Letter from the RFC Chair: A Look Back at 2016 and What to Expect in 2017

By Charles A. Odonkor, MD, MA

Source: https://www.linkedin.com/pulse/happy-holidays-marcelle-marboua

The RFC started off 2016 emboldened by your unrelenting support. It has indeed been a monumental year as we endeavored to continue the legacy of prior generations in working towards a renewed vision for our specialty– breaking boundaries, exploring new worlds. It has been my singular pleasure to lead an illustrious team of partners on the 2016-2017 resident and fellow council, who are passionate about our field. As we look back at 2016, we are proud of what we have accomplished together with your constructive feedback, suggestions and contributions.

Below are some highlights of successes in 2016:

  • Revamped Newsletter – New Name, New Logo: Physiatry in Motion, 4 issues published, and counting
  • New RFC Communication Platforms: Rehab Technology Blog on Medium, Adobe Spark Version of Newsletter, Expanded Presence and Trainee Engagement on Social Media including Facebook and Twitter
  • Reconstituted and vibrant RFC Alumni Network on Facebook
  • New Resident Health & Wellness Initiatives
  • Participation in AAP Advocacy on Capitol Hill for PM&R
  • Promotion of residents and fellows participation in State Societies of PM&R
  • New initiatives to promote and create more PMR Interest Groups (IG) in medical schools across the country. This includes a Medical Student PMR-IG Database
  • Updated RFC policies
  • Extensive review of AAP website and recommended changes that would enhance user experience
  • Mega Issues White Paper series: 1st paper submitted to AAP Board of Trustees for review and approval

Not resting on these laurels, we have some exciting projects lined up for 2017:

  • Health and Wellness Podcasts available for download on iTunes
  • PM&R Educational Video Series
  • PM&R Trivia Night at the AAP Annual Meeting in Las Vegas
  • Proposals for a new PMR Administrative Leadership Track in Residency Training

Readership for Physiatry in Motion, the RFC newsletter, continues to grow as we reach more than 800-plus medical students, residents and fellows across the country. On the international front, we have continued interests from international colleagues and trainees abroad. With the AAP slated to host the International Society of Physical and Rehabilitation Medicine World Congress in 2020, we hope to foster more collaborations overseas and welcome contributions from our peers, globally. As we leap forward into the future, 2020 marks the next calendar leap year and we hope with it comes many great tidings for PM&R.

We are grateful to the AAP Board of Trustees for their steadfastness, mentorship and tireless advocacy on behalf of academic PM&R and addressing trainee’s concerns as voiced by the RFC. Together, we gaze upward as we lift our specialty skywards and beyond. May the circle of love for what you do for our patients remain unbroken and may you find in our submissions much that entertains, educates and enlightens.

Wishing you and yours happy holidays and many blessings in the coming new year!

Charles A. Odonkor, MD, MA, RFC Chair, 2016-2017

Charles A. Odonkor​ is a senior resident in Physical Medicine and Rehabilitation and Armstrong Institute Fellow at the Johns Hopkins University School of Medicine.

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Applied VR at Cedars-Sinai Center

Exploring Virtual Reality: A Promising Tool in Rehabilitation Medicine

By Kevin Pelletier, MD

Earlier this year I had the unique opportunity to explore an underwater shipwreck. As I made my way around the wooden deck I saw an assortment of sea creatures inhabiting parts of the ship clearly never intended for such purposes. To my amazement, I even stumbled upon what appeared to be an ornate chest—a treasure chest perhaps?—I will never know, because what I saw next commanded my undivided attention. An enormous blue whale emerged from the adjacent darkness and bellowed as it swam dangerously close—its fin almost clipping my head [1].

At this point you might be saying to yourself “this story cannot be real.” Well, technically you are right—but to me it almost was. What I have described was my first experience with immersive virtual reality (VR). After putting on a head-mounted display and earphones, I felt fully immersed in the 360-degree audio-visual environment. It truly gave me goosebumps at the time and does so even now when recalling the experience. Immediately I began imagining the different ways this technology could be applied.

theBlu experience

The first thing that came to mind was that VR could transport patients with long hospital stays and life-altering prognoses to a tropical island, or flying through the sky like Super Man as a means of diversion. My next thought was how exciting it would be to use this cutting-edge technology as a tool for rehabilitation.

Vourvopoulus and Bermúdez I Badia published an article in the Journal of NeuroEngineering and Rehabilitation in August of this year on the use of VR as a means of stimulating sensory-motor networks in the brain. The participants wore a head-mounted display and earphones. They saw a virtual hand turning a crank which slowly opened a garage door. Meanwhile they heard sounds of a chain pulley system and the movement of a large metal door. Participants were then instructed to use mental imagery (i.e., to imagine they were performing the action without physically doing so) while experiencing the VR environment. The same participants were later asked to use mental imagery of the above motor task without using VR. EEGs were recorded throughout to measure electrical activity in the sensory and motor cortices.

They found that VR, in addition to mental imagery, produced brain patterns which more closely resemble those present during overt motor execution. Since motor imagery has been previously shown to help restore active movement through stimulation of sensory-motor networks [2], the results of the above study suggest that the addition of VR may be able to do so more effectively given that the combination was able to augment the electrical activity in the same regions of the brain [3]. Namely, repeated stimulation of the sensory-motor networks of the brain have the potential to induce neuroplastic changes such that a patient could regain function.

References

  1. Top image, Applied VR at Cedars-Sinai Center. Webhorse Digital Media. (c) 2016. Available here, posted 6/24/2016
  2. Experience provided by HTC Vive’s VR hardware running ‘theBlu: Encounter’ demo.
  3. García Carrasco D, Aboitiz Cantalapiedra J. Effectiveness of motor imagery or mental practice in functional recovery after stroke: a systematic review. Neurologia. 2016 Jan-Feb;31(1):43-52. doi: 10.1016/j.nrl.2013.02.003. Epub 2013 Apr 17.
  4. Vourvopoulos A, Bermúdez I Badia S. Motor priming in virtual reality can augment motor-imagery training efficacy in restorative brain-computer interaction: a within-subject analysis. J Neuroeng Rehabil. 2016 Aug 9;13(1):69. doi: 10.1186/s12984-016-0173-2.
  5. Hyungjun Im, MD et al. Virtual Reality-Guided Motor Imagery Increases Corticomotor Excitability in Healthy Volunteers and Stroke Patients. Ann Rehabil Med. 2016 Jun; 40(3): 420–431. Published online 2016 Jun 29. doi: 10.5535/arm.2016.40.3.420.
  6. Ana R.C. Donati et al. Long-Term Training with a Brain-Machine Interface-Based Gait Protocol Induces Partial Neurological Recovery in Paraplegic Patients. Sci Rep. 2016; 6: 30383. Published online 2016 Aug 11. doi: 10.1038/srep30383.
  7. AppliedVR Brings Therapeutic Virtual Reality Content To Cedars-Sinai Medical Center. mHealthTimes.
  8. Medical applications of VR is a burgeoning area of research and development, yet our knowledge of how best to apply this groundbreaking technology is still in its infancy. Given promising research and its vast potential for entertainment, I believe VR will be a welcomed therapy modality for a wide variety of patients.
Kevin Pelletier, MD

Kevin Pelletier is a second-year resident in Physical Medicine and Rehabilitation at the University of California Irvine.

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The New York Society of PM&R: A Resident’s Experience

By Sean Bemanian, MD

Initially founded in 1921, the New York Society of PM&R is a pillar of the physiatric experience in New York City. The society has strongly advocated for physicians and patients since its inception. Attendings, residents, and medical students gather for monthly lectures on the first Wednesday of each month at NYU Langone Medical Center. Talks are given by nationally and internationally known speakers. Board committee members meet monthly to discuss pressing issues that arise and plan for future events and activities. Meetings are followed by a networking happy hour in Midtown, where members interact with residents and fellows from nearly all PM&R programs in the NY/NJ area.

Just like many medical students I was introduced to PM&R during clinical rotations. After learning about the society from a few mentors, I was immediately drawn to the comradery and personable nature of its members. The gatherings provided a warm and friendly environment for medical students to become acquainted with the field of rehabilitation medicine. During residency, I continued my participation as a member of the legislative committee. The committee participates in advocacy events several times a year and updates members on governmental policy that specifically affect physiatrists. The annual Lobby Day draws members to the state capital in Albany to meet with elected representatives of the New York State Senate and Assembly. Meetings are conducted in small group sessions where physicians voice their concerns on central issues brought forth by doctors across New York State.

Residents and Faculty participants at the New York State Society Meeting

Throughout the academic year an array of educational activities are available for members. These include workshops conducted for musculoskeletal ultrasound, prosthetics and orthotics, as well as spasticity management. Residents also have monthly board review lectures and an annual mock oral board exam. Acute medical coverage is provided for a variety of sporting events, including the Special Olympics and the NYC Marathon. The annual Career Fair allows residents to meet with fellowship directors and job recruiters to learn about opportunities available post-residency. Research night is a platform for programs to highlight their commitment to research and for members to present their findings in a collegial environment. Finally, the Rehab Bowl is a competitive contest to determine which PM&R program takes home the trophy and claims bragging rights for the year.

State societies provide an engaging and interactive environment for exposure to rehabilitation medicine outside of residency training. Faculty attending are committed to providing mentorship and there are ample opportunities for networking and development of leadership and organizational skills. As the field of rehabilitation medicine continues to grow, getting involved will enrich the residency experience and provide a supplement to residency based learning.

Sean Bemanian, MD

Sean Bemanian is a third-year resident physician in Physical Medicine and Rehabilitation at the Kingsbrook Jewish Medical Center, Brooklyn, New York

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Improving the Lives of Patients with Hippotherapy: A Workshop on “Horses that Heal”

By Anne Kuwabara, Stanley Guillaume, & Samiran Bhattacharya

Introduction

“Walk on!” a boy confidently commanded. As directed, his 1,200-pound friend walked forward, keeping the boy safe and balanced on his back. This was not just any boy. This was a boy with cerebral palsy who had barely spoken more than a handful of words during his first five years of his life. This is just one example of the amazing work accomplished by the team at Maryland Therapeutic Riding (MTR). In collaboration with the team at MTR, the Physical Medicine and Rehabilitation (PM&R) Interest Group at Johns Hopkins School of Medicine hosted a workshop to educate medical students about the value of hippotherapy on November 12th, 2016.

Maryland Therapeutic Riding

Founded in 1996, MTR is a registered 501©(3) public non-profit organization that provides therapeutic options for children and adults with a range of physical, mental, and emotional challenges. Conditions served include: cerebral palsy, spina bifida, neuromuscular disorders, post-traumatic brain injury, autism, ADHD, and cognitive disorders. Program participants improve self-confidence, strength, balance, coordination, attention span, and language and social skills.

Utilizing certified instructors, licensed therapists, volunteers and specially trained horses, MTR provides two programs: Therapeutic Riding and Hippotherapy. In Therapeutic Riding, instructors use the horse as a conduit for achieving individualized therapy goals. Hippotherapy is derived from the Greek term hippos (horse). The term refers to therapy aided by a horse. Occupational, physical or speech therapists direct each highly structured, one-on-one session. Specialty programs are offered for veteran and active duty U.S. military wounded warriors, injured community-service personnel, and their families. MTR is a Premier Operating Center accredited by the Professional Association of Therapeutic Horsemanship International (PATH).

The Workshop

The day began with an overview of the program and personal experiences of program participants. Our group then proceeded to the stables. There, we were guided around the 25-acre farm by staff members and shared some nuzzles with a few horses from the herd. We observed riders as they saddled up and participated in their sessions. The transformations we saw were inspiring. On their steeds, children sat beaming with confidence, remarkable posture, and most importantly big smiles on their faces. Before our very eyes, the horses became extensions of the riders. We could appreciate the continued mastery of balance, strength, self-confidence and happiness. Several months ago, these same children could barely even stand, walk, or talk. The bond they made with the horses was transformative and bestowed the skills to live the life they had envisioned. These successes were expertly facilitated by the teamwork and passion of certified instructors, licensed therapists, and volunteers.

The Relationship to Physical Medicine and Rehabilitation

Programs such as hippotherapy define the philosophy of PM&R. The field of PM&R began in the 1930s and gained momentum after World War II to help restore the lives of returning veterans with disabilities. The American Board of Medical Specialties approved it as a specialty in 1947. Physiatrists specialize in designing comprehensive, patient-centered treatment plans to maximize function, performance and quality of life (medically, socially, emotionally, and vocationally) for patients after injury or disease. We focus not on one organ system but instead on patients as a whole in the context of his or her environments. Throughout our medical training, we often treat patients with the goal of being disease-free. However, in PM&R, we shift the goal towards treating patients to go beyond disease-free. We help patients work towards improved performance and quality of life. Our students were impressed by the effectiveness of this novel therapeutic option and approach. After this workshop, hippotherapy and the prioritization of patient performance and quality of life will be a part of our students’ repertoires for the care of future patients.

Future Directions

Share information about this life-changing therapy with your community to reach those who may benefit. Physicians can refer patients for hippotherapy. However, the therapy is not typically covered by insurance at this time. Research trials are currently being done to validate this form of therapy.

Take an opportunity to visit a hippotherapy center nearby. We know it will be as much of an enlightening experience for you as it was for our group. For more information on hippotherapy and on how to locate a PATH-accredited hippotherapy center near you:

  • http://www.horsesthatheal.org/
  • http://www.pathintl.org/
  • http://www.americanhippotherapyassociation.org/

Stanley Guillaume, Anne Kuwabara, and Samiran Bhattacharya are students at Johns Hopkins School of Medicine and members of the school's Physical Medicine and Rehabilitation Interest Group.

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Virtual Reality: An Alternative Prescription to Painkillers

By Brian Mayrsohn

Oculus Rift, source: https://www.oculus.com/press-kit/hardware/

According to the Medical Expenditure Panel Survey, about 100 million adult Americans live in pain. Prescription medications are very successful in blunting the perception of pain, however adverse effects are broad. To name a few, they include constipation, nausea, lethargy and not uncommonly, death. In 2014, 2 million Americans abused or were dependent on opioids and 160,000 have died since 1999. The need for alternative treatments for pain is evident. Early research into the utilization of virtual reality (VR) for both acute and chronic pain is promising.

The theory behind VR’s mechanism of action is firmly embedded within principles of psychology. By diverting attention away from a pain sensation towards a competing stimulus, such as a video screen that engages the body and senses through an immersive experience, the brain can refocus attention towards an enjoyable experience, and consequently the pain pathways are attenuated. A study published by Johnson and Coxon demonstrated the impact targeting two versus one sense had on pain tolerance. The study looked at 27 healthy volunteers and submerged their non-dominant hand in freezing water (around 1⁰ C or 33⁰ F). They had participants wear a head mounted display (HMD) and noise-canceling headphones. The study used a within-participant design, and obtained baseline pain data by applying freezing water without the HMD or music. They then exposed each participants to each variable: an immersive driving game with music, the immersive driving game without music, and no immersive game with music. The results demonstrated that the immersive content without sound and sound alone were able to significantly decrease pain as compared to the baseline. Furthermore, the combination of immersive content and sound had the greatest significant impact on pain tolerance. These interesting findings allude to the power of combining the senses in unique ways to refocus the brain for overcoming a painful experience.

A study by one of the leading experts in the field, Dr. Hunter Hoffman, compared an active VR experience (SnowWorld) versus no VR experience, demonstrated a statistically significant decrease in overall worst pain, time spent thinking about pain, and unpleasantness of the pain in the active VR experience group. Furthermore, the study included fMRI data for each participant and showed a decrease in pain-related brain activity in the anterior cingulate cortex, primary and secondary somatosensory cortex, insula and thalamus. The fMRI studies also showed an increase in activation of the prefrontal cortex. These findings are consistent with those of prior studies that utilized the counting Stroop test to show significantly diminished pain intensity scores by subjects performing a mentally taxing task resulting from cognitive-interference. A counting Stroop differs from the traditional Stroop test in that it asks participants how many words appear on the screen regardless of the meaning of the words. In a traditional Stroop example, the participants are shown a word that specifies a color; however, the actual color of the text may differ from what the word specifies, but the correct answer is the color the word specifies.

Examples of single trials for the two types of stimuli. Both sets of word stimuli are common words from a single semantic category. During ‘neutral’ trials, common animal names (dog, cat, bird, or mouse) are used. During ‘interference’ blocks, the words consist of number names (one, two, three, or four). In both examples, the correct answer would be to press button number 4. Bush et al 2006, used under license by NPG.

In a study published in Cyberpsychology, Behavior, and Social Networking, investigators created three groups and immersed all participants’ non-dominant hands in freezing water temperatures. One group had a Virtual Reality experience that displayed objects that defied the law of physics, another displayed sharp objects with irritating sounds that were intended to symbolize pain, and the last group had no VR experience. Participants in the sharp object and irritating sound group were instructed to manipulate the objects so the edges became rounded and the sounds became more peaceful. The results showed that those that had control over the objects reported having an increased sense of self-efficacy for tolerating pain and for reducing pain intensity. Without overstating the benefit, this study suggests that VR interventions can have a positive impact on cognition and augment pain-coping skills, which ultimately may lead to an increased ability to tolerate a lower amount of pain medications or remove the need completely.

The pain reducing ability of VR has also been observed in chronic pain patients as well. In a study by Jones, Moore & Choo (currently in review for publication) it was found that among chronic pain patients who played the VR game Cool!, 94% of patients had at least some pain relief during the VR experience and 92% had at least some relief after the experience had completely finished. This finding suggests that VR’s effects may last beyond the period of application in a similar fashion to a medication; however, the “half-life” is still unknown.

VR has shown to be therapeutic for burn patients too. One study assessed VR’s application during wound debridement and found a statistically significant decrease in visual analog scale pain scores over the first three sessions of wound debridement. By decreasing the pain of this procedure, patients’ outlook can be positively impacted which can have implications for mood, motivation, and overall satisfaction. Studies such as these that explore the various use cases for VR are paramount. While VR’s application in healthcare is very exciting, there is a strong need for further research to substantiate these early findings and validate the efficacy, dosing, content, adverse effects, and additional use cases.

References

  • http://www.nature.com/nprot/journal/v1/n1/full/nprot.2006.35.html
  • http://rsos.royalsocietypublishing.org/content/3/3/150567
  • https://www.ncbi.nlm.nih.gov/pubmed/15167542
  • http://brain.oxfordjournals.org/content/125/2/310.short
  • https://www.ncbi.nlm.nih.gov/pubmed/21685651
  • https://www.ncbi.nlm.nih.gov/pubmed/24892197

Brian Mayrsohn is a fourth year medical student pursuing a career in Physical Medicine and Rehabilitation. He is interested in the applications of emerging and existing technologies to the medical field.

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AAP News & Physiatry in Motion published on Medium

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The AAP 2017 Annual Meeting is in Las Vegas on February 7-11, 2017

94% of past attendees would recommend the AAP Annual Meeting to their colleagues and AAP 2017 Las Vegas is no different. Physicians, residents, and other PM&R professionals from around the globe are making plans to attend the 2017 AAP Annual Meeting in Las Vegas, February 7-11, 2017 - don't miss out on the 'can't miss' physiatry event of 2017!

Registration includes ALL educational and networking events including the President's Welcome Reception, two Poster Gallery Receptions, the Resident/Fellow Trivia & Networking Night and complimentary breakfast, lunch, and coffee breaks throughout the meeting.

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