The changing of the seasons signals life’s perpetual motion, a constant rebirth and an opportunity to start anew. Here at the RFC, we take pause to reflect on a rich legacy of service and leadership. Continuing in the footsteps of our predecessors, the RFC will be embarking on a number of new initiatives.
First, I am delighted to announce that the RFC newsletter has a new name, Physiatry in Motion. We also have a new icon, which encapsulates the essence of our specialty – pushing forward innovations to enhance patients’ functional independence. Our tagline – breaking boundaries, exploring new worlds– aptly embodies our vision for our specialty in a rapidly evolving healthcare landscape.
Physiatry in Motion will be featured online on the RFC section of the AAP website. We would love to have AAP residents and fellows, as well as medical students from across the country submit articles on the following topics (500 Word Limit):
- Emerging and innovative uses of technology in Physiatry
- Resident and Fellow-led program initiatives during Residency (Volunteering, Community Involvement et cetera)
- Trainee Research highlights
- Global Rehabilitation Experiences
- Lessons from the Rehab Ward
- Political Advocacy Pieces
- RFC Alumni Interviews: Transitioning from residency – What I wish I had known
- Medical Student Interest Group Highlights and Research Opportunities
Second, we have a new Facebook group and would like to encourage all our members to join the group and to invite all their colleagues (AAP students/residents/fellows). Our numbers continue to grow every day and the RFC is determined this year to provide a platform for ongoing dialog and conversations among all trainees across the country. To achieve this we need help from members who are adept at social media. Thus, we are sending out a call for RFC Social Media Ambassadors (please see announcement).
Third, the RFC will be working closely with the AAP staff to enrich the AAP website user experience (UX) for all users and in particular for our trainees. The goal is to re-organize and update the website content to make it more user friendly. We will be introducing a new Technology in Physiatry section of the website with tutorials on utilization of activity tracking devices like Fitbits and iPads in rehabilitation. The goal of this section on the website would be to provide regular updates on emerging uses of technology in physiatry.
Last, planning for AAP 2017 is underway and we are eagerly looking forward to an exciting meeting in San Juan next year. AAP 2016 in Sacramento had many successes to commend including the first-ever national jeopardy competition, fully packed career pearls and fellowship panel sessions, chief resident town halls, record attendance by trainees, a well-curated conference app and outstanding plenary lectures. Puerto Rico promises to be an equally fun and educational meeting, and we hope you are making plans to be there in 2017. The RFC is open to ideas and suggestions on how to make the students, residents and fellows’ sessions more engaging and interactive. If there are any specific topics or events that you’d like to see happen at AAP 2017, please feel free to send your suggestions to firstname.lastname@example.org.
I hope you will join the RFC in our proposed initiatives in the coming seasons. We hope to inform, entertain and enlighten you on the thrilling advances in our specialty. I look forward to reading your submissions and contributions in future issues of Physiatry in Motion.
With warm regards,
Charles A. Odonkor, MD, MA
2016-2017 AAP RFC Chair
The use of musculoskeletal ultrasound (MSUS) in clinical practice is rapidly expanding and there is a growing desire for increasing physician exposure. This coupled with the fact that in July 2015 the Accreditation Council for Graduate Medical Education (ACGME) now requires a minimum number of ultrasound procedures for Physical Medicine and Rehabilitation (PM&R) residents for graduation, is driving the need for the standardization of MSUS during residency training. Faculty from the Emory Department of Rehabilitation Medicine and Emory Sports Medicine, Under the supervision of Dr. Kenneth Mautner, helped with the develop a curriculum for MSUS which has been integrated with a comprehensive longitudinal musculoskeletal curriculum (MS-C) for the Emory PM&R residency program. As our foundation, we modified published curriculums by the PM&R residency programs at Mayo and Spaulding.
Previously, only the PGY-4 residents were able to get guaranteed exposure to MSUS while on a 2 month Sports Medicine rotation with Dr. Mautner, but there was no formal education done (with the exception of one non-mandatory weekend course) prior to the development of our new curriculum. At baseline, the majority of the incoming PGY-2 residents had very little exposure to ultrasound and virtually no MSUS exposure.
Since ultrasound relies on a sound knowledge of anatomy, we decided to institute a month long anatomy module that focused on the upper extremity, back, and lower extremity. This included 3 weekly two-hour didactic sessions taught by a senior resident, 12 hours of cadaveric dissection, and clinical anatomy review with a PM&R faculty member.
The second major component of the MS-C was to ensure that residents were confident in their physical exam skills so that MSUS could truly be an extension of the physical examination. We structured the components of the physical examination on the PASSOR Musculoskeletal Competencies List to include seven sessions that coincided with the anatomical MSUS sessions (i.e. shoulder, elbow, wrist/hand, spine, pelvis, knee, ankle/foot). At the completion of the 9-month MS-C, each resident was tested on their musculoskeletal physical examination skills competency via a proctored examination, akin to the objective structured clinical examination (OSCE).
The MSUS sessions were structured in a longitudinal approach over 9 months (1 two hour session per month) to ensure the highest yield and allow resident exposure three times prior to the completion of residency (i.e. once each of the 3 years from PGY-2 through PGY-4 years). The first session was an introduction to ultrasound session, which included a review of the basic principles (knobology, etc.) and physics, followed by 6 anatomical sessions (i.e. shoulder, elbow, wrist/hand, pelvis, knee, ankle/foot), and a final session on interventional procedures. To maximize reinforcement, we reviewed all of the relevant anatomy at each MSUS session.
Each of the MSUS anatomical sessions included a 15-20 min presentation reviewing the relevant anatomy and PASSOR exam maneuvers and viewing of a 10-minute demonstration video on the scanning principles for that session. Residents were then split into 3 small groups for a hands-on practice session. Small group sessions were moderated by two Sports-Medicine trained attending physicians (Drs. Lee Kneer and Oluseun Olufade) and a Sports Medicine Fellow (Dr. Walter Sussman), with structural checklists provided for each session. Sonosite graciously provided 3 or 4 ultrasound machines for each session. Prior to each session, the residents were assigned required and recommended.
Going forward, we will incorporate more peer-to-peer teaching to build upon baseline level of knowledge of trainees. Developing this curriculum has been extremely rewarding for me and was one of the primary goals that I wanted to accomplish during my tenure as the Academic Chief Resident. We would love to share our comprehensive curriculum with other PM&R residency programs throughout the country.
I would like to give a special thanks to several individuals that were also instrumental in the development of our curriculum, including: Anna Cruz, MD; Stephanie Meager, Sonosite Representative; and Regina Bell, Emory PM&R Residency Program Coordinator.
Chris Williams, PYG4
Academic Chief Resident
Research from ultramarathon races (foot races longer than a marathon) has not just helped us to understand what happens to the human body during long distance running, but has also provided novel information about what happens to an otherwise healthy human body, when it is pushed to its physiological limits for a prolonged period of time. As physiatrists, we are also increasingly likely to care for ultramarathon runners, as their numbers are increasing exponentially. Of note, ultramarathon running is widely considered to be a safe sport, however, as with many other sports, health and life-threatening situations can occur.
The dangerous consequences of hyponatremia resulting from rapid and copious water ingestion have been documented in the medical literature since the 1930’s (Helwig, 1938). However, it was not until the 1980’s that ultramarathon case reports and research began to demonstrate that exercise potentiates the risk of developing hyponatremia from fluid consumption (Noakes,1985; Frizzell, 1986). This is now known as exercise-associated hyponatremia (EAH). The etiology of the increased risk of hyponatremia during exercise is non-osmotic AVP (ADH) secretion causing impaired water excretion by the kidneys (Hew-Butler, 2015). There have been at least 14 deaths from EAH since 1981 (see box below).
Pictured below is 22-year-old fitness instructor, David Rogers, who died of hyponatremia due to water intoxication after finishing the London Marathon. Photo courtesy of dailymail.com.
The highest reported incidence of asymptomatic hyponatremia post-race has been consistently noted in 161 km ultramarathons, in which the reported incidence of EAH has been up to 51% (Hew Butler, 2015). The incidence of symptomatic EAH has been reported to be as high as 23% (Speedy, 1999) in athletes seeking medical care at an Ironman triathlon and 38% among ultramarathon runners seeking care (Lee, 2011). Health care personnel should have a high index of suspicion for EAH in endurance sporting events when an athlete presents to the medical tent, especially with mental status changes, other neurological changes or nausea and vomiting.
Some participants develop cerebral edema with seizures or other symptoms, and hypertonic saline (3%) is the appropriate treatment (Hew-Butler, 2015). Oral hypertonic saline may be used in less serious cases of confirmed or suspected hyponatremia (Hew-Butler, 2015). Rapid correction of plasma sodium does not pose a risk of central potine myelinosis when hyponatremia develops over less than 48 hours (Hew Butler, 2015).
Risk factors for EAH include overdrinking, weight gain during exercise, exercising for longer than four hours, event inexperience, inadequate training, slow running pace, high or low body mass index and readily available fluids (Hew Butler, 2015). Of note, hyponatremia can occur despite (excessive) sodium supplementation (Hew-Butler, 2015), and excessive sodium supplementation can be harmful and should be avoided (Hew-Butler, 2015). Athletes should instead be educated about the risks of excessive fluid consumption and told to drink according to thirst (See Figure Below: Fluid intake strategy for avoiding exercise-associated hyponatremia (EAH).)
The blood levels of creatine kinase (CK), a byproduct of muscle breakdown, among finishers of a 100-mile race averages 20,000 (U/L), which is approximately 100 times the upper limit of normal (See Figure Below: Distribution of Blood CK levels among finishers of the Western States 100-mile Endurance Run from Hoffman, 2012.)
This would be twice as high as the amount needed to diagnose rhabdomyolysis; however, permanent kidney damage among ultramarathon finishers is exceedingly rare (Schwabe et al, 2008; Hoffman, 2013). Although 30-80% of ultramarathon runners will meet the criteria for acute kidney injury (Hoffman, 2013; Lipman, 2014), the damage does not appear to be permanent (Hoffman &Weiss, 2015). It appears that an increased glomerular filtration rate during running clears waste products at a rate sufficient to protect the kidneys from permanent damage (Irving, 1990).
Athletes need not be routinely evaluated for rhabdomyolysis or kidney damage following ultramarathons, but should seek medical care if there is limited urine output post-race or persistent cola-colored urine despite adequate hydration (Hew-Butler & Hoffman, 2013). Additionally, athletes should avoid taking NSAIDS as they are associated with renal failure secondary to rhabdomyolysis (Hew-Butler & Hoffman, 2013). If there is a concern for kidney injury following or during a race, urine dipstick tests that read positive for at least 1+ protein, 3+ blood, and specific gravity of ≥1.025 can predict those at risk for kidney injury with excellent sensitivity and specificity (Hoffman, 2013.)
Dr. Høeg (the author) at the 2014 WS 100 measuring corneal thickness in a fellow volunteer. That year no runners experienced vision loss, so they were not able to document examination findings.
Three years ago, essentially nothing was known about ultramarathon-related visual impairment, except that it happened to approximately 3% of 100-mile race entrants (Hoffman & Fogard, 2011). This type of vision loss also happened to the director of research at the Western States 100 mile run, Dr. Marty Hoffman. He, Dr. Corrigan and myself set out to learn more about ultramarathon-related vision loss using web-based survey, including 173 ultrarunners that had experienced ultramarathon-related vision loss. We learned that it was self-limited (tended to resolve within a few hours and never lasted more than 48 hours), it occurred over the full range of ambient temperatures and altitudes and is significantly associated with a history of refractive surgery (Høeg, 2015).
The increased risk among those with a history of refractive surgery may suggest that these corneas do not respond as well to prolonged environmental irritation. Of note, approximately three quarters of the participants with vision loss had never had refractive surgery. But those who had also experienced vision loss more frequently. It was also significantly linked to being female, but that may be because females are more likely to take surveys than males (Høeg, 2015),
This type of vision loss does not appear to have any long-term visual consequences. Exercise-related corneal edema has also been documented in cyclists (Ettl, 1992). Athletes who have recurrent running or cycling related vision loss can be counseled to compete with protective eyewear and/or use artificial tears intermittently while racing. If vision loss is associated with pain or darkness (not simply described as foggy or blurry vision), or persists for over 48 hours, athletes should be advised to seek fundoscopic evaluation by an ophthalmologist.
1. Ettl AR, Felber SR, Rainer J. Corneal edema induced by cold. Ophthalmologica 1992;204:113-114.
2. Frizzell RT, Lang GH, Lowance DC, Lathan SR. Hyponatremia and ultramarathon running. Med Sci Sports Exerc. 1990 Oct;22(5):581-7.
3. Hew-Butler T, Hoffman T. Running, Rhabdomyolysis and Renal Failure – Who’s at Risk? Ultrarunning Magazine. 2013. Nov 24.
4. Helwig FC, Schutz B & Kuhn H. Water Intoxication: Moriburnd Patient Cured by Administration of Hypertonic Salt Soluation. JAMA 1938;110:644–5.
5. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the 3rd International Exercise-Associated Hyponatremia Concensus Development Conference, Carlasbad, California, 2015. Br J Sports Med 2015;49.1432-1446.
6. Hoffman MD, Fogard K. Factors related to successful completion of a 161-km ultramarathon. Int J Sports Physiol Perform 2011; 6:25-37.
7. Hoffman MD, Ingwerson JL, Rogers IA, Hew-Butler T, Stuempfle KJ. Increasing creatine kinase concentrations at the 161-km Western States Endurance Run. Wilderness Environ Med. 2012.23, 56-60.
8. Hoffman MD, Stuempfle KJ, Fogard K, Hew-Butler T, Winger J, Weiss RH. J Sports Sci. 2013;31(1):20-31.
9. Høeg T, Corrigan G, Hoffman M. ”An Investigation of Ultramarathon Associated Visual Impairment.” Wilderness Environ Med. 2015 Jun;26(2):200-4. doi: 10.1016/j.wem.2014.10.003. Epub 2015 Feb 26.
10. Irving RA, Noakes TD, Burger SC, Myburgh KH, Querido, van Zyl Smit R. Plasma volume and renal function during and after ultramarathon running. Med Sci Sports Exerc. 1990 Oct;22(5):581-7.
11. Lee JK, Nio AQ, Ang WH, et al. First reported cases of exercise-associated hyponatremia in Asia. Int J Sports Med. 2011;32-297-302.
12. Lipman GS, Krabak BJ, Waite BL, et al. A prospective cohort study of acute kidney injury in multi-stage ultramarathon runners: the Biochemistry in Endunce Runner Study (BIERS). Res Sports Med. 2014
13. Noakes TD, Goodwin N, Rayner BL, Branken T, Taylor RK. Water intoxication: a possible complication of endurance exercise. 1985 Jun;17(3):370-5.
14. Speedy DB, Noakes TD, Rogers IR, et al. Hyponatremia in ultradistance triathletes. Med Sci Sports Exerc 1999;31:809-15.
About the Author
Tracy Beth Høeg, MD, PhD will be a PGY3 this July at the University of California-Davis Department of PM&R. Before moving to the United States last year, she spent seven years working in Ophthalmology in Denmark. She has been an ultramarathon runner since 2008 and was a member of Team USA in the World Championships in Ultra Trail Running in 2013. She is also the owner and head coach at My Little Physiology. She can be contacted at email@example.com. If you are interested in volunteering as a physician at an ultramarathon event, you may want to consider going through http://ultramedicalteam.org/.
Research in using technology for rehabilitation is a burgeoning field. Many exciting high-tech devices such as bionic limbs and exoskeletons are in development with funding from large grant sources such as the Defense Advanced Research Projects Agency. However, there has also been an explosion in development of consumer-grade biometric sensors that have the potential for great utility in the rehabilitation environment as well.
These relatively low-cost commercial products offer free, easy-to-use programming libraries to access sensor data that can be used to create custom research projects. Some products are cheap enough that one can create proof of concepts and even pilot studies with little-to-no dependence on grant awards. Besides smartphones with standard accelerometers and pressure sensors, other new devices offer electromyography, electroencephalography, eye tracking, virtual reality, and more.
There has been a paradigm shift in the industry--rather than manufacture closed, proprietary hardware and software designed for specialized uses, companies now produce hardware with open access to data that can be used in a variety of fields. An early example of the shift is the Microsoft Kinect, an accessory that detects user's joint and limb positions in space. It was originally an exclusive item for Xbox gaming consoles but is now openly supported by Microsoft for use by anyone with a Windows PC. Many newer consumer products have launched with similar open data support.
The way devices offer access to their data is via an application program interface (API). The commands generally provide high-level information that has been filtered and processed already. For example, FitBit and iPhone will provide "number of steps" rather than the raw accelerometer force readings that define a "step." The hard part of the analysis is conveniently done, but the algorithms are usually proprietary. Thus, it is not always clear exactly how the high level data are generated, although some devices do provide raw data output as an option.
Generally, biometric sensors function as follows: sensors within the device (such as accelerometers, capacitive touch, bare electrodes, or infrared detectors) are sampled thousands of times per second to produce raw data. This data can be transferred to a computer for processing, or the data can undergo software analysis on the device and be stored as representations with higher-level meaning such as steps, pulse, or gestures. Data is usually transferred to a phone or laptop wirelessly via Bluetooth or wired via Universal Serial Bus (USB).
There are plenty of questions to consider regarding the fleet of new low-cost devices. How accurate are the data they produce? What clinical information does one hope to gather from a device, and can that information be obtained even if a device may not provide the level of accuracy and precision of its laboratory-grade alternatives? What is the best way to filter noise from the flood of biometric data points, and how can the data be further integrated to provide meaningful information to a clinician? Further research is needed, and it is feasible that short-term pilot studies can be conducted within the schedules of resident and fellow physiatrists.
To promote this initiative, I would like to develop a series of tutorials to create simple projects using different biometric sensors with a physiatric focus. My goals are: (1) to review what devices exist; (2) to suggest physiatric use cases and ideas for these devices; (3) to provide walk-through tutorials for building software to interface with data; and (4) to establish a community online of physiatrist builders for the exchange of ideas, support, and research collaboration.
In addition to technical tutorials, I would like to curate "case studies" in using technology with patients. These articles would focus on the experiences of using available technology in the rehab setting rather than technical development of software/hardware from scratch. For example, what commercial equipment is used? What are the upfront and operational costs involved? What is the training regimen like for patients and staff? What is the author's role in the setup? What are the advantages and disadvantages identified after using the system?
All of these articles would appear online as part of physiatry.org and some may be featured in future Physiatry in Motion newsletters. If anyone is interested in contributing to tutorials or case studies, please contact me!
George Marzloff, MD PGY-2
Icahn School of Medicine at Mount Sinai
RFC Technology Representative