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Physiatry in Motion ISSUE #10

Updates from the AAP RFC Chair

By Allison Bean, MD, PhD

Past (2017–2018) and present (2018–2019) members of the AAP Resident/Fellow Council

The first AAP Annual Meeting I attended was in 2014 in Nashville, TN during my third year of medical school. Sitting in the Resident/Fellow Council (RFC) town hall and elections, I was astounded by the residents’ passion to move the field of physiatry forward and their dedication to accomplish their goals by working together.

Serving as RFC Vice Chair last year was an incredible honor as I had the opportunity to work with a talented group of residents and fellows who accomplished a great deal in their year of service. However, while leading the RFC Town Hall at Physiatry ’18 in Atlanta, GA, I realized that many of these achievements were unknown to AAP members outside of the RFC and AAP leadership. As RFC chair I hope to resolve this disconnect by providing regular updates on the RFC’s work, and also to encourage others to share their ideas on what the AAP and the RFC can do to improve the PM&R trainee experience.

Going forward, we will provide quarterly updates on the RFC’s activities within each issue of Physiatry in Motion. Below are highlighted just a few of the many projects that the RFC has been actively working on:

  • Last year, the RFC successfully brought a proposal to the AAP Board of Trustees to establish the first national medical student council for PM&R. The inaugural AAP Medical Student Council was selected in January 2018 from a large number of impressive applications. This outstanding group has gotten off to a flying start with many initiatives underway to expand medical student exposure to the field of PM&R. You can find out more about the AAP Medical Student Council and it’s members here (http://www.physiatry.org/page/MedStudentCouncil).
  • The RFC has also launched a new medical student mentorship program, pairing medical students with residents from around the country. If you are a medical student interested in mentorship or a resident interested in serving as a mentor, please email our Medical Student Affairs Representative, Wyatt Kupperman, at wyatt.kupperman@sinai.org.
  • Dr. Walter Frontera, Editor-in-Chief of the American Journal of Physical Medicine and Rehabilitation has announced the creation of a Resident-Fellow Corner section of the journal. The RFC has been working closely with Dr. Frontera and the Resident-Fellow Corner Faculty Mentor, Dr. Dinesh Kumbhare, on developing this proposal which we hope will increase trainee involvement in academic peer review and publishing. The call for applications for residents and fellow editors has just completed, and the selected editors will be announced in the coming weeks. Be on the lookout for the official call for article submissions to start in the summer! All medical students, residents, and fellows will be encouraged to submit original articles related to PM&R education and training in a variety of formats.
  • Finally, the RFC is excited to announce the creation of a new RFC Forum. We hope that this discussion board will serve as a hub for all physiatrists-in-training to ask questions and find answers about anything related to residency programs and fellowship, as well as provide the RFC with feedback on how we can better serve our peers. One of our favorite things about the AAP Annual Meeting is having the opportunity to find out more about how other programs operate, allowing us to bring ideas back to our own institutions to improve our training. We hope that the RFC forum will provide an opportunity to keep these conversations going throughout the year, as well as foster collaborations in research and other leadership activities among trainees. Please check out the forum here (http://pmrresisandfellows.freeforums.net/). We recommend registering as a member with the email address you utilize for your AAP membership for administration approval.

These are just a few of the many projects the RFC is currently working on. We will continue to highlight our efforts throughout the year with quarterly updates in Physiatry in Motion. You can also find resources and stay up to date on our activities through our website and social media outlets:

  • Website: http://www.physiatry.org/page/AbouttheRFC
  • Facebook: AAP Residents/Fellows/Students
  • Twitter: @AAPhysiatry_RFC

If you have any other feedback or ideas for the RFC, feel free to post on the RFC Forum, or email us at residentsfellowcouncil@gmail.com. We look forward to hearing from you!

Allison Bean, MD, PhD is the 2018–2019 Chair of the AAP Residents/Fellows Council and a PGY-3 Chief Resident in the Department of Rehabilitation Medicine at the Icahn School of Medicine at Mount Sinai. Follow her on Twitter: @AlliBeanMDPhD

The Interplay Between Intestinal Microbiota & Bone Health

By Nadia Zaman, DO

Intestinal microbiota describes the myriad of microorganisms that reside in the human intestine, developing at birth and changing over time as a result of diet, inflammation, environmental exposure and antibiotic administration (1). It is thought to be comprised of 1014 bacteria, representing more than 5000 species and over 5 million genes (2). Intestinal dysbiosis, which is defined as a shift in the microbial constitution of the gut to an unhealthy state, has been linked to a wide range of disorders, such as diabetes mellitus type 2, obesity and inflammatory bowel diseases (IBD). Recent studies have started to look at the relationship between the gut microbiome (GM) and bone health, as well as its link to musculoskeletal problems such as osteoarthritis (OA) (1). OA is a common arthropathy, affecting over 30 million American adults. The development of OA can lead to decreased functional mobility and gait impairment over time, often leading many individuals to pursue joint replacements after other more conservative management strategies fail to stave off longterm debilitation. Until recently, how GM affects bone physiology and health was largely ignored, but scientists and clinicians alike have begun to look at how dietary changes, such as the administration of pre- and probiotics, can lead to changes in bone health.

Numerous animal model studies have shown that the oral administration of probiotics to arthritic rats and germ-free mice led to reduced expression of pro-inflammatory cytokines1 and increase in trabecular bone volume (3,4, respectively). Human studies looking at the use of probiotics still remain to be completed; however, a one-year RCT looked at the use of a prebiotic called inulin in adolescent girls and found that girls who were supplemented were found to have greater bone mineral density on DEXA scanning (2,5). There has also been a link associated between spondyloarthritis and gut inflammation in humans, such as ankylosing spondylitis and IBD (4).

Pre- and probiotics are generally considered safe to consume with little to no adverse effects and are ubiquitous in their availability to the general population. Prebiotics are non-digestible fibers that are found in many fruits and vegetables, such as leeks, asparagus, chicory root, onions and bananas (1,3). Bacteria of the genera Lactobacillus, Bifidobacterium, Escherichia, Enterococcus and Bacillus are considered probiotics and can be found in appropriate amounts in dairy products, such as yogurt, as well as in powder and tablet forms (3). As more evidence comes to light, physicians are turning to multidisciplinary approaches to treating arthritic patients, often using anti-inflammatory diets rich in pre- and probiotics as part of the strategy to further enhance bone and cartilage health.

There is still much to be learned about how GM is linked to musculoskeletal health, but the research already conducted has shown promising results that by altering GM through dietary modifications, one may be able to provide patients an alternative treatment plan for arthritic processes.

References

1. Steves CJ, Bird S, Williams FM, Spector TD. The Microbiome and Musculoskeletal Conditions of Aging: A Review of Evidence for Impact and Potential Therapeutics. J Bone Miner Res. 2016;31(2):261–9.

2. Weaver CM. Diet, gut microbiome, and bone health. Curr Osteoporos Rep. 2015 Apr;13(2):125–30.

3. McCabe L, Britton RA, Parameswaran N. Prebiotic and Probiotic Regulation of Bone Health: Role of the Intestine and its Microbiome. Curr Osteoporos Rep. 2015 Dec;13(6):363–71.

4. Hernandez CJ, Guss JD, Luna M, Goldring SR. Links Between the Microbiome and Bone. J Bone Miner Res. 2016 Sep;31(9):1638–46.

5. Abrams SA, Griffin IJ, Hawthorne KM, Liang L, Gunn SK, Darlington G, et al. A combination of prebiotic short- and long-chain inulin-type fructans enhances calcium absorption and bone mineralization in young adolescents. Am J Clin Nutr. 2005; 82:471–6.

Nadia Zaman, DO, is a PGY-3 physiatry resident at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, with an interest in Sports Medicine.

Gone Fishing

Gone Fishing at the Allegheny River in Pittsburgh

By Char Subrick, MPT, PT

A common request from administrators that I have heard throughout my 27 years as a physical therapist is to come up with an idea that is out of the box. Well my idea is more like out of the shipping crate. While sitting in my community college fishing class, I realized that a lot of my rehabilitation patients had something in common when asked, “What do you like to do for fun?” The answer is FISHING! So why not come up with a fishing outing? That is how my program “GONE FISHING” was born.

Gone Fishing is an interactive patient outing program that allows Rehabilitation patients and their family members to leave the hospital, adventure to the shores of the Allegheny River, and truly experience life in the community. Under the watchful eyes of therapy staff, participants encounter uneven sidewalk surfaces, street crossings, public transportation stations and many other obstacles on their journey to Pittsburgh’s North Shore, in addition to a river fishing experience with equipment adapted to meet their needs.

Our initial budget for this program was less than $10.00 to cover cost for water and popsicles that we enjoyed at the end of the trip. Our fishing equipment and bait were borrowed from a local fishing club. A suggestion was given to try to win a $10,000 Frontline Innovations Beckwith Grant so we applied and to our surprise… we won! With our new funds, we were able to purchase a variety of adaptive fishing equipment including hand and arm bracing, battery operated one hand push button fishing reel and rod, a chin controlled reel, a sip and puff reel and additional equipment.

Feedback we received from our patients and families has been tremendous. They were especially thankful for the opportunity to experience the outside world with a therapist in order to brainstorm any difficulties they may encounter when they return home. At that time, I realized what a tremendous program I had developed. Although the program involved community reentry activities and demonstrated that leisure activities were still possible after a life changing disability, the program also gave these individuals and their families HOPE…. Hope to continue living their lives.

As Martha Stewart would say, “That’s a good thing!” <:))))))))><

Char Subrick MPT, PT, is a senior physical therapist at The Rehabilitation Institute, UPMC Mercy Hospital, Pittsburgh PA.

Positive Reinforcement

By Allison Schroeder, MD

Many residents have had the experience of trudging through a busy day: working hard, hoping that you are providing good patient care, and hoping to live up to the standards of your attending physician. We have all probably experienced (or at least dreamed of) an ideal situation where these busy days of rounds, notes, staffing, admissions, notes, discharges, and, did I mention, notes(?) seemed to fly by, and possibly even be enjoyable.

What is the difference between these two situations? I would argue that the work environment plays a role: When you are surrounded by others who have a positive attitude in an environment that encourages collaboration and open communication, these busy days are much more manageable and rewarding.

As a resident, one is frequently thrust into different work environments, where this contrast can be very apparent and often seemingly out of our control. This can sometimes lead to feeling like we are “just spinning our wheels” or to (the dreaded term) “burnout.”

How many times are we working hard day in and day out, just wishing that someone would acknowledge our efforts or at least validate our daily challenges? In an effort to continue to boost resident morale and offer positive reinforcement, our residency program started a monthly “Props for Docs” program, where residents can anonymously submit an acknowledgement of something that they noticed one of their co-residents did well. This initiative has allowed us to praise our colleagues for simple things that might otherwise have gone unnoticed. Overall, we feel the program has boosted resident morale and comradery.

It might seem obvious that making a habit of building up resident colleagues increases successful collaboration and teamwork. Additionally, this environment can be contagious. Positive reinforcement of nurses, therapists, and other staff can have similar benefits, making our day-to-day lives more enjoyable. Positive reinforcement, in the form of praising and acknowledging things done well, has been clearly shown to be effective in strengthening and improving desirable behaviors (1).

Incorporating positive reinforcement into our daily, weekly, and monthly lives can help to create a work environment that encourages open communication. A simple “thank you for ___; I really appreciate that because ____” to a nurse might make it more likely that he or she performs the same behavior next time. Additionally, acknowledging that your attending physician explained a difficult topic concisely while rounding, and thanking them for taking the time to do so, might lead to more teaching on rounds in the future.

Although what is discussed above may seem like a simple exercise in common sense, I challenge you to think about how often you are offering positive reinforcement on a daily basis. When you appreciate the work of others, do you think to yourself, “well, that was very nice of them,” or do you outwardly acknowledge their gesture? It doesn’t even need to be about something they do that is “above and beyond” what is expected. We’ve all had those days where we just need a pick-me-up — for example, someone to validate that we’re doing a great job going through the 1000 page stack of records from an outside hospital transfer…

We feel that the “Props for Docs” program has substantially boosted morale in our residency program. If you have any questions about the program, feel free to contact me at aschroe1@alumni.nd.edu.

1. P. Gohari, A. Ahmadloo, M. B. Boroujeni and S. J. Hosseinipour, “The Relationship between Rewards and Employee Performance,” Interdisciplinary Journal of Contemporary Research in Business, Vol. 5, No3, 2013, pp. 543–570.

Allison Schroeder, MD, is a PGY-2 in Physiatry at the University of Pittsburgh Medical Center with an interest in Sports Medicine.

PyeongChang 2018 Paralympic Games Help Revitalize Resident’s Enthusiasm for Medicine

By Danielle Saenz, MD

Danielle holding the Olympic Torch

Over the course of PM&R residency I have grown a strong interest in adaptive sport, so I naturally follow the Paralympic Games on social media. In December 2017, I noticed a posting for a competition sponsored by the International Paralympic Committee and Samsung to be a Paralympic “super fan blogger” which required a video submission in response to the prompt “Do What You Can’t.” I saw the posting and immediately knew that this opportunity was made for me because of my interest in adaptive sports, my background in video editing, and my knowledge of function and biomechanics of adaptive athletes. During my next shift on call at Schwab Rehabilitation Hospital, I rounded up the nurses, CNAs, and physical therapists to help film my application video. I edited the video over the next few days with feedback from a few trusted friends and then anxiously waited to hear back from the review committee. This contest truly aligned all of my interests (adaptive sport, travel, video editing, etc) and I am so glad grabbed the opportunity and ran with it.

I was beyond excited when I heard I won the opportunity to be a guest blogger at the PyeongChang 2018 winter Paralympics and the entire experience was absolutely the trip of a lifetime. I was there for a total of twelve days, which allowed me attend everything from Opening Ceremonies to Closing Ceremonies. The International Paralympic Committee was a wonderful host and graciously provided access to all of the venues so I was able to attend a wide variety of the sporting events at the PyeongChang 2018 Winter Paralympic Games. While attending the different events I would then create a video blog with the lens of a physiatrist and focus on either biomechanics, prosthetics or athletic performance. While on my trip I won the Best Blogger Award for blogger with the most views. I am happy to report that my rehabilitation focused video blogs on the topic of sit ski biomechanics and amputee snowboarding captured 93K views and 91K views respectively.

The Paralympic Games exhibit world class athletes and successful rehabilitation medicine for everyone involved. The athletes, family members, coaches, staff, and prosthetists are a team that makes up a group of global activists to support anyone living with compromised physical abilities. As a whole, the Paralympic movement is helping to create lives that are thriving with optimal function. As a physiatrist, I am leaving this experience grateful and motivated to be a part of the Paralympic movement and I more dedicated now that ever to help my patients achieve their highest goals. If you are looking for a way to revitalize your relationship with medicine, I highly recommend a trip to support the athletes in future Paralympic Games. You will not be disappointed.

For a full list of the videos visit: https://www.paralympic.org/pyeongchang-2018/samsung-bloggers/danielle-saenz

PyeongChang 2018 Samsung Bloggers — Danielle Saenz https://www.paralympic.org/pyeongchang-2018/samsung-bloggers/danielle-saenz

Danielle with Team USA

Danielle Saenz, DO is a third year PM&R resident at Schwab Rehabilitation Hospital in Chicago, IL with an interest in adaptive sports.

A Physiatric Approach to Pelvic Rehabilitation Medicine with Dr. Kelly Scott

By Julie Hastings, MD

Kelly M. Scott, MD is an Associate Professor in the Department of PM&R at the UT Southwestern Medical Center where she is the Medical Director of the PM&R Department’s Comprehensive Pelvic Rehabilitation Program. Dr. Scott is one of a very small number of PM&R physicians who specialize in the diagnosis, treatment and rehabilitation of pelvic floor disorders. I sat down with Dr. Scott to learn more about her approach to pelvic floor disorders and what residents should know about this PM&R subspecialty.

What led you towards your specialization in Pelvic Rehabilitation Medicine?

The short answer is that I tried it out in residency and liked it. The long answer is that it fit into what I was looking for in a practice. I liked the abstract concept of pain management — helping to alleviate suffering. But I just wasn’t seeing much improvement in most of the typical chronic pain patients. And then when I tried out pelvic clinic, I found that the patients were getting better in much larger numbers than the chronic back or neck pain patients, and it was very gratifying to be a part of that. Moreover, what drew me to PM&R was the focus on improving quality of life. To me, there is nothing more inherent to “quality of life” than being able to urinate, defecate, have sex, and sit without having genital pain. My patients are totally miserable — some of them void every 15 minutes, some cannot leave the house because it takes 4–6 hours in the bathroom to defecate daily. I see relationships falling apart because people cannot engage in sexual intercourse and people going on disability because they cannot sit. Helping patients with these most intimate of functions is truly life-changing for them. I also like that I am doing something that very few people are doing, and it has been relatively easy to make a name for myself because I am doing such a niche thing that is at the same time something that has the potential to help so many people who are suffering. The prevalence of pelvic floor disorders in the general population are extremely high (5–25% women have chronic pelvic pain, 2–16% of men have chronic pelvic pain, 20% of women have dyspareunia, 50% of women have urinary incontinence, 14% of men have urinary incontinence, 20% of people have constipation, etc.)

What is unique about the physiatric approach to pelvic disorders?

Most of the doctors who try to help people with pelvic disorders are surgeons. They don’t have the understanding of muscles, nerves, and joints that we have as physiatrists. They tend to look at the organs as the cause of all pelvic problems. But pelvic muscle, nerve, and joint pathology can cause pelvic pain, urinary/fecal incontinence, urinary urgency/frequency syndrome, constipation, dyspareunia, and a slew of other pelvic complaints. As a physiatrist, I can do a detailed pelvic muscle, nerve, and joint examination to elucidate the causes of their dysfunction and pain. Moreover, with my PM&R training, I can put the pelvic exam findings in the context of the whole body — both physically and psychologically. Perhaps their pelvic floor muscles are dysfunctional because they have signs on their neurologic examination that point to a central process like Parkinson’s disease? Maybe they have constipation because of lower motor neuron neurogenic bowel via chronic cauda equina arachnoiditis caused by a dural tear in a prior lumbar surgery? Perhaps their anxiety and bipolar disorder are causing upregulation of their sympathetic nervous system, resulting in high tone pelvic floor dysfunction? I get a very thorough history, including a focusing on their life stressors and prior abuse histories, as well as a full neuro exam as well as lumbar spine and hip exam in addition to the pelvic floor exam — it is very helpful to put everything in context.

What advice would you give to residents interested in treating pelvic disorders?

I would advise residents to keep an open mind — I never thought I would be doing this. I didn’t even like my OB-GYN rotation in medical school! But if you think you might have an interest, try to get in contact with some of us in PM&R who are doing pelvic rehabilitation, go to our lectures (we speak on pelvic topics almost every year at AAPMR), and try to spend some time in the clinics with us. See if your residency will allow an away rotation, or if not, come and spend a week or two while on vacation. You can also check out the International Pelvic Pain Society website and conferences. We have chapters in Braddom about the Rehabilitation of Pelvic Floor Disorders and Sexual Dysfunction in Disability which are worth checking out, and a recent PM&R Clinics of North America edition on pelvic pain which is excellent.

What do you find most rewarding and challenging about your current work?

I think the most rewarding thing is being able to truly help people who are suffering. I feel like my patients suffer more than many of the more classically disabled patients I encountered in residency. Being able to help them understand themselves better and improve their quality of life is a great blessing — that’s what I went into medical school wanting to do. I like that the work is always challenging — I have to use my brain, rely on excellent physical examination skills, and be a great communicator in order to get through every patient encounter. I cannot just coast through my day. I also really enjoy the team approach to patient care that we have in our pelvic rehabilitation program — the pelvic PTs and I practice in the same space, meet weekly to discuss patients, and have a very collaborative and supportive relationship that I don’t always see in outpatient physiatry practices, but which I feel is essential when you are a pelvic rehabilitation physiatrist. The main challenge of practicing pelvic rehabilitation medicine is that the patients tend to have a lot of anxiety and sometimes other psychiatric disorders. The work is never boring, but the amount of suffering combined with the psychiatric co-morbidities can be overwhelming at times. There are other logistic challenges — having long enough appointment times to properly evaluate these complex patients, making enough RVUs when the role for procedures is more limited than in other PM&R subspecialties, managing long waiting lists due to the large number of patient referrals. But it is definitely worth it.

Julie Hastings, MD, is a PGY4 in Physical Medicine and Rehabilitation at the University of Colorado who will be going into pelvic girdle and pelvic floor dysfunction.

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