Fall 2010 Golden Goniometer

And this year's winner of the Golden Goniometer goes to EJ Hodel, Meg Martindale, Angela Boundy and Natalie Larsen for their work on the Ottawa Ankle Rules. Congratulations, gang! Well done!

AAOMPT Conference--San Antonio

Keith Scott and I, 3rd year students, just returned from this year's AAOMPT conference in San Antonio. We were there to do a poster presentation which entailed judges evaluating our study and 56 others. Talk about feeling like you're in the midst of a practical!

Anyway, I wanted to talk about how invaluable of an experience the conference was. But in order for you to fully realize how much this conference affected me, allow me to share a little about my background. I have been a chiropractor since 2002 and had decided in 2007 to go back to school for PT for many reasons. I have always been drawn to orthopedics, obviously, but was never really drawn to evidence-based practice; until spine class in the summer of 2009. Joe and Cheryl's class opened my eyes to EBP in a way that has clinically changed the way I will practice from now on. Basing my clinical decision making on the evidence rather than on what a guru says has truly given me confidence with patients that I never really had before. I have become a certified evidence junkie. I subscribe to 2 "push" services and can't get enough. One of the consistent patterns that I am seeing in the literature is that more and more studies are pointing to the efficacy of combining manipulation and exercise. I digress. Back to the conference.

AAOMPT Conference
Friday's keynote address speakers: Stanley Herring, MD; Chad Cook PT, PhD, MBA, OCS, FAAOMPT; Josh Cleland, PT, PhD.

Herring systematically laid out arguments for positioning PT as a first line of defense for musculoskeletal conditions and how we as a nation have spent disgusting amounts of money at improving spine care with little to no improvement in outcomes (cost has mounted as quality has declined).

Cook has authored many research articles, written or contributed to multiple texts, and is editor of the Journal of Manual and Manipulative Therapeutics (JMMT). His keynote address was on the best test for diagnosis of the spine and why its important. In his address he discusses the importance of differential diagnosis, diagnostic accuracy, and the best tests for diagnosis. He discussed the importance of the reference standard that is used to compared the proposed test and how it can make or break the validity of the test. Surprisingly, there are relatively few tests that have withstood the rigors of statistical analysis.

Cleland's talk was entitled "Manual Therapy: if it works, why isn't everyone doing it?" He discussed the evidence for manual therapy and the barriers that PT's need to overcome to incorporate it into their practice.

That was just Friday's addresses. There were breakout sessions all day Saturday as well, and into Sunday morning. All in all the talks were very dynamic and informative. They also had the student special interest group (sSIG) there to get the students more involved. There were exhibitors on hand with everything from rehab products to fellowship programs to journals....free pens galore.

It was such an incredible experience being around some of the greats in the research world. After seeing some of the same names over and over in the literature and then to finally see them in person it was definitely a room full of rock stars.

If you've made it this far I hope to end with one final note of encouragement: get involved. Joe and Cheryl have brought to Bradley an incredible enthusiasm for evidence-based practice. In the (near) future there will be many opportunities to improve your hands-on skills. Keep an eye out for the manual therapy club (coming up yet in Oct), Explain Pain seminar (spring 2011), and the AAOMPT student special interest group (sSIG) on campus (in progress).

As an additional plug for the manual therapy club, if you know that you're leaning toward orthopedics, specifically manual therapy PT, I'd remind you that it's a skill that must be practiced hundreds of times to develop the motor pattern. In chiropractic school we had about a year and a half of manipulation training and admittedly I wasn't completely comfortable for at least a year in practice. I can't stress enough the importance of getting your hands on willing participants. Get your fears out of the way now so you become proficient at it and can confidently treat patients using the best evidence. Hope to see you at the club meeting...

BU DPT 5k

Like to run? Prefer to walk? You can do both!

The BUDPT 5k will be held on September 25th, 2010 @ 9:00 a.m.

The Doctor of Physical Therapy Class of 2012 is sponsoring a 5k walk/run to help raise money for a variety of events. The money raised will defray some of the costs associated with traveling to our national conference in February 2011 and graduation expenses.

Please support the Department of Physical Therapy and run or walk in the 5k. Set a new PR on this flat, fast course! You will have the opportunity to win prizes and all will receive a t-shirt.

Register by September 17th. Registration is $15 for students, $20 for non-students. Click here to download the registration form.

Also available soon: Class of 2012 cookbooks featuring our favorite family recipes!! Please contact dmcooper@mail.bradley.edu for more information.

CSM revisited: Head trauma types: Blunt Force, Acceleration/Deceleration, and Blast

The Federal section of the APTA works to provide support for those who deliver quality physical therapy in Federal Medical facilities. As one can imagine, these PTs spend much of their time working with war veterans, many who have had a traumatic brain injury along with other injuries. The course at CSM was listed as “Balance at a high level: Vestibular training for the Amputee.” While much of the vestibular training is commonly used, the reason why these men with amputations require vestibular training is unusual. Kim Gottshall, PT, PhD, ATC and retired Colonel, US Army Reserves presented this training on this topic to about 150 PTs and PTAs at CSM. The information focused mostly on mild traumatic brain injuries and common associated symptoms.
The fact is blast type head injuries are fairly new. With new technology in body armor, the thorax is protected saving the life of the soldier, and helmets provide some protection from blunt force trauma and/or coup-countercoup (acceleration/deceleration) type head injuries. However, the blast type head injury, created by the shock-wave of the blast is different, and very little study has been done on this topic. The study of the other two types has been building for two to three decades, and there may be little to correlate with blast injuries.
In addition to body armor technology, the other factors that lead to this “signature” injury of the current two wars (Iraq and Afghanistan) is that much of the warfare is urban, as well as that improvised explosive devices are the weapons of choice for the opposition. The shock wave effect creates a sheering injury in the vestibular end organs, as well as a significant release of excitatory neurotransmitters. The result is oxidative cellular stress and direct stimulation of apoptotic pathways. Part of the presentation, then, is multiple site involvement. This means that there may be peripheral and central damage and resulting symptoms. Also common are cognitive difficulty and hearing loss or tinnitus. “Dizziness” is often reported as well, but the type and quality of the dizziness associated with blast injuries is still not characterized.
With lack of clinical research in this area, the current suggestions are to recognize that the neurological exam may result in findings that do not fall into a known pattern and to be as thorough as possible. In addition, quantifiable testing is helpful, such as using computerized dynamic posturography and VOR equipment if available. There are four suggested groups: 1. Post traumatic positional vertigo. 2. Post traumatic exertional dizziness. 3. Post traumatic migraine associated dizziness. 4. Post traumatic spatial disorientation. Blast head injuries also tend to have more cognitive difficulty and more hearing loss along with these different combinations of diagnoses.
Rehabilitation should be focused on the results of the examination. Video was shown and those with amputations were able to complete even the highest demands of rehabilitation with the prosthesis. Dr. Gottshall reported a study that she recently completed. While the exact study methods and procedures were not outlined, several notes were made about the subjects. The main observation was that cognitive rehabilitation seemed to correlate positively with vestibular rehabilitation. In addition, patients perceived improvement before functional gains were made. Finally, there is a temporal component to vestibular rehabilitation.
I look forward to seeing the published studies to come on the nature and sequelae of blast head injuries. For more information about the Federal section of the APTA: http://www.federalpt.org/ A full text article on what is known about
blast head injuries can be found at: http://www.pdhealth.mil/nlAttachments/DHCC-Uploads/21769.Taber.et.al.06.J.Neuropsych.Clin.Neurosci.Blast-rel.TBI.pdf

For other resourses, you can contact me at aalton@mail.bradley.edu

Sensory deficits post stroke

CSM revisit: Sensory deficits post stroke: best practice treatment
Jane E. Sullivan, PT, DHS from Northwestern University presented compelling evidence that Physical therapists need to be treating sensory dysfunction after stroke (Post Stroke Sensory Dysfunction, or PSSD). First, this is truly common, although it is rarely addressed by PT outside of proprioception (where is your arm? Are you sitting up straight? Where are your feet? Etc). In addition, the loss patterns do not follow motor loss patterns, and so these do need to be tested.
A study done by Connell in 2008 found that there was high agreement between different body areas for each modality, but there was low agreement between modalities in each area! This means PTs need to test each modality. Tyson et al in 2007 found that stroke severity and weakness are significantly correlated with PSSD, a finding later corroborated by Connell in 2008.
Also correlated with decreased sensory were outcomes such as increased length of stay, decreased bowel/bladder independence, decreased ability to perform ADL’s, etc. There were many studies cited in this presentation which link low sensory function with discharge placement, slow recovery of motor function, and even mortality.
The good news is this: the neurological system is moldable and trainable. We know that motor patterns can be learned; so too can sensory. There is natural recovery, anatomical redundancy, and bilateral pathways all improve the prognosis.
The reliability and validity of sensory tests were explored, and while there are some issues in this area, the following recommendations were made: 1. Screen everyone (post-stroke) for all modalities including stereognosis. 2. Formally test if linked to movement dysfunction and goals. 3. Standardize your exam.
Obviously, there is a need for more research, but there are promising studies that link improved upper extremity sensation with improved balance outcomes. Electrical stimulation studies have shown excellent potential for “waking up” the sensory system, with improvements noted in spasticity, force, perception, selective movement, as well as balance and gait. Vibration, thermotherapy, intermittent compression, graphesthesia and discrimination tasks and passive movement all show improvement (passive range of motion shows fMRI but not clinical improvement). Finally, these changes persist! There is yet to be any meaningful dose-response trial, however.
The parameters recommended at this time across interventions are: Brief (20-30 min – they will get tired!), and repetitive (3-5 days per week) for several weeks. With any of these treatments, practice mastered tasks first and last, take breaks, and aim for limbic involvement and active attention. Reduce the stress in the environment so the patient may attend to the task as well. A quiet nervous system will respond more dramatically to changes, and above all, PRACTICE!
** for references feel free to contact me at aalton@mail.bradley.edu

Combined Sections Meeting: Concussions and Mild Traumatic Brain Injury

This presentation featured four speakers about a very timely topic: concussions. ESPN has even had NFL players and others as guests to discuss this issue, including self-monitoring of athletes and team policy on the return of players to the field after concussion.
The message is becoming clear very quickly: These injuries are extremely serious and need to be treated as such. Not only are they serious, but it is an injury that has the potential affect all populations and all PTs, regardless of the specialty.
The first Speaker, Kevin Guskiewicz, PhD, ATC, FACSM gave background about concussions. There are about 1.6 to 3.8 million sports-related TBIs each year (Langlois et al, 2006), and that is only sports related. They have a cumulative effect and can have enduring consequences if not managed properly. It is estimated that 50% of these injuries go unreported in this “silent” epidemic (Giza, 2001; Guskiewicz 2003, 2007; Collins, 2003, McCrea, 2005).
The basic evaluation is the same as any other injury, including cranial nerve testing, cognition, coordination, history and physical, as well as basic PT evaluation. He cautioned that return to sport should not be considered if there was any loss of consciousness or amnesia, OR if the person is young or high school age, or if they are still experiencing signs or symptoms. However, any other return to play guidelines have not been made with evidence basis. There is work being done to rectify this.
Finally, severity of the injury cannot be determined initially. Because concussions are defined as a loss of function, not damage to structure, the severity is graded by how long the symptoms last, and how severe they are.
The strategies for addressing deficits are the same as any brain injury, remembering that the nervous system is plastic and can and will be affected by practice and rich environments.

The second speaker was none other than neurosurgeon Dr. Cantu of Emerson Hospital, who has treated many famous people with traumatic brain injury. He posited that there is really no such thing as a “MILD” traumatic brain injury. His focus was technical, as one would expect from a neurosurgeon, but the gist was that multiple concussions, especially those that do not heal correctly, can result in erratic and psychotic behavior and a syndrome called Chronic Traumatic Encephalopathy (CTE).
We have seen this play out in the news: the wrestler Chris Benoit who killed his wife and child and then killed himself, or the Steelers’ player who drove his car into an oncoming tanker truck. The problem is there is no way to diagnose CTE without an autopsy, where the presence of Tau proteins is noted.
Dr. Cantu, along with several others, is at the forefront of this in the national discussion. His goals are to better define and diagnose brain injury, develop guideline for treatment and return to sport/activity, and to educate the public about the seriousness of these injuries. He and his colleagues are lobbying congress and the court of public opinion to put this issue on the priority list for public and global health initiatives.

Third was Susan Whitney, a PT from University of Pittsburg Medical Center. Her focus was clinical: describing common symptoms and treatments for balance disorders associated with concussion and post-concussion syndrome. Dr. Whitney also shared some evaluation tools that are helpful in diagnosis and planning.
She also described some of the studies the UPMC is conducting and the results of the intervention protocols they are developing. Promising results are being reported with a program of gaze stabilization and standing balance and ambulation exercises.

The fourth speaker was Chris Nowinski, a Harvard graduate whose WWE wrestling career was cut short by a concussion. His goal was to provide a patient’s perspective of TBI. He described his last concussion, stating that he had been to eight doctors when the symptoms did not subside, and that it was finally Dr. Cantu who asked “How many times have you had your ‘bell rung’ or saw stars?” not the question that the previous doctors had asked (“how many concussions have you had?” – none diagnosed!).
After his rehabilitation, Chris teamed up with Dr. Cantu and his colleagues to help spread the word about this serious injury. He wrote a book with fellow wrestler Jesse Ventura called “Head Games” to explain to athletes why this is not an injury you should play through.

The program was extremely interesting and informative on a very well-timed topic. For more information about concussion prevention and the current work by Dr. Cantu and Chris Nowinski, go to: http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm and http://www.sportslegacy.org/




Ist speaker references:
Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school
athletes. Neurosurgery 2002;51(5):1175-9; discussion 80-1.
Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train 2001;36(3):228-35.
Guskiewicz KM. Assessment of postural stability following sport-related concussion. Curr Sports Med Rep
2003;2(1):24-30.
Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive
impairment in retired professional football players. Neurosurgery 2005;57(4):719-26.
Guskiewicz KM, Marshall SW, Bailes J, et al. Recurrent concussion and risk of depression in retired professional
football players. Med Sci Sports Exerc 2007;39(6):903-9.
Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. Jama 2003;290(19):2549-55.
McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate
Football players: the NCAA Concussion Study. Jama 2003;290(19):2556-63.
Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006;21(5):375-8.

BUDPT Class 2011 in San Diego

PT students and professionals from all over are attending the 2010 APTA Combined Sections Meeting (CSM) in San Diego this week. You can read their 'journals from the road' featured here on Bradley's home page. Many of our own Bradley students and faculty will be presenting their original research!