CSM 2012, Chicago Edition is Here!
Image courtesy Trey Ratcliff, Stuck in Customs via Flickr
My hat and gloves are packed, my boots are ready, although my ice walking skills may have gotten rusty having moved away from the northeast now 8 years ago. Regardless, I think I’m ready to dive in and embrace the winter wonder land that is Chicago, that is this year’s APTA Combined Sections Meeting.
PT Think Tank is going to be covering CSM in full force for those of you who can’t attend. Mike Pascoe, Kyle Ridgeway and myself will all be there and ready to tell you about the goings on either here, on Twitter, or however else we might discover. Dr. Pascoe is also planning some exciting live-blogging events from some sessions, so keep your eyes peeled and tune in REAL TIME from Chicago!
I’ll be representing the Orthopaedic Section as the Public Relations committee chair and performing tasks and attending events related to that role, and I’m excited to be presenting a research platform on Saturday afternoon.
Jason Tonley, PT, DPT, OCS, and Marcie Harris-Hayes, PT, DPT, MSCI, OCS, will be delivering a session entitled, “Don’t Forget to Be Hip: Looking at the Role of the Hip in Lumbar Spine Disorders” at 3:30pm Saturday. Part of that session will include several research platforms related to the topic. I’ll present the hip-spine case series I’ve been working on with Cheryl Sparks from Bradley U. and Derek Clewley from Benchmark in Atlanta. Check us out!
Here is our Twitter info: (Check out #CSM2012)
And check out, @AAOMPT, as it seems like they’re planning some fun, social gigs.
Also, don’t forget the APTA CSM Mobile App. Get it here. It’s way more convenient than trudging to those programming boards! I’m keeping my fingers crossed to see a little white stuff, but I do have some post-trauma from a failed attempt to get to Boston the last time CSM was held in a draft climate, so if it does snow, perhaps Friday night might be a good time. Can we schedule that?
See you there!
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.
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).
- Northeastern University (1967-1981)
- Massachusettes General Hospital (1981-1987), doctorate in education
- University of Colorado Denver (1988-1996), director of physical therapy program
- 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
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
Photo taken from APTA website
Fear of Re-Injury and Return to Sport Following ACL Reconstruction
Fear of Re-injury and Low Confidence 1 Year after ACL Reconstruction: High Prevalence and Altered Self-ratings: CSM2011 Sports Section Platform Presentation
Trevor Lentz, PT, CSCS
This study won the Excellence in Research Award from the Sports Section of the APTA. Trevor’s primary clinical and research interests include rehabilitation of shoulder pathology, especially of the overhead athlete, and ACL rehabilitation including advanced rehabilitation timeframes. He is part of the research group at University of Florida that includes Dr. Steven George PT, PhD. Dr. George has been involved in a large magnitude of research related to psychosocial variables in musculoskeletal conditions. His primary research interests involve the common theme of utilizing biopsychosocial models to prevent and treat chronic musculoskeletal pain and dysfunction. So, I am not the least bit surprised he is involved in this line of questioning.
Background:
34-47% of individuals do not return to prior sports participation following unilateral, isolated anterior cruciate ligament reconstruction. This number maybe up to 70% for contact sports.
Clinical Factors Associated with Disability Following ACL Recon:
- Knee Pain Intensity
- Knee Flexion ROM Deficit
- Quadriceps Weakness
- Fear of Movement and Re-Injury
**Multiple studies have supported those findings**
Differences Between Individuals Who Return to Sport and Those Who do Not:
- Knee Pain Intensity
- Quadriceps Weakness
- Fear
- Self-Reported Disability (International Knee Documentation Committee [IKDC] Score)
Fear of movement and re-injury consistently associated with self-reported function. But, not routinely measured or addressed in post-operative care.
Essentially, the group wanted to study whether fear of re-injury and or fear of movement was present, and a factor, in return to sport following anterior cruciate ligament reconstruction. They included individuals in their study who had isolated, unilateral anterior cruciate ligament reconstruction. Return to sport status was measured 1 year post-operatively. Roughly 100 participants were enrolled. They gave participants a questionnaire asking if they had returned to sport. If the answer was no, they gave a list of reasons including pain, weakness, lack of ROM, lack of clearance by MD, fear of re-injury/movement, and some other variables…
Findings
- 49% of their cohort had not returned to sport 1 year post operatively
- 50% of those that had not returned to sport cited fear as primary reason
- Fear was the most commonly cited primary or secondary reason for not returning to sport
A subset of the population may not only benefit from, but require, fear of re-injury interventions. Addressing psychosocial impairment may aid in function and return to sport status. But:
- What interventions can/should be utilized?
- At what point during rehabilitation?
- How do confidence, self-efficacy, and pain castrophizing affect return to sport?
The speaker did a nice job of pointing out that we need to do a better job of operationally defining and measuring “return to sport.” For example, return to any sport? return to their sport? I would go one step further and say return to previous level of function (40 yard dash time, vertical leap, strength)? Previous level of performance (minutes played, game statistics, self-perceived ability)?
In my opinion, future investigations MUST specifically tease out return to sport and return to previous level of sport performance. It is useful whether measured subjectively through self-perception and self-report OR objectively through playing time, statistics, etc. Any athlete, especially high performing athletes, will tell you that there is a difference between playing/participating in their sport AND performing at their pre-injury level.
As far as intervention, it may range from graded exposure of feared activities/sport specific tasks or graded activity progression. [Many of these cognitive behavior approaches are being utilized and studied in patients with chronic and persistent pain] Some may require even further intervention (psychological or otherwise) for their biopyschosocial impairments and barriers for return to sport.
So, fear of re-injury has been identified as present following ACL surgery and a very real, patient perceived barrier for return to sport. Now, we need to figure who develops it and why? What are the risk factors? When do we intervene and how? And, what are the long term consequences of this impairment? Looks like we have some work to do!
Physical Therapists in the Emergency Department
Findings indicated that these physicians found ED physical therapy services to be of value to themselves, to their patients, and to the department as a whole and described specific manners in which such consultations improved emergency care. Implementation and maintenance of the program, however, presented various challenges.
Emergency Department Physical Therapist Service: Removing Barriers and Building Bridges
To start, a brief introduction of who comes into the emergency department. Fewer and fewer are coming via ambulance, even fewer by life flight. People are using the ED in new and different ways. For example, many have non-urgent and non-life threatening conditions.
The average wait is upwards of 1 hour, with the average length of stay in the ED upwards of 4 hours. The ED physician spends an average of 11 minutes on direct care. That time includes research, orders, and making referrals.
Patient satisfaction with ED care is generally low. Management of common musculoskeletal, pain, and soft tissue injury complaints is varied and poor. Individuals are routinely given cervical soft collars for neck pain, immobilization including CASTS and or instructions for non-weight bearing for ankle sprains, and MULTIPLE days of bed rest for low back pain.
What do the PATIENTS want? Answers, instructions, and to feel better!
What do the patients receive? Imaging. Medications. Prescriptions. No follow up.
The fact of the matter is this that more and more individuals are utilizing the ER as their primary stop for health conditions. By the time they seek care these conditions are more chronic and less well controlled. Thus, more and more people seen in the ED are not necessarily in an emergent state. And, I believe, more and more would benefit from the skills of a physical therapist.
Now, I also believe physical therapist’s can play a vital role in deciding when imaging of musculoskeletal conditions is and is not necessary. Further, the treatment they provide may (again my belief) decrease imaging, medication prescription/usage, and decrease re-visit rates for the same complaint. And maybe, just maybe, if we plug these people into physical therapy sooner their conditions (pain, chronic medical diagnoses, etc) will be better managed and controlled. And, I think, that all links back to the Physical Therapist’s Role in Health, Wellness, and Prevention as per Healthy People 2020.
The data that does exists suggest that having PT’s in the ED results in decreased wait time and increased patient satisfaction. [Unfortunately, much of the data on PT's in the ED has been obtained outside the United States.] At the large, academic hospital I practice high priority is placed on “patient satisfaction.” [However, flawed that concept may be. Refer to Patient Satisfaction is Useless Part I and Part II on the Evidence In Motion Blog]. Further, wait time in the ED is directly related to the costs for that department. Therefore, decreasing wait time is a very real way to decrease costs. Not surprisingly, wait time is inversely related to patient satisfaction. So, already those are two powerful take home points regarding the positive effects PT’s ARE ALREADY having in the ED already. But, what does the future hold?
In expanding PT services in the ED, we can look to other sources of evidence and data to support PT treatment of individuals in the emergency department:
- PT Management and Evidence for Specific Musculoskeletal Conditions
- Outcomes when PT is involved earlier in care of painful episodes
- Outcomes when PT is delayed
- Future healthcare costs with advanced, and over, imaging
- PT’s Knowledge and Decision Making In Medical Screening and Diagnosis
Specifically, there is evidence supporting specific PT approaches to common orthopaedic conditions such as low back pain, neck pain, knee pain, ankle sprains, etc. Also, there are innovative practice models where physical therapists are involved earlier in care providing FRONT end intervention for painful episodes. Virginia Mason (out of my hometown of Seattle) received a lot of publicity even a Wall Street Journal Article for their model of sending patients with work related musculoskeletal complaints to a PT FIRST. They decreased costs by over 50% (!!!) and decreased time away from work.
Future Research and Data Tracking
- Readmissions
- Time between ER visits
- Medication Prescription and Usage
- Imaging Utilization and Costs
- Falls and Injury from Falls
The talk was very interesting, and I think this practice area will continue to grow. It actually reminds me of the growth of early mobility and rehabilitation of individuals in intensive care units. I also think there is really good research and data from other areas of practice supporting not only the treatment PT’s can provide, but also our training, decision making, and skills in medical screening and aiding in diagnosis. Not to mention, I did not even mention fall risk screening and intervention, splinting, wound care, assistive device recommendations, and aiding in discharge planning.
Where will physical therapy go next?
Resources
- Physical Therapists in the Emergency Department: Development of a Novel Practice Venue. Physical Therapy. March 2010.
- The Physical Therapist as a Musculoskeletal Specialist in the Emergency Department. Physical Therapy. March 2009
- Emergency Department Physical Therapist Service: A Pilot Study Examining Physician Perceptions Internet Journal of Allied Health Sciences and Practice. 2010.
Healthy People 2020: Physical Therapists in Health and Wellness
CSM kicked off with a talk about how physical therapist’s can fit into the Healthy People 2020 initiative . Further, the roles and potential roles of physical therapists in health, wellness, health promotion, and public health.
- Work towards health focused practices
- Health as an outcome
- Physical Therapy is about movement and function
- Address societal needs of movement, function, living with disability, and health/wellness
- Ethics > Meet the health needs of people locally, nationally, and globally
- Link to our work to individual patient’s, societal needs, overall healthcare
- How to obtain reimbursement for preventive care?
The speakers gave broad information about health promotion and physical therapists. Each gave some interesting case examples. Each advocated for physical therapy in serving the societal needs of not only health, but living with disability. I absolutely agree! But…
Especially in private practice how do we not only incorporate health promotion, but make it fiscally sustainable and or profitable? Sometimes it is difficult enough to obtain reimbursement and or private pay for a current condition let alone chronic health conditions such as hypertension control, obesity, healthy exercise habits, and smoking cessation. But, on the other hand, the personal fitness and health industry (i.e. weekend trained personal trainers at 24 hour fitness) is booming. How can PT’s obtain a slice (or a big chunk) of this market?
I think they speakers brought a good point that we need a critical mass of not just PT’s, but legislators, public policy makers, patients, and other healthcare professionals committed to societal health in various practice settings. And a recognition of rehabilitation and physical therapy as essential parts of not only health care, but health promotion.
Why aren’t we moving in that direction? Do we all need to broaden our view of our professional role? What is the SWOT [Strengths, Weakness, Opportunities, and Threats] Analysis of the PT profession, and each us as individual practitioners, in regards to health? I think there are a lot of opportunities, but many, many barriers.
Do we have what it takes to step up to the plate? Or, at least get a place at the table?
- How do we measure health and outcomes related to health?
- How do we market and spread the word to: patients, physicians, legislators, payors (ha!), the media, educators, public health professionals, and thus society?
- What role does technology play in our promotion of health and wellness?
- Can we leverage technology to achieve and spread the above goals and ideas?
I think the first talk brought up many, many questions, problems, and ideas…
CSM Kick Off
Arrived in New Orleans, and man I am excited!
A full flight from Denver to New Orleans, with many Denver area physical therapists and even some PT students from University of Southern California. Oddly enough, I sat next to a very nice PT Student from UCSF. We chatted the entire flight about early mobility in the ICU and physical therapy treatment of individuals who are critically ill (which if you know me gets me talking!) as well as PT education and research.
We even exchanged e-mails via our smart phones. Tomorrow should be a great day. Stay tuned here at PT Think Tank for updates and information.
Follow Me on twitter for quick blurbs and links.
Follow the Hashtag #CSM2011 for tweeps chatting about the conference! Let the technology leveraging begin…
APTA 2010: Boston Wrap
The Annual Conference and Exposition of the APTA was recently held in Boston. It was a fun time and had the highest attendance in the past 4 years! Boston is a great city.
My personal conference highlights included a an amazingly constructed and delivered McMillan Lecture by Dr. Andrew Guccione, and getting to catch up with some of my former classmates and professors from Quinnipiac University. I also had the opportunity to present two educational sessions. One session was with Dr. Tim Noteboom from Regis University on Collaborative Web Tools, and another was with Rachael Lowe on the future of text books and Physiopedia.
Head on over to Physiopedia to check out our slides from that presentation! I’ll be posting the slides from the web tools talk in a day or so.
Capitol Hill Day
Today, hundreds of physical therapists, members of the APTA’s Othopaedic section, and members of AAOMPT, are spending the day on Capitol Hill meeting with as many legislators as we can.
In today’s rapidly changing healthcare arena, the timing of this event couldn’t be better. Providing input from the physical therapist’s perspective is important as so many decisions are about to be made. The day has started out well, with some excellent breakfast at the Russell Senate Office Building. Present were the leadership of representative organizations. Left to right: Jay Irrgang (APTA-Orthopaedic section) Scott Ward (APTA) and Bob Rowe (AAOMPT).
I'm back and so here's a link
General apologies and regrets for the long delay between posts. One of the things I was up to was presenting at the annual APTA Conference in Baltimore with Tim Noteboom. I thought it might be nice to direct all those folks who I coerced into subscribing to my blog by way of a how-to demo to the slides from the presentation.
Here they are posted on my Physiopedia Page.
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The online encyclopedia of Physical Therapy.
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