Abstract
Background Heightened awareness of the lasting effects of mild traumatic brain injury (mTBI) has amplified interest in interventions that facilitate recovery from persistent post-mTBI symptoms.
Purpose The purpose of this study was to systematically review the literature to identify potential physical rehabilitation interventions that are safe, feasible, and appropriate for physical therapists to utilize with patients with persistent mTBI-related symptoms.
Data Sources The electronic databases PubMed, Cochrane Library, CINAHL, Scopus, SPORTDiscus, and Web of Science were systematically searched from database inception until June 2015.
Study Selection Studies were included if they utilized physical rehabilitation interventions and the study's participants had a diagnosis of mTBI, a mean age of 8 years or older, and symptoms persisting an average of 2 weeks or longer. Exclusion criteria included blast injuries, diagnosis of moderate or severe TBI, or psychosis.
Data Extraction Data extraction and methodological risk of bias assessments were performed for each study.
Data Synthesis Eight studies with a range of study designs, intervention types, and outcome measures were included. The interventions investigated by the included studies were categorized into 3 types: physiological, vestibulo-ocular, and cervicogenic.
Limitations The identified studies had several significant limitations including: small sample sizes and low-level study designs.
Conclusions The results of this systematic review indicate that several physical rehabilitation options with minimal risk for negative outcomes are available for treating patients experiencing persistent post-mTBI symptoms. These options include: vestibular, manual, and progressive exercise interventions. Conclusions surrounding efficacy and ideal dosing parameters for these interventions are limited at this time due to the small number of studies, the range of interventional protocols, and lower levels of study design.
Approximately 1.2 million people in the United States are treated in emergency departments annually for mild traumatic brain injuries (mTBIs)—commonly known as concussions.1,2 Historically thought of as a relatively harmless injury that typically resolved within a few days, there is mounting evidence that mTBI may not be as benign as was once popularly believed.3 For example, approximately 10% to 33% of patients may remain symptomatic for months to years after the initial injury.4–6 Increased recognition of the potential for lasting effects has accelerated the effort to identify methods to facilitate recovery from persistent post-mTBI symptoms.4,7 Physical therapists are trained to address many of the post-mTBI symptoms and impairments that patients experience (eg, dizziness, physical activity intolerance, headaches) and are increasingly recognized as integral members of the interdisciplinary team that treats these patients.8,9
There is a rising interest in studying patients with persistent mTBI symptoms.4,8,10,11 However, studying this population can be challenging, as there is a wide range of factors that can contribute to prolonged post-mTBI symptoms.4,10 Moreover, there is growing recognition that the mTBI patient population may be relatively heterogeneous, with underlying impairments that vary from patient to patient.12,13 For example, some patients may experience global physiological or cognitive dysfunction, whereas others may experience more peripheral impairments such as cervical musculoskeletal dysfunction or vestibular hypofunction.10,12
Numerous consensus statements are available to help guide general post-mTBI management.14–17 However, these guidelines tend to only vaguely discuss specific physical rehabilitation interventions that may be useful in treating these patients. A recent survey by Yorke et al18 indicated that although physical therapists are generally supportive of participating in mTBI management and many have received formal training in mTBI care, there is no clear consensus for how to best facilitate physical recovery for this patient population. A systematic review and synthesis of the specific evidence pertaining to interventions applicable to the field of physical therapy would be beneficial to inform and guide physical therapist management of this rising patient population. The purpose of this systematic review was to identify potential interventions that are safe, feasible, and appropriate for physical therapists to implement with patients experiencing prolonged symptoms following mTBI.
Method
Data Sources and Searches
A systematic literature search was performed on January 18, 2014, using the following databases: PubMed, Cochrane Library, CINAHL, Scopus, PEDro, SPORTDiscus, and Web of Science. Multiple search terms were utilized to optimize the capture of potential physical interventions. No restrictions on the year of publication or gray literature were applied during the search process. The initial search was supplemented with a manual search of the references for articles selected for inclusion. A second systematic search using the same key terms and search strategy was performed on June 28, 2015, to identify any new studies disseminated in the time since the initial search and the final stages of the drafting of the manuscript. A comprehensive list of search terms and limits for each database is provided in Table 1, and the full search and assessment process is outlined in the Figure.
Search Terms and Limits Used in Database Searches
PRISMA flow diagram.
Study Selection
Two stages of screening of potential articles were conducted. For the first stage, article titles and abstracts were screened by 2 members of the study team (A.C., C.G.) based on established inclusion and exclusion criteria. Any discrepancies between the 2 screeners were resolved through consultation with a third screener (T.H.). The final determination was made based on a unanimous consensus of all 3 reviewers. In stage 2, the same study team members reviewed the full texts of articles that made it past the first stage using the same process and criteria.
Inclusion criteria for the review were set as: a physical rehabilitation intervention study, published in English in a peer-reviewed format, human participants with a biomechanical mild traumatic brain injury or concussion and with symptoms lasting at least 2 weeks, and a mean age of at least 8 years. Exclusion criteria included: blast injuries, severe traumatic brain injury, and case reports with fewer than 10 participants.
The inclusion criteria were designed to ensure inclusion of intervention studies that were not necessarily designated as “physical therapy intervention” studies but entailed the use of interventions that are appropriate and safe for physical therapists to implement as defined by the American Physical Therapy Association's Guide to Physical Therapist Practice 3.0.19 Therefore, studies investigating interventions that could fall within the scope of care for physical therapists would have the potential to be included in the systematic review, whereas studies investigating other types of interventions (eg, hyperbaric chamber treatments, pharmacological treatments) would not be included. Gray literature studies published as abstracts or reports were included in the final pool of results if they provided sufficient details regarding the methods such that repeatability of the study would be possible and no published study reporting on the same data and results was available.
The age of 8 years was selected as the cutoff age for participants because children of this age have been shown to be capable of self-reporting reliable and valid health information.20 Because the validity of symptom reports is a key aspect in the assessment of recovery in this population, studies with a sample mean age under 8 years would have the potential to compromise the integrity of the studies for older populations. No upper range cap was set for the age of participants. Finally, case reports and case series describing interventions for fewer than 10 participants were excluded from the review. This exclusion was based on the goal of having data that were more representative of a summary of outcomes for the patient population as a whole, rather than rich descriptions of a few patients.
All systematic review articles identified through the search process were carried forward into the full-text review. The reason for this was to consider each of the studies within a systematic review as a potential study for the purposes of our review. Each identified systematic review was hand-searched to determine whether any of the studies within the review met our criteria and were not identified in our original search process. The systematic reviews themselves were excluded at the phase of the full-text review, as none of them directly answered the question posed for the purpose of this systematic review (eAppendix).
Data Extraction, Risk of Bias, and Quality Assessment
Following the full-text review stage, data extraction was completed by 2 members (S.V., T.H.) of the study team and verified by a third team member (C.Q.). Studies also were classified into 3 categories based on the types of interventions that were investigated: physiological interventions, vestibulo-ocular interventions, and cervicogenic interventions. These categories were chosen to match the heuristic classifications proposed by Ellis et al12 in which 3 different types of post-concussion disorders (PCDs) were identified (ie, physiological PCDs, vestibulo-ocular PCDs, and cervicogenic PCDs). In alignment with the model of Ellis et al,12 physiological interventions were characterized by interventions targeting autonomic, cerebral blood flow, or cerebral metabolism dysfunction (eg, graded exercise progressions). Studies were classified in the vestibular-ocular category when the intent behind the interventions was to target dysfunction of the vestibular and oculomotor systems. Studies were classified in the cervicogenic category when the interventions provided were designed to target dysfunction of the cervical spine. Studies that utilized interventions that fell into more than one type of intervention category were categorized under all of the classification categories relevant to that study.
Each study was quality appraised using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach21–23 and initially classified into quality categories based on study design. There are 4 initial levels of quality categories: (1) high, (2) moderate, (3) low, and (4) very low. In alignment with the GRADE approach, we graded randomized control trials as high initially, observational studies with group comparisons as low initially, and all case series as very low initially. Randomized control trials and observational studies were then further evaluated for potential grade changes based on the GRADE recommended factors.21 Two independent reviewers (C.Q. and D.K.) then evaluated each study's potential biases utilizing the Cochrane Risk of Bias Tool.24 This tool is recommended by the Cochrane Collaboration as a means to make a quality judgment based on criteria that address specific features about a study.
We planned to downgrade any randomized controlled trials rated with a high risk for bias to a moderate or low level based on reviewer consensus of the specific biases and the relative impact of potential confounding variables to the observed study outcomes. We also planned to downgrade any observational studies for which any biases or confounders were identified that had the potential to significantly impact the observed results. Finally, we planned to upgrade any observational studies if there was a large magnitude of effect or dose response or if, despite a small effect size, the intervention was not likely to be harmful and future studies would not likely result in substantially different results or interpretations.
Data Synthesis and Analysis
All studies meeting the inclusion and exclusion criteria were included in the synthesis and analysis stage regardless of methodological quality. As the identified studies were so few and utilized a variety of methods, a meta-analysis of the identified studies and respective results was not deemed appropriate. Instead, studies were grouped by intervention classification and synthesized by intervention-to-outcome pairings. A final evidence grade was assigned for the overall pool of evidence supporting the use of each intervention type relative to safety, feasibility, and appropriateness for physical therapists to administer. In alignment with the GRADE approach recommendations, this final synthesis grade was a group judgment based on considerations of the available studies, the balance of desirable versus undesirable outcomes, and general perceived value of the intervention. As this grade was multifactorial, it could potentially be higher or lower than what the grade of the study designs within the pool of evidence may suggest if the rationale to do so was strong.25
Results
The systematic search process identified 8 studies that met the inclusion criteria for this review (Figure). Five studies10,11,26–28 categorized as distinctly physiological interventions met the inclusion criteria, 1 study29 categorized as distinctly vestibulo-ocular met the inclusion criteria, and 1 study30 categorized as cervicovestibular met the inclusion criteria. One additional study31 utilized interventions that fell under all 3 categories and was evaluated under all 3 intervention types. Summary details for each study are provided in Table 2.
Study Extraction and Synthesis
Study design quality ratings varied from very low to high (Tab. 3). The specific interventions and outcome variables differed both within and across the intervention types (Tab. 4). Consequently, the ability to pool and synthesize the results across outcomes was limited. The most consistently studied outcome was improvements in symptom reports. As no studies reported adverse events for any of the interventions and the improvements observed were generally favorable across the studies and outcomes, the study team assigned each intervention type an overall grade of moderate (Tab. 4). Details regarding each study are provided under their respective intervention types.
Study Design Quality Appraisalsa
Evidence Synthesis and Overall GRADE Assignmentsa
Physiological Interventions
The studies receiving the categorization of physiological interventions utilized a form or multiple forms of progressive exercise treatment as an intervention. Some of the exercises were more aerobic or anaerobic in nature, and others targeted coordination. Schneider et al31 utilized progressive exercise treatment as one of several treatments for both an intervention group and a control group in a randomized control study to investigate vestibulo-ocular and cervicogenic interventions. As both groups received the physiological intervention, and the focus of the study was really more to evaluate the vestibulo-ocular and cervicogenic interventions, that particular study will be discussed in greater detail under the sections dedicated to those interventions.
Baker et al10 conducted a case series of clinical data for patients who were treated for persistent postconcussion symptoms assessed with an exercise test to determine whether their symptoms had a physiological basis. Ninety-one patients met the inclusion criteria, with time from injury ranging from 1 month to several years. Of the 91 patients, 65 experienced symptoms during the test prior to maximum exercise capacity and thus were classified as having a physiological basis for their symptoms. A total of 63 of the initial 91 participants also had follow-up data available regarding their functional status approximately 2 years later. Of these 63 participants, only 6 had declined participation in the exercise protocol. Overall, 41 of the 57 participants completing the exercise rehabilitation program returned to full daily functioning (27 out of 35 from the physiologically based postconcussion syndrome group and 14 of 22 from the nonphysiologically based group). Only 1 of the 6 participants who declined exercise rehabilitation returned to full functioning.
Leddy et al28 performed a quasi-experimental study that compared functional MRI (fMRI) activation patterns during a cognitive task, exercise capacity, and change in postconcussion syndrome symptoms among an exercise treatment group (n=5), a placebo stretching group (n=5), and a healthy control group (n=5). One member from each group was ultimately excluded from the analysis. Two of the 4 members in each group were athletes. Time from injury until first fMRI assessment ranged from 33 to 270 days. Participants in the exercise intervention group exercised for 20 minutes a day with a heart rate monitor for 6 days per week. Programs were monitored and changed as the heart rate threshold for symptom exacerbation increased. The stretching group was given a standardized, progressive, 12-week, low-impact breathing and stretching program. A statistically significant increase in exercise heart rate was noted for the exercise group over the course of the study, but there was no significant change in exercise heart rate for the stretching group. The exercise group also experienced a statistically significant decrease in number of symptoms, whereas no change was observed in the stretching group. The fMRI results indicated that the participants in the exercise group showed activation patterns that resembled those of healthy controls, whereas the activation patterns for the stretching group continued to show impaired function.
Leddy et al32 performed a prospective cohort study with 12 participants an average of 19 weeks postinjury (range=6–40 weeks). Six of the participants were athletes. Participants performed an incremental treadmill exercise test according to a standard Balke protocol to the first sign of symptom exacerbation. They were exercise tested at baseline and again after a 2- to 3-week baseline period. After the second exercise test, the participants performed aerobic exercise for the same duration that they had achieved during the prior treadmill test but at an intensity of 80% of the maximum treadmill heart rate once per day for 5 to 6 days per week. All of the participants reached physiological criterion for treatment success in that they could all exercise at or near the age-predicted maximum heart rate without symptom exacerbation. Symptom reports decreased significantly after the treatment period. The range of days treated was 11 to 112. Athletes completed treatment in about one-third the amount of time compared with nonathletes. Exercise time also improved significantly from baseline to posttreatment assessment. Although the athletes improved in a shorter period of time than nonathletes, there was no difference in the amount of improvement between the 2 groups. The participants achieved significantly greater peak heart rates and systolic blood pressure after treatment compared with before treatment.
Using a case series design, Gagnon et al27 evaluated a postconcussion rehabilitation program consisting of graded exercise rehabilitation at 50% to 60% maximum capacity on a treadmill or bike, a home exercise program, coordination exercises, and a visualization program for 16 patients aged 10 to 17 years who had been experiencing postconcussion symptoms for more than 4 weeks. Children were able to participate in 5 to 15 minutes (X̅=9.3 minutes) of aerobic activity at their initial visit before symptom exacerbation was reported. Tolerance gradually increased over time, with a mean of 12.2 minutes at the second visit and 14.2 minutes at the third visit. All participants showed significant improvement in symptoms. All children were able to resume their normal physical activity participation at the end of the program. Mean duration of the intervention was 4.4 weeks after a mean of 7.0 weeks of persistent symptoms.
In a follow-up case series, Gagnon et al27 reported on the responses of 10 adolescent athletes, between 14 and 18 years of age, who were referred consecutively to the same intervention program as the previous case series for a slow recovery from sport-related concussion (range=3.6 weeks, 26.2 weeks postinjury). The intervention period lasted a mean of 6.8 weeks. All of the adolescents were assessed twice (approximately 6 weeks apart) by an independent study evaluator. Overall, postconcussion symptoms significantly decreased for the participants from the initial assessment to the second assessment (Cohen d=1.83). Specifically, participants reported a statistically significant improvement in fatigue levels and depression scores from the initial assessment to the follow-up assessment (Cohen d ranging from 0.48 to 2.44). In addition, an improvement in cognitive processing speed was identified from the initial to the follow-up assessments (Cohen d=0.54).
Vestibulo-Ocular Interventions
Two of the studies utilized some form of vestibular rehabilitation as an intervention.29,30 Of these 2 studies, 1 was a randomized controlled trial31 (graded as high from a study design standpoint) and 1 was a case series29 (graded as very low). Vestibular interventions included gaze stabilization, repetitive optokinetic stimulation, standing balance exercises (standing with feet apart and feet together on foam with eyes open and eyes closed), walking balance challenges (walking with head turns, tandem walking, and obstacle avoidance), visual perturbations, Stroop task, and canalith repositioning maneuvers.
Schneider et al31 performed a randomized controlled trial comparing the return to sport timing for individuals who received a combination of vestibular rehabilitation, cervical spine manual therapy, range of motion exercises, stretching, and graded exercise progressions with a control group that did not receive vestibular or cervical spine interventions. The median time since injury prior to enrollment was 53 days for the treatment group and 47 days for the control group. Participants were treated once weekly by a physical therapist for 8 weeks or until the time of medical clearance for return to sport. Of the participants who completed the study, those in the treatment group were 10.27 times (95% confidence interval=1.51, 69.56) more likely to be medically cleared to return to sport within 8 weeks than those in the control group.
Alsalaheen et al29 performed a case series of 114 consecutive patients referred to a tertiary balance center for vestibular rehabilitation after a concussion (median of 96 days postinjury [range=8–2,566]). The vestibular rehabilitation consisted of customized programs for each patient's impairments and limitations as they related to dizziness, ocular-motor function, and gait and balance function. Interventions included gaze stabilization, standing balance exercises, walking with balance challenges, and, in a few cases, canalith repositioning. Eighty-four patients returned for at least one additional visit, and the median number of visits was 4, occurring over a median duration of 33 days. For patients receiving the vestibular rehabilitation, there was a significant treatment effect for each self-report and performance measures. There was also a significant interaction between treatment and age, with children experiencing greater improvements in dizziness severity reports and balance performance over the course of the treatments. For all other measures, both the younger and older cohorts showed similar improvements in response to the treatment.
Cervicogenic Interventions
Two of the studies included in this review examined the effects of manual therapy in their studies. Both studies were randomized controlled trials graded as high for study design. One study31 utilized manual therapy in addition to vestibular rehabilitation and progressive exercise treatment. The second study30 utilized manual therapy as the primary intervention.
Jensen et al30 performed a randomized controlled trial with 19 patients with a concussion diagnosis. Time since the injury occurred ranged from 302 to 423 days. The treatment consisted of mobilization, high-velocity manipulation with low-amplitude thrust, and muscle energy techniques to the cervical and upper thoracic spine. The control group received a cold pack placed under the neck and shoulders for 15 to 20 minutes. Following treatment, pain index, use of analgesic, and frequency of associated symptoms were lower in the manual therapy group; however, the differences were not statistically significant. The maximum reduction was found in the fifth week of treatment. In this week, the pain index of the manual therapy group was 43% of the pretreatment level, which was a statistically significant difference compared with the pain index of the cold pack group and in relation to pretreatment.
Discussion
The purpose of this systematic review was to identify interventions that are safe, feasible, and appropriate for physical therapists to implement with patients who experience prolonged post-mTBI symptoms. The systematic search yielded 8 studies with design levels ranging from very low to high quality. Using the GRADE approach,33 our study team judged the body of evidence for each intervention category (physiologic, vestibulo-ocular, and cervicogenic) to provide moderate support for safety, feasibility, and appropriateness for physical therapists to implement. This judgment was primarily derived by the group's belief that despite relatively low level study designs and a small volume of efficacy evidence, the evidence surrounding these interventions suggests that potential benefits do outweigh the potential risks of the interventions. The primary caveat to this conclusion was the potential risk for publication bias, which led to a moderate grade instead of a high grade. Further research is needed to provide evidence supporting or refuting the efficacy for these interventions.
The highest quality of evidence in terms of study design was found in support of manual therapy interventions to the cervical and thoracic regions when patients reported having headache or dizziness. As Becker34 noted, many structures in the neck can be sources of nociceptive input, including the zygapophyseal joints, intervertebral disks, ligaments, muscles, and skin. Both of the cervicogenic studies30,31 provided evidence to support manual therapy to identify areas of hypomobility in the spine and use of mobilization or muscle energy techniques to attempt to normalize mobility. Many physical therapists have foundational training in manual therapy, and a number of physical therapists have specialty training in this area. Therefore, treatment of the cervical spine using manual therapy is a distinctive and beneficial intervention that physical therapists can offer patients with persistent symptoms.
The evidence synthesis also indicated that patients experiencing persistent symptoms may benefit from vestibular-based physical therapy interventions.29,31 This may particularly be the case for younger individuals.29 As indicated by the study designs, vestibular treatments may be most beneficial for a specific subset of patients with persistent post-mTBI symptoms.12 However, the studies in this review do not provide a clear delineation for how to identify which patients are most likely to benefit from vestibulo-ocular interventions. For assistance in this regard, physical therapists may find it helpful to refer to a recent Delphi study conducted by Reneker et al35 that provides an overview of the clinical tests and measures that may be helpful to distinguish between different types of postconcussion dizziness.
A synthesis of the results for the 6 studies that examined progressive exercise training provided preliminary support for aerobic, anaerobic, and coordination exercises as safe and feasible. As physical therapists are well trained in exercise prescription and monitoring physiological responses, progressive exercise interventions offer a good opportunity for physical therapists to help facilitate recovery in this patient population. As with the other intervention types, additional studies would promote better understanding of the efficacy, dosing, and potential moderating and mediating variables associated with utilizing progressive exercise interventions.
It is important to acknowledge that the studies in this review collectively had several big limitations for drawing stronger conclusions. These limitations included small sample sizes, lower-level study designs, and variable sample compositions (eg, athletes versus nonathletes). Moreover, the studies used different tests and measures to evaluate intervention responses. This limitation makes it difficult to truly synthesize results across the studies. Readers are encouraged to refer to the original articles, as a full report of all of the tests and measures is outside the scope of this review.
All of the included studies utilized some form of participant self-report of postinjury symptoms to monitor recovery, many of which used this as the primary outcome variable. In addition to being subjective, symptoms are often subtle, can vary significantly both within and across patients, and are not always specific to mTBI. For example, there are common overlaps with symptoms associated with attention deficit disorder and migraine headaches. There is also potential for patients to ignore, hide, or exaggerate their symptoms.36,37 These factors make it difficult to use patient-reported symptoms alone to identify ongoing mTBI-related impairments.38 Moreover, some of these interventions may lead to transient increases in symptom reports, which may actually be necessary to achieve the desired intervention outcomes (eg, habituation for vestibular interventions). Consequently, further research is needed to provide clarification about what is safe in terms of pushing symptom thresholds for interventions.
It also is important to note that there is little information to help guide clinicians on how to optimally match patients to specific interventions or in what order to address impairments should the patient present with multiple needs. As such, physical therapists must use their best judgment and their clinical expertise to provide individualized care plans for each patient. Given the varied nature of the presentation of post-mTBI symptoms, it also is important that physical therapists refer patients to other specialists as appropriate and necessary (eg, optometrists, psychologists, speech pathologists) to ensure the best possible outcomes for their patients.
A final important consideration regarding the studies in this review is the variable timing in which the interventions were initiated. The timing of intervention implementation often varied even within each study. Additional research is needed to discern whether responses vary relative to the timing of the initiation of the interventions. We also specifically placed a limiter of a mean of a least 2 weeks postinjury for inclusion in this review. Therefore, it is difficult to know how the safety, feasibility, and appropriateness may fare for early time points. Recent evidence indicates that strict and prolonged cognitive and physical rest following an mTBI may result in greater symptom severity and slower symptom resolution.39 There is some evidence that suggests moderate-level physical and cognitive activities in the acute recovery phase may actually expedite rather than hinder recovery.40 Thus, even the acute period of recovery may become a critical intervention window for involvement of physical therapists to help safely monitor and progress patients through return to activity protocols.
As with all studies and investigations, there are also a number of limitations present within our systematic review. First, key word searches are inherently limited by the database search algorithms. To minimize this limitation, we performed our search in multiple databases and supplemented our key word search with manual searches. A second limitation is that there is potential that our group may have misinterpreted or misunderstood the findings presented in the studies included. To minimize this concern, we did utilize a group consensus process throughout the various stages of the study selection and synthesis processes. Finally, the critical appraisals and assignments of grades are naturally a subjective process. Although we utilized tools (GRADE approach and Cochrane Risk of Bias Tool), there is potential that a different set of reviewers may have judged the evidence differently.
Patients with mTBI are a surging patient population for physical therapists. There is a growing need for high-quality studies regarding mTBI interventions to determine the efficacy of these therapies and potential mediating and moderating variables to better guide physical therapists in making treatment decisions to achieve optimal outcomes. Questions still remain as to when to initiate these treatment options, the efficacy of these interventions in isolation and in combination with other treatments, and the dosing and intensities at which these interventions should be implemented. Further research is necessary to answer these important questions.
Footnotes
All authors provided concept/idea/research design, writing, data analysis, and project management. Dr Quatman-Yates, Dr Cupp, Dr Gunsch, and Dr Vaculik provided data collection. The authors also acknowledge Mary Sroka, Sara Constand, and Anna Bailes for assistance with search and formatting verifications and Dr Michael Tevald for his consultative methodological support.
Professor Kujawa is an Orthopaedic Certified Specialist.
- Received October 1, 2015.
- Accepted May 4, 2016.
- © 2016 American Physical Therapy Association
References
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