Manage the Evidence Like a Pro

The problem. You are trying to stay current with the literature because that’s a great way to ensure quality treatment of your patients OR your a student in a physical therapy school that has a strong evidence based practice curriculum AND you end up having a hard drive littered with PDFs, like this:

Image by mekentosj.com

The solution. Papers2 by software developer mekentosj. This app makes it dead simple to organize your PDFs. Think of it as iTunes for PDFs, where instead of double clicking a track to listen, you double click to open the PDF in your favorite PDF viewer. You can search for articles quickly, email them to a colleague, even takes notes, all within the app. There are so many neat features I just had to put together a brief screencast demo, which you can view below:

Managing Physical Therapy Articles Like a Pro from Mike Pascoe on Vimeo.

In this 5 minute screencast, I show off some of the key features of Papers2. This video is directed toward those with a physical therapy background.

Papers2 can be downloaded here:

http://www.mekentosj.com

April 7, 2011 | Filed Under Evidence and Technology, Health IT, Research

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From Bench to Bedside: Spinal Cord Physiology -> Clinical Interventions

Having just defended a dissertation in the field of neuroscience, this session was my guilty pleasure. I felt right at home hearing about the modulation of intrinsic motor neuron properties. But, the question I’ve had since graduate school was the focus of this session – how does the lab work in cat/rat/monkey motor neurons translate to human patients?

This session was presented by four brilliant researchers interested in brainstem modulation of the motor system. The patient population discussed was spinal cord injury, a condition in which the connection between the brainstem and the motor neurons are disrupted. Each researcher discussed the implications for force generation, spasticity, and locomotion. I’ll summarize their reports below.

Allison Hyngstrom, PT, PhD

First up, Dr. Hyngstrom highlighted a few key researchers that have influenced treatment of patients:

Sherrington – contributed the concept of the spinal motor neuron as the final common pathway – contributed to the understanding of locomotion by examining “air stepping” elicited by stretching hip muscles of spinalized
Eccles – introduced the idea that inhibition could sculpt the output of motor neurons, particularly the reciprocal inhibition pathway
Brown/Grillner/Lundberg – descending input, as well as specific neurotransmitters, could activate spinal networks without sensory inputs

The Dr. Hyngstrom progressed to ‘Motor Neurons 101′, including these key points:

MNs possess huge denritic trees to receive inputs from several sources (higher brain, local interneurons, afferent)
Two categories of receptors are expressed on the MN membrane – ionotropic and metabotropic
The activation of metabotropic receptors by monoamines create persistent inward currents (PICs)
PICs can amplify the output of the MN
In acute spinal cord injury there is a loss of seratonin in the spinal cord that decreases the excitability of spinal MNs

Moving to the spinal cord injured cat, researchers have found that by adding monoamines to the spinal cord the cat could walk again [link to article in PubMed]

Next Dr. Hyngstrom described some of her own work on MNs. In her dissertation she was interested in the factors that regulate PICs. One way she did this was by altering the amount of reciprocal inhibition.

In summary

Monoamines (like seratonin) increase the gain of the MN > which implies PTs could reduce effort for a given movement
Monoamines facilitate automatic movements
Dysregulation of monoamines likely contributes to alterations in cellular excitability in chronic spinal cord injury
Altered cellular excitability not necessarily a bad thing > consider other ideas
Targeted medications could be used to harness spinal network excitability

Chris Thompson, PT, DPT

Next up Dr. Thompson presented his talk, titled – “Activation of spinal networks in patients with spinal cord injury to improve volitional movements”.

He began with a bold statement – “indiviuals with motor incomplete SCI do not fatigue”. How could this be? It seems that in a repeated stimulation protocol, patients with acute SCI do not exhibit a reduction in force generating capacity, whereas patients with chronic SCI and healthy controls do exhibit a reduction in the same protocol.

I also seems that people with incomplete SCI have a reserve of volitional force generation – 115% of maximal force can be achieved across the first 4-5 maximal contractions.

In acute spinal cord injury there is a period of spinal shock and spinal reflex responses are suppressed. But after time (chronic) the responses become super sensitive to seratonin.

Dr. Thompson want to know why and he looks to the motor neuron persistent inward current as a mechanism for the following three reasons:

There is an increased EMG amplitude across contractions, through increased recruitment and rate modulation of motor units
Prolonged torque in response to electricla stimulation using top hat stim protocol, which was abolished when a nerve block was in place
There are alterations in motor unit activity due to pharmacological agents (SSRI), which block the reuptake of seratonin

Dr. Thompson concluded by review attempts at translation of the findings in animal models to humans patients. The idea best examined by his lab group basically involves applying a ‘top-hat’stimulation protocol made popular in cat experiments to human patients. Something very interesting happens when comparing humans and cats. The amount of force and the strength of the persistent inward current are larger when muscles are at shorter lengths IN HUMANS. However, the amount of force and the strength of the PIC are larger when muscles are at longer lengths IN CATS. Explaining this difference is the next task on Dr. Thompson’s plate.

Arun Jayaraman, PT, PhD

Alright, that was a lot of motor neuron physiology and I appreciate you hanging in there so far. So, how can the above information be put into clinical practice? This is what Arun enthusiastically addressed – developing the rehabilitation protocol.

His main question was how can we harness the reserve in force generating capacity seen in patients with incomplete spinal cord injury?

This was tested in 10 patients with chronic motor incomplete SCI in a cross-over design with a two month washout period between the testing conditions. The phenomenon examined was that the harder you work, the more force enhancement you observe in the SCI population. As the time between maximal contractions gets longer, the enhancement in force production becomes lower (15 s is best). This phenomenon is present both concentric and isokinetic contraction modes.

Subjects trained with 65-80% of their one repetition maximum until they plateaued in function. Arun found that just isometric trained alone enhanced berg balance scores and walking distances in the 6-min and timed up and go tasks. Noxious stimulation at an intensity of 50 mA on the stomach skin was not so effective.

A follow up direction Arun is investigating is the use of intermittent hypoxia. It has been shown in rats that electromyography and force measurement improved in a ladder climbing task following a hypoxic state. How will patients with chronic SCI respond to hypoxic conditions during locomotor training? Arun is hopeful that benefits are realized in his patients.

In summary

Volitional drive can be enhance by working very hard
Does improve walking and balance
Can be done at home
What are long term effects?
Can this be complimented with intermittent hypoxia?

George Hornby, PT, PhD

The topic addressed by Dr. Hornby at the end of the session was the combination of physical therapy and pharmacological interventions.

It seems that providing glutamate can generate locomotion patterns and we also know that monoamines can excite central pattern generators (CPGs).

There is an increased Babinski Sign in SCI due to effects of monamines.

Seratonin (5HT) is effective in initiating locomotion in rats with SCI.

It seems that humans respond better to 5HT than norepinephrine (NE) when administered.

Lastly, Dr. Hornby has seen that strength, not spasticity, is related to locomotion function.

April 5, 2011 | Filed Under APTA, CSM 2011, Physical Therapy, PT Think Tank, Research

CSM 2011 – The Pauline Cerasoli Lecture

Photo taken from APTA website

This lecture honors one of physical therapy’s best and brightest – Pauline ‘Polly’Cerasoli (Feb 25, 1939 – Sept 11, 2010).

The Cerasoli lecture began with a tribute to Polly by a long-time friend and colleague Bette Ann Harris in which we learned more about the places she spent time:

Northeastern University (1967-1981)
Massachusettes General Hospital (1981-1987), doctorate in education
University of Colorado Denver (1988-1996), director of physical therapy program

We also learned of the major contributions made by Polly to the physical therapy profession:

Started the Boston Education Consortium in the 1970s
Published a landmark paper titled ‘Research experience in an undergraduate physical therapy program’– [pubmed link]
First appointed clinical specialist at Massachusetts General Hospital in 1981
Mentored a blind physical therapist in 1992

Next, APTA President Scott Ward asked for a moment of silence, as it was the first Cerasoli lecture since she passed away in Sept of 2010. Dr. Ward announced that the 2012 Cerasoli Lecture will be given by Christine Baker from UT Galveston.

Dr. Ward then introduced us to the 14th Cerasoli Lecturer – Dr. James Gordon. Dr. Gordon is associate dean and chair in the division of biokinesiology and physical therapy at USC.

Dr. Gordon’s talk was titled ‘Excellence in Academic Physical Therapy – What Is It and How Do We Get There?’I’ll try my best to summarize the talk below.

We (physical therapists) must accept the challenge that lays before us – pursue excellence.

On January 15, 1921, that 30 PT aides formed the APTA at the Keene’s Chop House in NYC. Now, a century later, Vision 2020 is lies ahead. It is the challenge.

What is needed to meet this goal is a strong academic foundation. It is in the academic setting that the physical therapy profession does its thinking.

Dr. Gordon defined a strong academic foundation as having three pillars – Education, Research, and Clinical Practice. All three pillars need to be in place. A classic three legged stool analogy, the foundation will topple with the absence of just one of the three pillars.

Dr. Gordon stated that excellence today is the norm for tomorrow. Excellence is the engine of the train, accredidation is the caboose (crowd chuckles).

So what is the agenda to achieve excellence? It is fulfilling all three pillars of the academic foundation.

1. Education

The most urgent task is to standardize curricular competencies. There is “unwarranted variation in physical therapy practice”. For example, there is large variation in the prerequisites, and program length. An emphasis on preparing generalists is the problem. Accreditation offers a list but no priority. Curricular competency needs to be standardized. Students need to have the ability to treat a patient with a defined condition under a defined set of characteristics (settings, acuity, age).

2. Research

Not much to say here. All programs should be involved and the big should help the small.

3. Clinical Practice

All programs across the country need to be involved. Currently, only 22% of programs have any form of program sponsored practice. Practice is important because it enhances teaching and provides a venue for research.

Lastly, Dr. Gordon addressed the infrastructure requirements to achieve program growth. Of the 213 accredited physical therapy programs in 200 institutions, 206 offer a DPT degree. Currently, 75% of faculty are PhD-level prepared. Many of these programs are very small. 50% are in Universities with research institutions and 35% of physical therapy programs are in medical centers. The average class size is 42.5, and 20% of programs have class sizes less than 20.

Why emphasize program growth? Dr. Gordon argued that this will bring a greater breadth of knowledge, support more research, and meet the need for more physical therapy students.

Dr. Gordon then wrapped up with his two take-home points:

A strong academic foundation is essential for achieving excellence in physical therapy

A strong academic foundation is dependent on three pillars (Education, Research, Clinical Practice), and you need them all