posture

Treatment• This is very surgeon dependent when starting OP

PT, (1-3 months)

• Early Phase (1-3 months)

• Modalities- Pain/swelling control

• Recumbent Bike

• Scar Tissue mobility, Neural glides

• Educate- avoid excessive flexion, extension, rotation

• UE/LE light resistance exercises

Treatment Continued• Intermediate (3-4 Months)

• Continue with bike

• Progress UE/LE to tolerance

• Begin Joint mobilizations to adjacent levels

• Neutral Spine core stability exercises

• Static/Dynamic Balance/Proprioception activities (incorporate standing functional activities with good spine control)

References1. Fry AC. The role of resistance exercise intensity on muscle fibre adaptations.

Sports Med. 2004;34:663–679.

2. Holm L, Reitelseder S, Pedersen TG, et al. Changes in muscle size and MHC composition in response to resistance exercise with heavy and light loading intensity. J Appl Physiol. 2008 Nov;105(5):1454-1461.

3. American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2009 Mar;41(3):687-708. doi: 10.1249/MSS.0b013e3181915670.

4. Burd NA, Mitchell CJ, Churchward-Venne TA, Phillips SM. Bigger weights may not beget bigger muscles: evidence from acute muscle protein synthetic responses after resistance exercise. Appl Physiol Nutr Metab. 2012 Jun;37(3):551-4. doi: 10.1139/h2012-022. Epub 2012 Apr 26.

References Cont’d5. Zanettini R, Centeleghe P, Ratti F, Benna S, Di Tullio L, Sorlini N. Training

prescription in patients on beta-blockers: percentage peak exercise methods or self-regulation? Eur J Prev Cardiol. 2012 Apr;19(2):205-12. doi: 10.1177/1741826711398823. Epub 2011 Feb 28.

6. Chen YW, Hunt MA, Campbell KL, Peill K, Reid WD. The effect of Tai Chi on four chronic conditions-cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses. Br J Sports Med. 2016 Apr;50(7):397-407. doi: 10.1136/bjsports-2014-094388. Review.

7. Arthur HM, Patterson C, Stone JA. The role of complementary and alternative therapies in cardiac rehabilitation: a systematic evaluation. Eur J Cardiovasc Prev Rehabil. 2006 Feb;13(1):3-9.

8. Yadav R, Yadav RK, Khadgawat R, Mehta N. Beneficial effects of a 12-week yoga-based lifestyle intervention on cardio-metabolic risk factors and adipokines in subjects with pre-hypertension or hypertension. J Hypertens. 2016 Sep;34 Suppl 1 - ISH 2016 Abstract Book:e252.

9. Apor P. Preventive and curative value of yoga in cardiometabolic]. Orv Hetil. 2016 Feb 28;157(9):323-7. doi: 10.1556/650.2016.30361. Review.

10. Achttien RJ, Vromen T, Staal JB, Peek N, Spee RF, Niemeijer VM, Kemps HM. Development of evidence-based clinical algorithms for prescription of exercise-based cardiac rehabilitation. Neth Heart J. 2015 Dec;23(12):563-75. doi: 10.1007/s12471-015-0761-y.

11. Iellamo F, Manzi V, Caminiti G, et al. Validation of rate of perceived exertion-based exercise training in patients with heart failure: insights from autonomic nervous system adaptations. Int J Cardiol. 2014 Sep 20;176(2):394-8. doi: 10.1016/j.ijcard.2014.07.076. Epub 2014 Aug 1.

12. Garvey C, Bayles MP, Hamm LF, Hill K, Holland A, Limberg TM, Spruit MA. Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Pulmonary Disease: Review of Selected Guidelines: AN OFFICIAL STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION. J Cardiopulm Rehabil Prev. 2016 Mar-Apr;36(2):75-83. doi: 10.1097/HCR.0000000000000171.

References Cont’d

13. Tyagi A, Cohen M. Yoga and heart rate variability: A comprehensive review of the literature. Int J Yoga. 2016 Jul-Dec;9(2):97-113. doi: 10.4103/0973-6131.183712.

14. Papp ME, Lindfors P, Wandell PE, Nygren-Bonnier M. Effects of yogic exercises on functional capacity, lung function and quality of life in participants with obstructive pulmonary disease: a randomized controlled study. Eur J Phys Rehabil Med. 2016 Nov 10. [Epub ahead of print]

15. Ranjita R, Badhai S, Hankey A, Nagendra HR. A randomized controlled study on assessment of health status, depression, and anxiety in coal miners with chronic obstructive pulmonary disease following yoga training. Int J Yoga. 2016 Jul-Dec;9(2):137-44. doi: 10.4103/0973-6131.183714.

16. Yang ZY, Zhong HB, Mao C, et al. Yoga for asthma. Cochrane Database Syst Rev. 2016 Apr 27;4:CD010346. doi: 10.1002/14651858.CD010346.pub2. Review.

References Cont’d

17. Hustedt JW, Goltzer O, Bohl DD, Fraser JF, Lara NJ, Spangehl MJ. Calculating the Cost and Risk of Comorbidities in Total Joint Arthroplasty in the United States. J Arthroplasty. 2016 Aug 9. pii: S0883-5403(16)30447-8. doi: 10.1016/j.arth.2016.07.025. [Epub ahead of print]

18. Bozic KJ, Lau E, Kurtz S, Ong K, Rubash H, Vail TP, Berry DJ. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am. 2012 May 2;94(9):794-800. doi: 10.2106/JBJS.K.00072.

19. Jakobsen TL, Husted H, Kehlet H, Bandholm T. Progressive strength training (10RM) commenced immediately after fast-tract total knee arthroplasty: is it feasible? Disabil Rehabil. 2012;34(12):1034-1040.

20. Yoshida Y, Zeni J, Snyder-MacklerL. Do patients achieve normal gait patterns 3 years after total knee arthroplasty? J Orthop Sports Phys Ther.2012: 42(12):1039-1049.

References Cont’d

21. Farquhar SJ, Resiman DS, Snyder-Mackler L. Persistence of altered movement patterns during sit to stand task 1 year following unilateral total knee arthroplasty. Phys Ther. 2008;88(5):567-579.

22. Yoshida Y, Mizner RL, Snyder-Mackler L. Association between long term quadriceps weakness and early walking muscle co-contraction after Total Knee Arthroplasty. The Knee. 2013:Dec426-431.

23. Zeni J, Abujaber S, Flowers P, Pozzi F, Snyder-Mackler L. Biofeedback to promote movement symmetry after Total Knee Arthroplasty: a feasibility study. JOSPT 2013;43(10):715-726.

24. Bade MJ, Stevens-Lapsley JE. Early High-Intensity Rehabilitation following Total Knee Arthroplasty Improves Outcomes. JOSPT. 2011;41(12):932-943.

References Cont’d

25. Murphy ME, Gilder H, Maloney PR, et al. Lumbar decompression in the elderly: increased age as a risk factor for complications and nonhome discharge. J Neurosurg Spine. 2016 Nov 18:1-10. [Epub ahead of print]

26. Bohl DD, Webb ML, Lukasiewicz AM, et al. Timing of Complications After Spinal Fusion Surgery. Spine. 2015 Oct 1;40(19):1527-35. doi: 10.1097/BRS.0000000000001073.

27. Umpierre D, Ribeiro PA, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011;305:1790-1799.

28. Liu X, Miller YD, Burton NW, Chang JH, Brown WJ. The effect of Tai Chi on health-related quality of life in people with elevated blood glucose or diabetes: a randomized controlled trial. Qual Life Res. 2013 Sep;22(7):1783-6.

References Cont’d

References Cont’d29. Hansen D, Peeters S, Zwaenepoel B, et al. Exercise assessment and

prescription in patients with type 2 diabetes in Private and Home Setting: Clinical Recommendations from AXXON (Belgian Physical Therapy Association). Phys Ther. 2013;93:597-610.

30. Egger A, Niederseer D, Diem G, et. al. Different types of resistance training in patients with type 2 diabetes mellitus: effects on glycemic control, muscle mass and strength. Eur J Prev Cardiol. 2012, May 25; 1-10.

31. Busch AJ, Webber SC, Brachaniec M, et. al. Exercise Therapy for Fibromyalgia. Curr Pain Headache Rep. 2011; 15:358–367.

32. Kelley GA, Kelley KS, Hootman JM, Jones DL. Exercise and global well-being in community –dwelling adults with fibromyalgia: a systematic review with meta-analysis. BMC Public Health. 2010;10:198

References Cont’d33. Hauser W, Klose P, Langhorst J et. al. Efficacy of different types of aerobic

exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. Arthritis Res Ther. 2010;12:R79.

34. Jones KD, Liptan GL. Exercise interventions in fibromyalgia: clinical applications from evidence. Rheum Dis Clin North Am. 2009;35:373-391.

35. Mannerkorpi K,Nordeman L, Ericsson A, Arndorw M. Pool exercise for patients with fibromyalgia or chronic widespread pain: a randomized controlled trial and subgroup analysis. J Rehabil Med. 2009;41:751-760.

36. Wang C, Schmid CH, Rones R, et, al. A randomized trial of tai chi or fibromyalgia. N Engl J Med. 2010;363:743-754.

References Cont’d

37. Williams K, Abildso C, Steinberg L, Doyle E, Epstein B, et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine. 2009;34: 2066-2076.

38. Tilbrook HE, Cox H, Hewitt CE, Kang’ombe AR, Chuang LH, et al. Yoga for chronic low back pain: A randomized trial. Ann Intern Med. 2011;155: 569-578.

39. McCaffrey R, Park J. The Benefits of Yoga for Musculoskeletal Disorders: A Systematic Review of the Literature. J Yoga Phys Ther. 2012;2(5):1-11.

40. Klein PJ, Adams WD. Comprehensive therapeutic benefits of Taiji: a critical review. Am J Phys Med Rehabil. 2004 Sep;83(9):735-45.

References Cont’d41. Tousignant M, Corriveau H, Roy PM, Desrosiers J, Dubuc N, Hébert R.

Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial. Disabil Rehabil. 2013 Aug;35(17):1429-35.

42. Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. The role of pain and function in determining patient satisfaction after total knee replacement.Data from the National Joint Registry for England and Wales. JBoneJoint Surg Br. 2007 Jul;89(7):893–900.

43. Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated onbetween 1981 and 1995 in Sweden. Acta Orthop Scand. NORWA; 2000Jun;71(3): 262–7.

44. Noble PC, Conditt M a, Cook KF, Mathis KB. The John Insall Award: Patientexpectations affect satisfaction with total knee arthroplasty. Clin OrthopRelat Res. 2006 Nov;452(452):35–43.

45. Gandhi R, Davey JR, Mahomed NN. Predicting patient dissatisfactionfollowing joint replacement surgery. J Rheumatol. Canada; 2008 Dec;35(12): 2415–8.

46. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patientsatisfaction after total knee arthroplasty: who is satisfied and who is not? ClinOrthop Relat Res. 2010 Jan;468(1):57–63.

47. Singh J a, Gabriel S, Lewallen D. The impact of gender, age, and preoperativepain severity on pain after TKA. Clin Orthop Relat Res. 2008 Nov;466(11):2717–23.

48. Fisher D a, Dierckman B, Watts MR, Davis K. Looks good but feels bad:factors that contribute to poor results after total knee arthroplasty. J Arthroplasty. 2007 Sep;22(6 Suppl 2):39–42.

References Cont’d

49. Kendell K, Saxby B, Farrow M, Naisby C. Psychological factors associatedwith short‐term recovery from total knee replacement. Br J Health Psychol.2001 Feb;6(Pt 1):41–52.

50. Rehabilitation Measures Database. Available at: http://www.rehabmeasures.org. Accessed December 12,2016.

References Cont’d