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Physiatry in Motion Issue #12, Autumn 2018

Updates from the AAP RFC Chair

By Allison Bean, MD, PhD

For information on Physiatry '19, please click the hyperlink below.

https://www.physiatry.org/page/Abstracts2019

The official announcement for abstract acceptances for Physiatry ’19 went out last week and we are excited to welcome a record number of PM&R trainees to the beautiful island of San Juan, Puerto Rico from February 19–23, 2019! The number of abstracts submitted has continued to rise, and more importantly, research abstracts increased dramatically this year. We hope that these experiences will encourage physiatrists to continue to perform high quality research throughout their careers, driving the field forward in the future.

The resident/fellow/medical student program for Physiatry ’19 is set to be the best yet! The incredibly popular half procedural skills workshop will be held again on Wednesday, February 19. Be sure to sign up for this hands-on experience when registering for the meeting. Additional workshops will cover important topics including how to get involved with research at any stage of training, writing wheelchair prescriptions, and solving challenging cases in ASIA classification. Career pearls sessions including advice on job/contract negotiations as well as roundtables with fellowship program directors will arm trainees with important information for the next stage of their careers!

The number of medical students interested in PM&R is growing rapidly! The inaugural AAP Medical Student Council has put together a series of sessions with program directors and residents on Saturday, February 23 to guide medical students towards success on their PM&R rotations and in the residency match.

The annual meeting also marks the time for transition in the RFC leadership. Neal Rakesh will be taking over RFC Chair duties, but all other positions are open and we are eager to welcome in a new group of leaders! This year, instead of written statements, we are asking applicants to submit a short video (2 minutes) introducing yourself and describing why you want to join the RFC. The video should be filmed in a single shot of you speaking in front of the camera — no props, fancy animation, special guests, or post-processing! We will be highlighting these videos on social media in the weeks leading up to the meeting, and encourage all AAP resident/fellow members to cast their votes. Position descriptions can be found here. Applications can be submitted online and are open now through December 31st. You must be present at the official election session at Physiatry ’19 to be eligible.

Finally, we are excited to announce that the Resident and Fellow Section of the American Journal of Physical Medicine and Rehabilitation is officially accepting submissions! Check out the author guidelines and submit your articles for peer-reviewed publication today!

The RFC is dedicated to representing all residents and fellows. Please let us know if you have any questions or comments about what we can do to help you grow into the future leaders in physiatry by emailing us at residentfellowcouncil@gmail.com or posting on the RFC forum.

You can also find out more information about the RFC on the AAP website and on social media!

Website: http://www.physiatry.org/page/AbouttheRFC

Facebook: AAP Residents/Fellows/Students

Instagram: @aaphysiatrists

Twitter: @AAPhysiatry_RFC

Allison Bean, MD, PhD is the 2018–2019 Chair of the AAP Residents/Fellows Council and a PGY-4 Chief Resident in the Department of Rehabilitation Medicine at the Icahn School of Medicine at Mount Sinai. Follow her on Twitter: @AlliBeanMDPhD

Developing a Career in General Physiatry: An Interview with Dr. Maria Twichell

By Marissa Pavlinich, MD

I connected with Dr. Maria Twichell, who is currently a general physiatry attending at the University of Pittsburgh Medical Center, to discuss her experiences pursuing general physiatry as a career.

What attracted you to general physiatry rather than a physiatric subspecialty?

I love the variety! Every day, I see patients with concussion, burn injury, recent polytrauma, stroke, amputation, critical illness myopathy, neuropathy, back pain, joint ailments, etc. Each case is so unique. I like having the first crack at management and procedures, but I’m also glad that I can refer the more complex patients to my specialized colleagues. Watching the daily improvement of the patients I get the privilege to treat is so rewarding.

Which factors did you find to be the most important in choosing your first general physiatry job?

I wanted a dynamic department with an excellent reputation that was growing and contributing to medical knowledge as well as the community. I envisioned working in a department that was well-integrated and respected by the surrounding health care system. I wanted a work environment that was supportive and collegial, where I could enjoy coming in every day. A degree of flexibility in order to balance my family’s schedule was also important to me.

What did you do early in your career that enabled you to define your patient population and recruit the types of patients that you were most interested in caring for?

Whenever possible, highlight your skillset. There are certain things I am not interested in doing—EMGs for example. I was able to discuss my preferences up front, then let my department chair know where I could contribute instead of doing EMGs. Efficient consults are within my skillset, but another colleague may not feel as comfortable in that role. In this way, you can further define your practice preferences.

In addition, don’t be afraid to market your skills to providers that could be referral sources. Showcase what you can do for their patients and reach out to them via the email or phone call to discuss specific cases. Close the loop. Word of good work spreads fast, so you can expect increased referrals if you provide excellent care and follow it up with feedback.

How do you maintain a balance between inpatient and outpatient medicine duties?

The secret is to be as efficient as possible so that the majority of your inpatient responsibilities and time-stamped documentation is completed prior to beginning outpatient clinic. Completing your outpatient notes during or just after clinic will reduce the amount of angst about closing your charts prior to restarting the next day. Your documentation will also be more accurate. Staying as close to caught up as possible is the key!

What do you like most about practicing as a general physiatrist?

As a general physiatrist, you get to define your own path. There is no patient population or practice environment that is out of your realm. You can choose how to evolve and grow over time.

What advice would you give to residents considering a general physiatry practice?

You absolutely are ready! It’s intimidating to think about being the most responsible provider (attending physician), but everything you have accomplished to this point has prepared you well. A strong residency program has provided you with the skills necessary to be an excellent general physiatrist. There is a learning curve, of course, but you never stop learning. Every patient you see is an opportunity to learn something, so take every day as a chance to enhance your knowledge, compassion, and skillset.

Marissa Pavlinich, MD is a PGY4 at the University of Pittsburgh Medical Center who is interested in interventional pain medicine.

Introduction to Pediatric Physiatry

By Naomi Kaplan, MBBS

As is often said, “Children aren’t tiny adults.” Pediatric physiatry has breadth and depth that few outside the field are familiar with. Pediatric physiatrists work in both inpatient and outpatient settings, providing care for children of all ages: from infants with torticollis to adolescents with cerebral palsy heading off to college. Caring for the disabled child with a patient and family-centered approach is at the heart of every pediatric rehab encounter.

Pediatric rehabilitation departments are sprinkled across the country and families often must drive many hours and miles for their child to be seen by a specialist. Outpatient departments often run clinics where children are seen by a physiatrist, multiple therapists, as well as providers from other pediatric sub-specialties (such as urology, orthopedic surgery and pulmonology). These monthly, or bimonthly, multidisciplinary clinics are particularly helpful in managing complex conditions such as cerebral palsy, spina bifida, neuromuscular conditions and limb deficiencies. “General” clinic appointments provide interim follow-up and allow specific problems to be addressed.

Procedures are an established part of pediatric physiatry, whether they be toxin injections, baclofen pump management or EMGs. Children present a unique challenge, not always being able to tolerate needle sticks and sometimes requiring oral or IV sedation. Toxin injection is being done under EMG, e-stim, and increasingly ultrasound guidance.

Children are still developing in all aspects of their being, from a cognitive, emotional, and physiological standpoint. Static insult or injury can have chronic effects, as the child continues to develop. Knowledge of normal pediatric developmental milestones is integral to the practice of pediatric physiatry.

There are many allied health professionals, not often seen in the adult realm, who provide enrichment and therapy for the pediatric patient, allowing the child to stay engaged in treatment, stimulated by their environment, and emotionally and psychologically grounded during chronic medical treatment and rehabilitation. These include, but are not limited to Child Life specialists, licensed massage therapists, music therapists and child psychology. Incentivization, through use of sticker charts, hospital “money,” and rewards, is a challenging but fun aspect of pediatric rehabilitation used to maximize participation and help achieve specific functional goals.

The importance of advocacy for the pediatric physiatry patient cannot be overstated. These patients are vulnerable with complex needs. Guardians have a responsibility to bring patients to their appointments. The team should help to facilitate clinic attendance by sending timely reminders and assisting with transportation barriers. Social workers are an important part of the pediatric rehab team, but the safeguarding of children is everyone’s responsibility. Cases of non-accidental trauma or abuse require input from all angles, to ensure safe discharge planning for the patient and appropriate documentation.

Pediatric physiatry is a field ripe with research opportunities, from bench work to clinical trials. Qualitative and quantitative research can be initiated, as well as quality improvement studies.

Pediatric rehabilitation is an expansive and rewarding sub-specialty with an opportunity for great career satisfaction. Maria Montessori once said, “Play is the work of children,” and pediatric physiatry is the path to play, function and quality of life.

Naomi Kaplan, MBBS, is a PGY-4 resident in PM&R at Zucker SOM at Hofstra/Northwell with an interest in pediatric rehabilitation.

The Role of PM&R in One Life

By Lisa Wiesenberger

My sister has a specific way that she walks. Her gait is unusual and one that I can immediately recognize. There is a sort of shuffling and dragging of the right foot that seems to slightly lag behind as she steps forward with her left foot. To a stranger’s eyes, it may appear that she has trouble walking, but in my eyes, I see the victory of rehabilitation medicine that made walking an improbable possibility.

My older sister, Selina, is a twenty-five year old with Down Syndrome who has an array of severe physical and developmental complications. She underwent two spinal surgeries for severe atlantoaxial instability and has spent most of her life wearing ankle foot orthoses (AFOs) to steadily improve her balance and gait over time. I grew up carefully watching how her care team, particularly her pediatric physiatrist, cared for Selina and nurtured her to become a strong, independent individual, both physically and mentally. Before my eyes, the physiatrists and physical therapists used their expertise and the latest technology in the field of physical medicine and rehabilitation to transform Selina’s musculoskeletal strength and coordination. Through the years I watched my sister progress from a wheelchair, to a walker, to her feet (still in AFO’s), and to the front stage to continue her love of dancing.

Selina 2001

As her sister, I witnessed the power of healing that physical medicine and rehabilitation can provide. This has instilled in me a deep appreciation for the role of PM&R in healthcare. PM&R goes beyond medicine and improves function, long term outcomes and quality of life. These are a few reasons why I believe PM&R is unique and why many of us are drawn to the field. It is a commitment to bettering the lives of patients in the way that it has for Selina.

Selina 2017

Lisa Wiesenberger is an MS3 at the Central Michigan University College of Medicine who is interested in PM&R.

The Role of Nutrition in Osteoarthritis

By Caroline Schepker, DO

Osteoarthritis (OA) is the fastest growing form of disability worldwide (1), and treatment options for symptomatic OA are fairly limited and often only provide temporary relief. Furthermore, OA has classically been considered a non-inflammatory arthritis while only rheumatologic arthritides were considered inflammatory in nature. However, recent research suggests an underlying low-grade inflammatory component to OA that may be rooted in chronic systemic inflammation and the metabolic syndrome (2,3,4). Furthermore, synovitis has recently been identified as a hallmark feature of OA. Other critical features likely involve subchondral bone as a source of inflammatory mediators, as well as the release of matrix metalloproteinases by cartilage in response to both systemic and localized cytokines and prostaglandins (5). Increased adiposity is associated with adipokine release and activation of pro-inflammatory interleukins. Hyperglycemia and high LDL cholesterol are also independently associated with systemic inflammation. These systemic metabolic derangements could possibly be playing a role in triggering pain attacks in patients with non-post-traumatic osteoarthritis.

The role of addressing systemic inflammation through lifestyle, particularly dietary modifications, dates back several thousand years to the advent of Ayurvedic and Traditional Chinese Medicine dietary practices, which have historically sought to address arthritis by eliminating foods that produce “heat” in the body and emphasize “cooling” foods. More recent research examining the effects of diet on the most inflammatory form of arthritis—rheumatoid arthritis (RA)—suggests that these age-old traditions might have had something right. There is an abundance of literature examining dietary interventions in rheumatologic diseases, given the high concordance of these conditions with gastrointestinal diseases such as IBD. Fraser et al. studied a group of RA patients who were advised to engage in “subtotal fasting”—they were allowed to consume a limited amount of vitamin and mineral supplementation, carbohydrate, and energy in the form of vegetable juice for one week. As compared with controls, this group was found to have decreased CD4+ lymphocyte activation and numbers—a process indicative of progression of RA. Their theory was that transient immunosuppression was able to suppress the pro-inflammatory process underlying RA (6). Michalsen et al. also showed clinical improvement in RA patients who underwent fasting protocols (7). Kjeldsen-Kragh et al. asked RA patients to fast for 7-10 days with partial nutrient intake of vegetable broth, herbal teas, parsley, garlic, potatoes, and juice extracts from carrots, beets, and celery. This period was followed by either one year of a 100% plant-based (vegan) diet or an omnivorous diet. The participants who followed the fast with a vegan diet demonstrated statistically significant clinical decreases in swollen and tender joints and pain, as well as blood markers of inflammation (ESR and CRP) (8).

Thomas et al. performed a literature review of the relevance of dietary interventions to OA management in 2018. This group found six modifiable nutritional factors that may be implicated in OA: adiposity/obesity, metabolic syndrome, type 2 diabetes, consumption of long-chain n-3 fatty acids, blood cholesterol levels, and vitamin K intake (9).

Adiposity and Obesity: Obesity increases axial load compression on weight bearing joints; over time, overweight and obese individuals are increasingly more likely to electively have a knee replaced than their normal-weight counterparts (10). Interestingly, higher BMI is also associated with higher risk for OA in non-weight-bearing joints as well—particularly the hand—which suggests a non-mechanical and perhaps inflammatory or biochemical etiology (11). One theory underlying the inflammatory role of fat tissue lies in adipokines—proteins secreted by adipocytes that trigger a cascade of pro-inflammatory cytokines. Leptin is a specific adipokine that is elevated in the postprandial state and is often chronically elevated in obesity. High blood levels of leptin are also independently associated with inflammation and cartilage degradation (12, 13).

Metabolic Syndrome: The metabolic syndrome is defined as the coexistence of central obesity, insulin resistance, dyslipidemia, and hypertension. The Research on Osteoarthritis/Osteoporosis Against Disability cohort (n=1384) showed increased radiographic incidence and progression of knee OA with accumulation of components of the metabolic syndrome; this was similarly observed in the Melbourne Collaborative Cohort Study (14, 15). Possible mechanisms underlying this correlation include increased systemic inflammation, higher axial compression/weight bearing secondary to increased BMI, and impaired blood flow to microvasculature in the setting of dyslipidemia and atherosclerotic disease, which may ultimately prolong and impair healing and repair from the daily wear-and-tear on bones and soft tissues of the musculoskeletal system.

Type 2 Diabetes: Impaired glucose tolerance and prolonged, chronically elevated blood sugar results in accumulation of AGEs, or advanced-glycation end products—proteins and lipids that become glycated when exposed to sugars. AGEs are believed to play a role in the pathogenesis of many degenerative diseases including atherosclerosis, chronic kidney disease, and neurodegenerative diseases. AGEs induce a pro-coagulant state, vasoconstriction, pro-inflammatory cascades, free radical formation, and lipogenesis. A German cohort study found type 2 diabetes to be an independent risk factor for severe OA, as well as a predictor for knee and/or hip replacement (16). A subsequent French study assessed patients with knee OA over 3 years; type 2 diabetes was again a statistically significant predictor of reduction of joint space width in men (17).

Dietary lipids: Interestingly, dietary lipids can make their way into the matrix and chondrocytes of articular cartilage and act as a source of inflammation—a study by Plumb et al. found high levels of pro-omega-6 fatty acids, precursors to pro-inflammatory eicosanoids, in cores of cancellous bone taken from the femoral heads of patients undergoing orthopedic surgery to address OA (18). Furthermore, in individuals with knee OA, a positive correlation has been identified between serum levels of the omega-6 polyunsaturated acid arachidonic acid and synovitis; conversely, an inverse relationship has been identified between serum levels of omega-3 docosahexaenoic acid (DHA) and patellofemoral cartilage loss as measured by MRI (19). Finally, a larger prospective study of OA patients found that higher intakes of both total fat and saturated fat were associated with increased radiographic evidence of knee joint space loss (20). The Western diet typically boasts a high ratio of omega-6 to omega-3 fatty acids, which may predispose individuals to inflammation. Arachidonic acid, a metabolite of omega-6 fatty acids, is pro-inflammatory and typically sourced from animal fats such as meats, dairy, and eggs, as well as some vegetable oils—namely safflower and sunflower oil. EPA and DHA, anti-inflammatory metabolites of omega-3 fatty acids, are predominant in walnuts, flaxseeds, and algae- or fish-based oil supplements.

Cholesterol: Dyslipidemia has long been identified as an independent risk factor for OA—backed by several epidemiologic studies (21, 22, 23). An Australian cohort of healthy middle-aged women found that, for every 1 mmol/L increase in total serum cholesterol, the adjusted odds of developing a bone marrow lesion were 1.84 (24). Statin use seems to ameliorate some of the symptoms of OA—a 10-year longitudinal study in a cohort of 16,609 participants found that increasing statin dose in dyslipidemic patients was associated with decreased clinical features of OA (25). Statin use was also found to be associated with improved imaging findings—resulting in over 50% reduction in radiographic progression of knee OA (26). It is possible that this effect could be mediated not only by the LDL-reducing effects of statins, but also by their anti-inflammatory effects; statins have been shown to reduce expression of inflammatory cytokines and exert chondroprotective effects—with atorvastatin in particular inhibiting interleukin 1B and matrix metalloproteinase 13 in vitro (27). The mechanisms underlying the interplay between serum cholesterol and OA are unclear—but cholesterol, like fatty acids, has also been found to accumulate in the articular cartilage of individuals with OA, and high LDL in particular may play a direct role in triggering synovitis and subsequent osteophyte formation (28). Statins may not be necessary; dietary and exercise interventions alone can have dramatic affects on lipid profile. Strategies include restricting saturated fat to 11% or less of total energy, generous consumption of soluble fiber, moderate consumption of soy protein (25g/daily), and a dietary foundation in plant sterols and stanols—found in virtually all whole plant-based foods. In fact, there appears to be a dose-effect relationship between plant stanols and LDL cholesterol, with 9-10g of daily stanols lowering LDL cholesterol by 18% (29).

Vitamin K: Vitamin K is involved in bone and cartilage mineralization, and is largely obtained in the diet from green leafy vegetables (vitamin K1) and bacteria (vitamin K2). Suboptimal vitamin K intake may cause decreased carboxylation of vitamin-K dependent proteins, which induce anabolic processes in bone and cartilage (30). In several longitudinal studies, individuals who were deficient in vitamin K were more likely to have articular cartilage and meniscal damage in the knees (31, 32). Only one randomized, controlled trial examining the effect of vitamin K supplementation on OA exists—and although it failed to find a beneficial effect of supplementation on progression of OA, only a small percent of the cohort was truly vitamin K deficient at baseline. Within that small group, those who achieved therapeutic blood levels demonstrated 47% less joint space narrowing at follow-up (p = 0.02)(33).

Conclusions: Osteoarthritis, which was once believed to be a pure reflection of years of mechanical wear-and-tear on joints, is in reality a complex degenerative disease that likely has roots in the underlying health of the individual. OA risk factors may be even more heavily modifiable than many clinicians consider or address with their patients. Chronic, low grade systemic inflammation from diet and adiposity; suboptimal blood flow secondary to increased viscosity from hyperglycemia and hypercholesterolemia; subtle underlying nutritional deficiencies that hamper optimization of growth and repair mechanisms; research has only begun to scratch the surface of the many factors at play. However, when taken as a whole, many of these modifiable risk factors can be addressed in the same way: by prioritizing a whole foods and plant-rich diet—one that is relatively low in energy density to support normalization of weight, high in fiber and plant sterols/stanols to promote healthy blood lipid levels, and high in leafy greens and omega 3 fatty acids to support optimal micro- and macronutrient intake. In 2015, a six-week, prospective, randomized study of 37 patients aged 19-70 with symptomatic OA found statistically significant improvements in self-reported energy, physical functioning, joint mobility, and pain in the group randomized to a whole-foods plant-based diet as compared with participants who ate their usual diets (34). As we progress in our understanding of the complex underlying biochemical and endocrinological underpinnings of this disease, we just may come to appreciate the efficacy of the simplest of approaches to symptom management and the slowing of disease progression.

References

(1) Conaghan PG, Porcheret M, Kingsbury SR et al. Impact and therapy of osteoarthritis: the Arthritis Care OA Nation 2012 survey. Clin Rheumatol 2015; 3:1581.

(2) Sturmer T, Brenner H, Koenig W, Gunther KP. Severity and extent of osteoarthritis and low grade systemic inflammation as assessed by high sensitivity C reactive protein. Annals of the Rheumatic Diseases 2004; 63:200-205.

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