Concussion

The Future of Concussion

and Medical Education

Original artwork by Jessica Schwartz Rendered by Chris Freeman

Original artwork by Jessica Schwartz Rendered by Chris Freeman

Jessica B. Schwartz PT, DPT, CSCS

There is a paucity of quality concussion education in entry level, residency, and post-professional medical education.

Why?

Because there is no evidence based medicine for concussion.

A bold statement as I introduce what I believe to be the worlds first yearlong, multidisciplinary, and post-professional concussion education program for clinicians.

Let me start with a story:

It was the week I got promoted to junior partner of my company.

The week I took a deep breath for the first time in my life and said “OK Schwartz…You’ve arrived.”

I was surrounded by people whom I genuinely cared about, professionally and personally, and I felt like my nose to the grindstone personality the last 13 years of formal didactic education, business mentorship, and the chase to this finish line had come to fruition.

That was the week I was hit by a car.

That was the week my life changed forever.

On October 3, 2013, I went from being Dr. Schwartz to patient 237427 in a NYC Emergency Department getting rolled through a CT Scan.

It’s a difficult journey being on “the other side of healthcare.”

I was that patient rolling to CT with my MD Calculator in hand who was able to recite the Canadian CT Head Rules like a proud elementary school student who had just learned her speaking part for the school play.

Physical therapy was my craft. I was mastering the craft of treating the patient as person, developing my patient rapport tools, building a wonderful international referral network, and understanding the nuances of running multiple successful businesses.

I loved every minute of it. The more I learned the more I wanted to learn.

A one week medical leave of absence turned into 10+ hours of rehabilitation a week for a year.

How could an injury so seemingly benign change my life forever?

What We Know:

In 1997, the CDC reported 300,000 concussions in the United States. In 2016, the CDC estimates are 1.6-3.8 million sports related concussions based off of the most recent 2006-2010 data.

I strongly believe that these numbers continue to be greatly underestimated based off of the heterogenous nature of this injury, underreporting[1-4], ~25% of people not seeking emergency department or other medical care[5], and lack of an agreed upon definition and consensus on what the injury is in the literature[6-8].

We know that approximately 20-30% of patients develop persistent symptoms crossing over into the post concussion syndrome threshold each year with ranges from 5-58% in the literature[9-11].

If we look at ~30% of all concussions crossing over into the persistent symptom category, that is 1.14 million people in the United States based off of the current data alone.

Remember, I continue to believe that this data continues to be grossly underestimated.

The Gaps:

We know that TBI is grossly underfunded yet it is a major cause of death and disability in the United States, contributing to about 30% of all injury deaths[12].

NIH TBI v Cancer Funding

According to the National Institutes of Health (NIH), Cancer research received $5.6 Billion in 2015. Comparatively and up from $88 million in 2015, TBI is estimated to receive just $91 million in 2016[13]. Approximately 5.6 million people are living with the long terms effects of TBI and 138 deaths occur per day[12] amounting to ~50,000 deaths per year in the US. In 2015, there were 1,658,370 new cancer cases diagnosed and 589,430 cancer deaths in the US[14].

Why compare cancer and TBI? Because cancer has made huge gains by breaking down cancer. We don’t treat cancer. We treat large cell non-Hodgkin lymphoma. We need to do the same in the concussion community.

Scientifically, we must start with agreeing upon a universal definition of concussion, mTBI, and TBI. From there we need to be able to break down the injury appropriately based off of neurophysiological changes and injury to specific areas of the brain. While these are lofty goals, I also don’t see this being tangible in the near future nor is it clinically and functionally relevant to the patient seeking care in front of us today.

The above statistics indicate that we are doing much better at saving patients lives from severe cases of TBI vs cancer; however, the true burden exists with TBI survivors suffering from the lasting effects of what a TBI does to a person as a whole being.

We know that 100% of all neuroprotection phase III studies are negative, less than 5% of New Medical Entities (NME) in clinical assessment make it to FDA approval, and 100% of all Phase III trials in TBI are negative.

This means that there have been zero phase three clinical trials in TBI that have moved on to completion, there are zero drugs for TBI, and that TBI and concussion are strictly a clinical diagnosis.

We have to do better. And we can.

Medical Education and Healthcare:

Daniel Goleman discusses the key concept of “iatrogenic suffering” in medicine. This is an added anguish by medical personnel delivering insensitive messages that can often engender more emotional suffering than the actual illness itself[15].

Historically in medicine if we do not understand an injury or disease pathway, we prescribe rest or send the patient to a psychologist e.g. syphillis, low back pain, B12 deficiency, cardiac issues in women, etc.

We’ve missed the mark in the concussion community as medical providers. Over the last few decades, we’ve allowed the medico-legal literature to get ahead of us in the medical community.

It wasn’t until 1989, a neuropsychologist by the name of Jeffrey Barth, was part of the first group to suggest that cognitive testing in preseason athletes may have some value due to concussive injuries presenting lasting effects.

We’ve enabled a culture of “I got my bell rung” to prevail and have not addressed concussion from a systems level until recently.

I’ve heard time and time again that “We can’t teach it because there’s no empirical evidence”.

Nonsense.

As I was being well-cared for by my team of physicians and clinicians, I continued to do my best to take a step back and look at the inner workings of the healthcare team, system and educational offerings that are made available to all clinicians from physician to PT et al.

When I learned that 2015 was the first year that neurology residencies were receiving formal didactic education in concussion within the ‘Behavioral Neurology’ section springing from the work and advocacy of the Sports Neurology Section of the American Academy of Neurology, I knew there had to be something done.

A change.

A change in the global architecture of medicine with respect to the concussion patient of today.

A concussive injury is an all hands on deck injury. It can often require a team of clinicians to identify, treat, and manage this patient population.

Leading Causes of TBI

Concussion patients port of access to the clinician of today is infinite. It can range from the athletic trainer, the emergency department physician, the primary care physician, the pediatrician, the nurse practitioner, the physician assistant, the school nurse, psychologist, physical therapist, occupational therapist, speech therapist, and anyone who has direct access to the patient of today.

I emphatically deliver this message when I speak publicly: it is not a matter of if you treat concussion patients. It is a matter of when you will encounter, treat, and/or refer a concussion patient.

A concussion is not a broken bone. That’s easy. We know normal tissue healing parameters in healthy populations.

A concussion is a neurophysiologic injury that can affect all domains of a person’s life from somatic, cognitive, emotional, vestibular, sleep, and behavior often with non-specific answers to the all important patient question of “when will I get better?”

It is gut-wrenching as a clinician to have the self awareness to look into a patient’s eyes and say “I don’t know.” It is even more painful as a patient to be completely unaware of if you will ever get better when you are being cared for by one of the best clinicians in the world.

We can do better. And we will. Here’s how.

Healthcare Teams:

Long gone are the days of the one physician model, yet we seem to be in a conundrum when it comes to communication and teamwork in medicine.

The Doctor Sir Luke_Fildes_(1891)

The Doctor Sir Luke Fildes (1891) https://commons.wikimedia.org/wiki/File:The_Doctor_Luke_Fildes_crop.jpg

In the fall of 2014, I had the privilege to virtually attend the International College of Residency Education’s (ICRE) opening plenary delivered by rhetorician scientist Dr. Lorelei Lingard on Collective Competence: Adapting our concept of competence to healthcare teams[16].

During this time, I was finalizing my concussion rehabilitation and Dr. Lingard’s words helped facilitate my eureka moment of how I can aide in providing a solution to this medical world of specialists all attempting to treat the same poorly defined and heterogenous injury.

Summatively, she states that individual competence does not equal good healthcare.

She elaborates reviewing a case scenario describing the maze of disconnected care episodes that the patient of today is experiencing.

Dr. Lingard states that we need to “evaluate in situ, broaden focus beyond individual actions to include inter-actions among individuals, capture the ‘cracks’ between the care episodes, and consider interactions among elements of the system, not just among people…Competence is a way of ‘seeing’ that both directs and deflects our attention. The cracks between care episodes, experts cultivating collective competence ‘know how the system usually fails in this situation, and plans accordingly.’ Our attention is directed towards individual competence and deflected from collective competence. We need both[16].”

My role is to facilitate collective competence in the concussion community.

Let’s think about the concussion patient of today.

A concussed individual can experience any one of the following myriad of symptoms all at once or over a period of time [See Chart].

Concussion Signs and Symptoms

Each of these symptoms can be managed by individual specialists that may or may not cohesively integrate their treatment models with a co-treating clinician.

Concussion identification, treatment, management, and having the self awareness to know when and whom to refer appropriately can be a complex team model and clinical algorithm.

Each concussion case is unique and treatment models are 100% situationally dependent.

Kenneth Burke, an American literary theorist, once said that “every way of seeing is a way of not seeing.”

We can’t simply “treat the headache” or “treat the balance issue.” Treating the concussion patient of today involves a complex series of evaluations across all domains in order to systematically identify injury deficits in order to appropriately make the decision of what to treat, when to treat it, and when to refer appropriately.

If you treat together, you must learn together.

Here’s how.

Rapport and Clinician Synchronicity:

“To feel with, stirs us to act for[15].”

Get in-synch with your concussion patients.

These patients often feel very disconnected to the medical community. Patient stories of seeking care from 5+ medical providers until they “find their person” in healthcare is not uncommon.

Rapport is key to successful patient, provider and caregiver interactions. When people are in rapport, their physiology actually attunes. Robert Rosenthal published a landmark article revealing the central tenets of “relationship magic,” the recipe for rapport. This only exists when three elements are present: mutual attention, shared positive feeling, and a well-coordinated nonverbal duet. As these three emerge cohesively, we spark rapport[15].

This is how lifelong patient-provider and provider-provider relationships are formed.

Nature is based upon energy and timing. Basic science has identified symbiosis throughout the natural world ranging from the firing of an action potential to the marvelous making of what happens between winter and spring.

Concussion is an injury of asynchronous firings at a cellular level which accumulate amounting to a functional dysfunction with ones self and environment.

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

We need to learn how to adapt to the needs of our patients who carry a host of pre and post morbid medical conditions and circumstances presenting with the complexities that the heterogenous nature of a concussive injury presents.

The Program:

The Evidence In Motion Concussion Certificate Program is committed to educating the post-professional multidisciplinary clinician of today in concussion identification, treatment, and management by fostering a rehabilitative team approach.

This 12-month program provides the latest clinical conversations, evidence-based guidelines, and consensus statements while integrating real world experiences from patients, providers, and caregivers who have navigated the complex healthcare network of today.

Content delivery is both interactive and dynamic, exposing the student to some of the most influential clinicians in the concussion community coupled with the unique learning experience of provider to provider, patient to provider, and caregiver to provider storytelling.

By fostering a rehabilitative team approach, the EIM Concussion Certification hopes to facilitate collective competence across the healthcare continuum in order to better triage, treat, and appropriately refer the concussion patient of any age from acute to chronic stages.

This year long multidisciplinary concussion certificate sets the learner up for success utilizing an asynchronous and synchronous online learning environment for the busy post professional of today.

The in-person weekend intensive reviews the psychomotor properties of the concussion evaluation, treatment, management, and referral options based off of the providers scope of practice during the 12 month didactic education experience.

As a pre-requisite to the program, each post-professional student will undergo a therapeutic neuroscience education course. As we embark on a multidisciplinary educational journey together, I sincerely believe that we all speak the same language of medicine; however, we bring many different dialects to the clinical table.

Current best-evidence shows that therapeutic neuroscience education improves pain ratings, function, pain catastrophization, physical movement and cost of healthcare utilization.

I will utilize the TNE course to cohesively meld the post-professional multidisciplinary EIM Concussion students in language, compassion, and competency of the therapeutic neuroscience evaluation in order to jumpstart their experience of learning together in a new environment. 

A few months before physician Kenneth Schwartz died, he stated that “Quiet acts of humanity have felt more healing than the high dose of radiation and chemotherapy that hold the hope of a cure. While I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me[15].”

I hope to create kind, compassionate, and clinically efficient clinicians who foster rapport with patients, interdisciplinary colleagues, and across disciplines.

Care for the concussion patient. Care for him/her together. And care for him/her well.

The Faculty:

I’ve been fortunate enough to have returned back to patient care and have surrounded myself with some of the brightest and most dedicated faculty in the world in their respected specialties.

Over the last year, the energy that I’ve felt from this group of men and women has been palpable. I am honored everyday to have worked with and continue to collaborate with each and everyone of these passionate clinicians.

What do they all have in common? I systematically screened all interviewees for passion, high IQ, high EQ, and low ego who have the self awareness to take a step back from themselves and look at the big picture of clinical care.

We have a tall order in front of us and I know we’re here to do our best to help clinicians of today put our best foot forward to educate each other and our communities of coaches, parents, spouses, teachers, caregivers, and loved ones on the multifaceted injury that concussion can present itself as to the provider and patient of today.

Why Story?:

Paul Zak, a neuroeconomist, eloquently stated “Stories are powerful because they transport us into other people’s worlds but, in doing that, they change the way our brains work and potentially change our brain chemistry — and that’s what it means to be a social creature[17].”

Storytelling allows us to step back, view, and listen from an aerial and reflective standpoint while creating the neural groundwork of patient exposure by connecting to the story, the provider, the caregiver, and the patient.

Schwartz Rounds were invented by an ill physician who also experienced the dichotomy of both doctor and patient. His purpose was to facilitate understanding of how the patient perceives their own illness and treatment by deploying empathy and building rapport[15].

If we have no empirical data, then we need to learn from each other. I believe by deeply listening to each other, patients, and caregivers fosters an excellent way to change the way in which we begin to shift the global architecture of medicine with respect to the concussion patient of today.

How can we help and treat a mutual patient if we don’t sincerely understand what each of us can collectively do for one another in the best interest of the patient.

Story allows us to experience the injury through the eyes of experienced providers, patients, and caregivers who have navigated the complex healthcare system of today.

We need to learn from each other.

When we learn together we can treat together.

Welcome to the beginning of the Evidence in Motion Concussion Certificate Program.

“I did then what I knew how to do. Now that I know better, I do better.” ~Maya Angelou

#Concussion.

Bibliography

1. Register-Mihalik, J.K., et al., Using theory to understand high school aged athletes’ intentions to report sport-related concussion: implications for concussion education initiatives. Brain Inj, 2013. 27(7-8): p. 878-86.

2. Llewellyn, T., et al., Concussion Reporting Rates at the Conclusion of an Intercollegiate Athletic Career. Clin J Sport Med, 2014. 24: p. 76-79.

3. Kroshus, E., et al., Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education. Clin J Sport Med, 2015. 25(3): p. 243-7.

4. Kroshus, E., et al., Norms, athletic identity, and concussion symptom under-reporting among male collegiate ice hockey players: a prospective cohort study. Ann Behav Med, 2015. 49(1): p. 95-103.

5. Sosin, D.M., J.E. Sniezek, and D.J. Thurman, Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj, 1996. 10(1): p. 47-54.

6. Menon, D.K., et al., Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil, 2010. 91(11): p. 1637-40.

7. Quarrie, K.L. and I.R. Murphy, Towards an operational definition of sports concussion: identifying a limitation in the 2012 Zurich consensus statement and suggesting solutions. Br J Sports Med, 2014. 48(22): p. 1589-91.

8. Rose, S.C., A.N. Fischer, and G.L. Heyer, How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Inj, 2015: p. 1-6.

9. JJ, B., et al., Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj, 1999. 13(3): p. 173-189.

10. Iverson, G., Outcome from mild traumatic brain injury. Curr Opin Psychiatry, 2005. 18(3): p. 301-317.

11. Babcock, L., et al., Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr, 2013. 167(2): p. 156-61.

12. CDC. Traumatic Brain Injury in the United States: Fact Sheet. 2016  January 11, 2016].

13. NIH. Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC). 2015  [cited 2016; Available from: https://report.nih.gov/categorical_spending.aspx.

14. ACA. Cancer Facts & Figures 2015. 2016  [cited 2016 January 11, 2016].

15. Goleman, D., Social Intelligence: The New Science of Human Relationships. Kindle ed. 2006: Random House.

16. Lingard, L., Collective Competence: Adapting Our Concept of Competence to Healthcare Teams. 2014.

17. Zak, P. The Neurochemistry of Empathy, Storytelling, and the Dramatic Arc, Animated. 2012  [cited 2016; Available from: https://www.brainpickings.org/2012/10/03/paul-zak-kirby-ferguson-storytelling/.

Infant Swimming Resource (ISR)

Infant and Toddler Rescue Floating and Swimming:

What the Medical Community Needs to Know about Safety and Prevention

Today Show HD Video and Article:  www.today.com/video/today/55513113

Dr. Kristine McCarren PT, DPT

Editors note: I initially learned about ISR when I saw a piece on NBC’s Today Show. I’m thrilled to have Dr. McCarren educate the medical community about the benefits of infant and child rescue swimming via her guest blog post on PT2Go. Here, she will touch upon pediatric emergency department drowning epidemiology, the American Academy of Pediatrics stance on swim lessons, and differentiate between the Infant Swimming Resource and traditional swim lesson model.

“All children should learn to swim before they learn to walk…”

I hope the above quote challenges your thought process. It certainly did mine. Allow me to introduce Dr. Kristine McCarren, PT DPT. ~JS


 

The American Academy of Pediatrics (AAP) recently changed its position statement on drowning prevention based on the study concluding “participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in 1 to 4 year old children…”.[1]

Other than congenital anomalies, drowning is the number one cause of accidental death in children 1-4 years old. [2] 

As clinicians who work directly with pediatric patients or treat an adult patient population, we all have contact with parents of young children professionally and familially.

As spring months turn into hot summer days and nights, what is the solution to assist our communities in keeping our children safe from the number one cause of pediatric accidental death?

The answer: Infant Swimming Resource (ISR).

What is Infant Swimming Resource (ISR)?:

Infant Swimming Resource (ISR) is a program that teaches infants as young as 6 months how to save themselves in the event they make it into the water alone.

ISR is recognized internationally as the safest provider of survival swimming lessons for children 6 months to 6 years.

With nearly 50 years of research and development, Dr Harvey Barnett adapted his theoretical knowledge as a behavioral scientist in order to pioneer ISR’s Self-Rescue® method after witnessing the drowning of his neighbors infant son.

How Does ISR Work?:

Infants 6-12 months learn survival floating. Lessons focus on teaching the child to roll onto their back to float, rest, and breathe maintaining this life-saving position until help arrives.

Children 1-6 years old learn to swim until they need air, roll back to float, and then resume swimming until they reach the side of the pool.

As of April 2015, there have been more than 800 documented cases where former ISR students have used their Self-Rescue® skills to independently save their own lives.

Since 1966, ISR has taught more than 260,000 children internationally.

Is an ISR Instructor More Specialized Than a “Typical Lifeguard”?:

ISR Instructors are infant aquatic specialists who have been trained to teach water survival skills to infants and children 6 months to 6 years.

Instructors undergo an intensive 8-week program.

There is a minimum of 60 hours in-water training and 40 hours academic preparation and testing.  

Similar to many medical models, continuing education is required coupled with yearly re-certification to ensure maintenance of teaching skills.

Many ISR instructors come from medical backgrounds (physical therapy, occupational therapy, nursing, et al) and use evidence based knowledge regarding sensorimotor learning to teach these Self-Rescue® skills.

The ISR instructor monitors the child’s temperature through vasoconstriction checks throughout the lesson, and if the child is too cold, the lesson is over.

ISR instructors check for temperature fatigue and abdominal distention throughout lessons.  

Temperature fatigue precedes muscle fatigue, which leads to inefficient learning. Abdominal distention makes it hard to breathe, and if left untreated, can be dangerous.

ISR instructors rely on sensorimotor principles and positive reinforcement to teach each infant and child during their personalized lesson.

Based off of these sole principles alone, this is why the allied healthcare professional is the perfect fit to undergo this highly specialized training.

Tactile guidance and prompt reinforcement is the primary means of instruction.

ISR teaches infants as young as 6 months old; therefore, verbal instruction cannot be relied on to teach survival swimming skills which primarily involve instinct, cognitive and motor planning tasks.

The ‘Anatomy’ of an ISR Lesson:

ISR lessons are always one-on-one with the same instructor.

A child learning ISR receives 100% of the instructor’s attention 100% of the time.

Each child attends lessons for 5 days per week for 10 minutes each session.

The 10 minute lesson structure has been scientifically proven to optimize learning and increase retention for this pediatric age population.

A child learns survival skills by actively engaging in his/her environment. Instructors use the ambient air as a teaching tool coupled with the instructor’s touch. This facilitates creating an independent infant and/or child if they are ever faced with a dangerous water scenario.

How are Lessons Different than a Traditional Lifeguard Lesson?:

ISR pools are maintained at 78 to 88 degrees Fahrenheit.

Prolonged exposure to environments that are lower than a child’s body temperature are inefficient for motor learning.  ISR lessons are limited to a maximum of 10 minutes to prevent temperature fatigue and optimize efficiency. Children are monitored for temperature fatigue frequently throughout each lesson via vasoconstriction checks.  

Up to 86% of children who drown are fully clothed at the time of drowning [3]. ISR makes sure to build in real world scenarios with respect to having the infant and toddler fully clothed in the water upon graduation. 

ISR 16 Month Old Infant Survival Floating in Full Winter Gear

ISR Infant Survival Floating in Full Winter Gear

Training begins in summer clothes, sandals and sneakers. After this initial level of mastery, winter clothes including a coat, boots, hat, and gloves are added into the lesson. Swimming and floating in clothes is a completely different experience than in a bathing suit. The extra weight of the clothes and fully saturated diaper make moving in the water more difficult.

ISR lessons ensure that a child is competent and confident swimming and floating fully clothed.  

ISR Infant Sweater and Hat

ISR 6 Month Old Infant Survival Floating in Full Winter Outfit with Dr. McCarren

 

Infant Swim Resource

Traditional Swim Lesson

Registration

Family medical history, developmental milestones , current health conditions, developmental issues and medications. Specific conditions are reviewed by MDs and nurses, and instructors are notified of any specific safety measures to be applied during lessons

Child’s name and age is recorded and a parent signs a waiver to acknowledge risk of lessons.  

Specific health information is usually not recorded or taken into account

Documentation

Daily bowel, urine, diet and sleep patterns are documented in order to assess changes that may compromise the safety of lessons.  

If warranted, lessons will be shortened or cancelled

Do not assess the infant/child’s daily habits, and health concerns that may affect or compromise lesson safety

Lesson Duration& Frequency

10 Minutes

5 Days/Week

6 Weeks

30-45 Minutes

1 Day/Week

Instructor Training

CPR/First Aid Certified

Trained in:

Behavioral Psychology,

Sensorimotor Learning,

Shaping Behaviors,

Physiological conditions as they relate to exercise in the water, Emotional learning,

80+ hours of practical experience & studying/analyzing video.

Yearly recertification & continuing education required

Often medical professionals such as PT’s, OT’s, RN’s

CPR Certification not required

No formal training required

 

Critical Numbers:

For every pediatric fatal drowning, there are an additional 5 pediatric patients who visit the emergency department (ED) for nonfatal submersion injuries.

Within 2 minutes of submersion, a child loses consciousness. When a child is submerged underwater for 4-6 minutes, they can be left with irreversible brain damage.  

More than 50% of drowning victims treated in ED’s require long term hospitalization or transfer for further care. This potential irreversible brain damage may result in long term deficits, such as memory problems, learning disabilities, and permanent loss of basic functioning.[2]

Healthcare Community Challenge:

As an ISR instructor, it’s imperative to educate the community that water isn’t recreational until a child can survival float and swim. Accidents happen when children explore their environment by crawling, cruising or walking. Ensuring that infants and toddlers can survival float and swim before they walk is critical to prevent drowning.

If you are interested in holding a pediatric Grand Round for more in depth information, Harvey Barnett PhD provides in depth information to the healthcare community on the behavioral approach to pediatric drowning prevention.

I challenge you to educate five other healthcare professionals, friends, or family after reading this article. Not only will you be educating the medical community, you could directly be a part of saving a child’s life.

Kristine McCarren, PT DPT

Email: k.mccarren@infantswim.com

Facebook: ISR Seal Team Survival Swimming, Inc.

New York Contact: www.ISRNewYork.com

International Inquiries: www.infantswim.com

Twitter: @InfantSwimKris

Bibliography:

1. Brenner, R.A . et al., Association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med, 2009. 163(3): p. 203-10. 

2. CDC: Centers for Disease Control and Prevention. [Accessed April 18, 2014]; Available from: www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html

3. ISR: Infant Swimming Resource. [Accessed April 19, 2015]; Available from: www.infantswim.com/blog/2012/01/86-of-children-who-drown-are-fully-clothed.html

 


Kristine McCarren ISRKristine McCarren is a Doctor of Physical Therapy (DPT) and Certified Infant Swimming Resource (ISR) Instructor residing in Mt. Sinai, NY.

Dr. McCarren received her B.S. in Exercise Science from Ithaca College and went onto receive her Doctoral degree in Physical Therapy at the University of Stony Brook. She underwent her Infant Swim Resource certification in Casselberry, Florida where she became a Certified ISR Instructor.

Dr. McCarren is experienced in the pediatric setting and dually practices physical therapy in the outpatient orthopedic and homecare settings. She is most passionate about preventing childhood drowning through parent education and instruction of ISR techniques. Her dream is to ultimately open an aquatic facility to teach infants and children ISR Self-Rescue® skills and practice aquatic physical therapy with the pediatric population. 

 

post

Nutrition 101 Series

Nutrition 101 Series for Healthcare Providers:

Keeping Healthy Eating Simple for You and Your Patients Part I

PT2Go Nutrition 101 Series

Written By Ms. Jenna Larsen, M.S.

Edited By Dr. Jessica B. Schwartz PT, DPT, CSCS

“Eat food, not too much, mostly plants.” – Michael Pollan

In the United States, a society that can be overly satiated with consumer information, we’ve made healthy eating complicated.

As a nutrition education professional working in the public health sector in New York City, I’ve learned that the most effective methods for delivering nutrition education to the community is to shift language away from weight loss and highlight the benefits of healthy eating.

Goals need to be clearly delineated with the limited amount of time providers have with patients. When speaking with patients, gently introducing nutritional concepts in a digestible format can make healthy eating fun and accessible.

I challenge you to move away from directly discussing weight loss and facilitate open ended conversation.

This shouldn’t take more than 3 minutes of an office visit. Keeping time constraints in mind, you should be able to quickly assess if your patient is eating primarily a whole food, fast food, or processed food diet.

This is a great segway to engage mutual conversation and ask your patient what their barriers are to healthy eating? (time, cost, lack of cooking skills, education) and gently facilitate the thought process of how eating healthy can benefit their life.

I’ve found that high yield language delivery can be as simple as educating communities with the following points*.

1. Choose more whole foods. A whole food has NOTHING added and NOTHING taken away from how it was found in nature.

2. To determine if a food is more whole, focus on the ingredients list instead of specific nutrients on a label. Choose foods that have the fewest ingredients. This removes confusion associated with marketing and labeling language found in supermarkets. Better yet- choose foods without a label (i.e. fruits and vegetables).

3. View food choices on a spectrum – the most whole foods on one end and the most processed on the other- rather than focusing on whether a food is ‘good’ or ‘bad’. Starting with short-term achievable goals, will be easier and more realistic for patients to turn healthy eating into a habit.

4. Taste buds will change and you’ll learn to like fruits and vegetables. Help patients understand that they will truly enjoy the experience of eating healthy, although perhaps not right away. They will feel more energized as they incorporate more whole foods into their diet.

Have patients set one goal for themselves to address at the follow up**. This will range depending on the patient, but it should be something they view as feasible. Encourage them to keep a journal.

Journal ideas include:

1. Try three new fruits or vegetables you don’t normally eat.

2. Drink fewer sugary drinks and more water. Carrying a water bottle will help.

3. Replace at least one snack with a fruit or vegetable each day.

4. Cook at home at least twice per week. Encourage friends and family- including children- to cook with you.

5. Make a salad for lunch at least one day per week.

It is important provide easily accessible and reliable resources to help patients address barriers.

If you work with low-income families, encourage them to check eligibility for SNAP (Supplemental Nutrition Assistance Program), or food stamps, and provide them an avenue for signing up.

Just Say Yes to Fruits and Vegetables (JSY) ***, a USDA-funded program, features valuable money-saving tips that can provide excellent talking points in a discussion where cost barriers are almost certain to surface. Over 200 fruits and vegetable recipes are the highlight of the website and are featured in both English and Spanish. All recipes are simple with few ingredients, low-cost, and easy to prepare. They also offer valuable storage and preparation tips. Print some to offer as a resource. Make a few recipes yourself to provide a personal recommendation.

If you are be excited about healthy eating, your patients will be too!

Until next time,

Jenna

*Please note that these messages may require tweaking for certain patient populations, such as those with involved medical problems.
** Follow-up at subsequent appointments throughout your provider-patient relationship is key. This will let your patients know you are connected to them
***Just Say Yes to Fruits and Vegetables (JSY) is one of New York State’s premiere nutrition education services available to low income families. JSY is a nutrition education initiative designed to prevent overweight/obesity and reduce long term chronic disease risks through the promotion of increased fruit and vegetable consumption.

 

 

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Physician LBP Paradigm Shift and the DPT

Low Back Pain: Physician Paradigm Shifts and the Doctor of Physical Therapy 

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Dr. Jessica B. Schwartz PT, DPT, CSCS

What do the common cold and low back pain (LBP) have in common? They are the top 2 symptomatic reasons for primary care visits in the United States (US) [1, 2]. 

In 1998, total US health care costs for LBP were approximately $90 billion [3, 4]. Musculoskeletal (MSK) conditions account for roughly 25% of patient complaints in the primary care setting [5, 6].

In the emergency department (ED), MSK dysfunction accounts for 20% of all chief complaints with 2.7 million visits specifically devoted to LBP [7]. In fact, MSK conditions rank second only to respiratory illness with respect to prevalence of most common presentations in the ED[8].

The intent of this article is to identify global systematic weaknesses in medical education while discussing implementation of best practices as it pertains to low back pain intervention.

My hopes are that by exposing the physician to potential clinical decision and behavioral paradigm shifts that can be immediately implemented, we can reduce cost, increase efficiency, and make our patients feel better quicker.

One thing is for sure: I bet you didn’t learn this in Medical School…

II. Physician Confidence and Competence of MSK Conditions:

It has been recently cited that newly graduated medical students and residents lack the clinical knowledge and confidence necessary to care for patients with MSK injuries. Deficiencies have been shown at all levels of training from medical student to attending [8-11].

Approximately 50% of family practice physicians feel inadequately trained in MSK medicine [8, 12]. There have been similar numbers reported amongst the emergency physician with marked deficiencies in musculoskeletal education ranging from trainees to attending staff[8].

As exposure to MSK conditions increase and physician confidence remains low, we need to address this dilemma head on.

Identification and efforts to improve quality of MSK exposure and future physician education is presently being reviewed and developed[11].

What happens to present day practice in the mean time?

Allow me to take you down a paradigm shift in thinking for the present day physician as it pertains to patient access and prescriptive intervention.

III. Knowledge Translation Gaps:

Clinical Prediction Guidelines (CPGs) have proven to be an excellent tool to meld clinically relevant interdisciplinary conversation via individually competent clinicians.

CPG’s have been copiously produced in an effort to guide a broad range of clinicians along a mutually agreed upon diagnostic pathway. In conjunction with the Choosing Wisely campaign, CPGs combined with 2 of the 3 central tenets of Evidence Based Medicine, doctors should be prescribing fiscally responsible and safe interventions for our patients.

Unfortunately, this isn’t always the case.

There continues to be overuse of imaging in the emergency and primary care setting despite evidence based recommendations from the American College of Physicians, American Pain Society[4, 13], and the Choosing Wisely Campaign[14].

These organizations call for lumbar spine imaging only for patients who have severe or progressive neurologic deficits or signs and symptoms that suggest a serious or specific underlying condition[13].

Another example of physician knowledge translation failure occurs with the Ottawa Foot and Ankle Rules (OFARs). In a 2014 study of emergency physician application of the OFARs, there was no statistical evidence that application of the OFARs decreases the number of imaging orders.  In fact 58 of the 60 patients that qualified under the OFARs were imaged [15]. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

Unlike the foot and ankle complex, pathoanatomic diagnoses in the lumbar spine is often more detrimental to clinically relevant patient care than not.

Excessive spinal imaging can lead to downstream pathways that can lead to instilling fear of the unknown or “too-much known” into the patient, unnecessary invasive interventions, time lost from work, familial, and social life, and the fiscal burden that all of the above places on government, third-party and private payers.

Evidence of false rates of herniated discs are shown on computerized tomography (CT) scans[16], MRI[17], and myelography[18] in 20% to 76% of persons sans radicular pain[19].

Savage et al[20] reported that 32% of their asymptomatic subjects had “abnormal” lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression) and only 47% of their subjects who were experiencing low back pain had an abnormality identified[19, 20].

Pathoanatomic abnormalities are so common in the asymptomatic individual it should be viewed as a normal sign of aging with present day knowledge of MSK advanced imaging.

As it pertains to the geriatric population, a cross- sectional study revealed[17] 36% of asymptomatic persons aged 60 years or older had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc [4, 17].

With 22% of the population about to cross over into the geriatric cohort, are we going to continue to expose our patients to undue radiation, opioids and costly-clinically irrelevant tests?

IV: Knowledge Translation Gaps due to…?

Minimal exposure to musculoskeletal education in medical school has previously been highlighted as a significant issue in both North America and the United Kingdom[8, 21-27].

Over the years, my physician friends and colleagues, international and domestic, have congruently agreed upon one common theme amongst their MD/DO medical education: a paucity of MSK learning opportunities during their formative years in medical school and residency training[11].

I’m fortunate to surround myself with people who are as equally as enthusiastic and curious with respect to medical learning.

My small conversational sample size over the years finally took me to the literature.

V. The Literature:

As the geriatric population continues to grow exponentially, there is an $848 billion annual fiscal estimate for treatment, diagnosis, and lost wage amounting to ~7.7% of the gross domestic product for MSK chief complaints [11, 28].

In 2030, the pediatric and geriatric population will account for 21% and 22% of our population due to the baby boomer surge[29].

Think about this for a moment. There will be more people 65 years and older than 17 years old and under.

As the geriatric population continues to stay active and educated, MSK conditions of all age cohorts are going to skyrocket. More severe forms of LBP increase with age with overall prevalence increasing until ages 60-65[19, 30, 31].

In a 2010 national study on LBP and diagnostic testing in the ED, imaging was performed in nearly 50% of all LBP patients and opioids were administered to nearly 2/3’s of the sample[7].

Emergency Medicine physician Judith Tintenalli, stated that we need increased “efforts to change consumer behaviors” with respect to patient access and referral to the ED. It has been cited that up to 43% of direct access ED visits are deemed unnecessary. When referred by a PCP, up to 44% of those referrals were also deemed inappropriate. [32] 

A modification of the Tintenalli statement would be we need increased efforts to change consumer and clinician behaviors. Clearly patients and providers are both lacking awareness of who should be utilizing ED skilled clinical services for MSK conditions.

With rates of chronicity related to an episode of LBP increasing [2], there needs to be a significant shift in intervention and clinical decision making for patients of all ages.

Change in behavior, intervention, and clinical decision making?

What else is there besides the physician ordered image, oral medication, invasive procedure and surgery?

Snarky @DPT2Go Wonka

VI. The role of the Non-Physician Doctor in Modern Day MSK Management:

Experienced doctors of physical therapy have higher levels of knowledge in managing musculoskeletal conditions than all physician specialists except for orthopedists [6]. This includes medical students, physician interns, residents, and attending physicians.

Open Access: www.biomedcentral.com/1471-2474/6/32

Childs J, et al A description of physical therapists’ knowledge in managing musculoskeletal conditions. Open Access: www.biomedcentral.com/1471-2474/6/32

I know that piece of information was not imparted on you in medical school.

Allow me to provide some high-yield clinical pearls that will hopefully expand your breadth and depth of knowledge as it pertains to low back pain and your patients.

Who is the present day Doctor of Physical Therapy (DPT)?

Simply stated, DPTs are body mechanics. Our sole purpose is to make people move and interact with their environment in the most energy efficient, symptom free, safe, and functional way.

DPTs are skilled doctoral degree level clinicians with core knowledge of all systems to allow us to appropriately screen and differentially diagnose all patients that we come in contact with for evaluation and treatment. Similar to the traditional medical model, we have intensive board specialities in cardiology, orthopedics, sport, geriatrics, pediatrics, neurology and hand. Residency and fellowship are also becoming more prevalent with ~2,500 DPT’s trained in residency or fellowship from 1999-2013[33].

Accessed: www.abptrfe.org/Home.aspx

Accessed: www.abptrfe.org/Home.aspx

As of January 2015, all 50 states will have direct access to DPT’s. This means that a prescription is no longer required to access our care for the MSK patient.

Image: http://webreprints.djreprints.com/1715540469703.html

Image: http://webreprints.djreprints.com/1715540469703.html

Direct access privileges have been present in the US Army for over 40 years. In fact, Army DPT’s are able to order imaging and administer medication as necessary.

A retrospective analysis of 472, 013 patient visits at 25 military healthcare sites, 45.1% of the visits were determined to be patients with direct access and without physician referral. No adverse events were determined from either physical therapy diagnosis or management [34].

What does direct access mean for the civilian population?

Simply stated: autonomy.

This means that patients can have instant access to a DPT as soon as they have MSK pain or dysfunction. We’ve accepted the role of greater diagnostic responsibility by achieving the clinical rigors of a doctoral education; this autonomy doesn’t mean we stop communicating with the medical community. DPT’s have worked hard to achieve autonomous practice. Working and communicating with the physician, physician assistant (PA-C), and Nurse Practitioner (NP) are still priority as our profession tends to lead the way in collective competence as we learn to adapt to today’s healthcare systems.

What’s new on the low back pain rehabilitation front?

Accessing LBP patients early is critical to improved outcomes and decreased economic, social, psychological and familial burdens. Early physical therapy (within 14 days of primary care) was associated with decreased use of advanced imaging, additional physician visits, lumbar surgery, lumbar injections, and opioid medications, as compared to delayed physical therapy [2, 35].

LBP is not a homogenous entity.

Pathoanatomic diagnoses are no longer the gold standard for diagnosis and treatment of patients with acute, subacute or chronic LBP. Factually, this is why many LBP studies failed to achieve anything substantial, measurable and remarkable over the last two decades (see false positive and true negative rates above).

Presently, there has been some excellent work done by Fritz[36-38], Childs[6, 39], and Delitto[19] working on sub-grouping LBP patients. If you choose to do any interdisciplinary reading these are the articles you should be reading to expand your knowledge base.

The development of classification systems has been identified as a priority among researchers in the primary care management of patients with low back pain[19, 40].

An entirely separate article can be devoted to sub-groups and treatment based classification systems; however, for immediate knowledge translation integration, I’ve identified four of the subgroups for you below.

Treatment based classification systems use an in depth history, mechanism of injury, and physical examination. They include 1. mobilization, 2. specific exercise, 3. immobilization, and 4. traction subgroups [19].

We know that LBP is not a homogenous entity, therefore, we need to identify, triage, and treat these patients differently depending on where they are along the spectrum of their dysfunction and pain episode.

Every subspecialty in healthcare is going to come in contact with a LBP patient due to the incidence, prevalence, and potential debilitating nature of the injury.

Now is the time to think differently. Now is the time to stop putting the square peg in the round hole.

In a landmark study by Daker-White et al in 1999[41],  a randomized controlled trial was done comparing care of patients solely seen by the physician v. the PT.  Entitled, Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments, 244 patients were seen by a post-fellowship physician and 237 patients were seen by a physical therapist.

The results?

Patient centered outcomes in this RCT favored the PT.

Orthopedic physical therapy specialists are as effective as post-fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs. [41]

Lower costs, increased clinically relevant outcomes, and competent clinicians expediting patient care?

Image-1 (3)

Ladies and gentleman, welcome to the future of healthcare.

VII. Possible solutions:

There is a scarcity of dually trained specialty board certified, residency, and/or fellowship trained doctors of physical therapy in the US; however, we do exist and there are more and more physical therapists pursuing doctoral level degrees, speciality certification, and advanced training every year.

There needs to be a healthy interaction, rapport building and conversation amongst the physician and DPT in the #MedEd community. We need your presence for prescriptive intervention for the biochemistry needs and red flags that can occur with this patient population just as much as there is a need for a paradigm shift in prescriptive, existing clinical decision making, and intervention as it pertains to the LBP patient.

Doctors of Physical Therapy have slowly been introduced to the emergency medicine team and thus far with great success[42]. As this trend continues to grow, a more immediate solution needs to occur.

All 50 states in the US will have direct access to physical therapy services in January of 2015. Now is the time to refer that patient directly to the orthopedic physical therapy office (with or without prescription) so we can decrease unnecessary ED visits leading to opioid prescriptions, imaging, and other prescriptive screening tools leading to costly downstream clinically irrelevant interventions.

Use us. No, really. Use us.

Let us safely screen and differential this cohort of patients. Most of the time they need reassurance that they will be ok and we can provide them with the screening tools to differentially diagnose and refer out to the proper physician as needed.

Most important to the patient, we can make them feel better-if not physically, psychologically usually within the first visit in order to decrease fear-avoidance behaviors[37].

Providing patient education on positioning for comfort, relief and functional positioning for their activities of daily living while utilizing our manual therapy skills to massage, mobilize, manipulate, therapeutically exercise, or stretch this population of patient is key to successful clinically relevant outcomes.

Remember, the LBP patient is not a homogenous entity and neither is their interventional prescription. Let us identify their sub-group based off of treatment based classifications and safely intervene right away (ideally within the first two weeks).

I hope this review provided some new and thought provoking ideas that will hopefully plant the seed for you to share this blog with a fellow colleague, look further in to the literature, and expand the breadth and depth of your MSK knowledge base.

My name is Dr. Jessica Schwartz. I am a residency trained Doctor of Physical Therapy. How can I assist you and your patient’s needs today?

Quick Points:

1. Physician, PA-C, and NP colleagues #ThinkDifferent and take a pause in your clinical decision thought processes when encountering your next low back pain patient. Do you know a PT that you trust and can directly refer to? Now you have excellent conversational tools to engage in a conversation in an interdisciplinary way to best suit the patients needs.

2. PT’s in the United States will have direct access in all 50 states starting January 2015. This means a patient does not need a prescription to access our services. This can be for an acute, subacute, and chronic condition. Allow us to differentially screen and refer out as needed. See the American Physical Therapy Association (APTA) Overview

3. Use this article to expand the breadth and depth of your MSK knowledge base when speaking with fellow colleagues. Think beyond the opioid, radiographic image, and the “wait and see approach”. Take action within the first 14 days of an acute episode and be participative in your patients intervention

4. To my international colleagues, please use this article to engage in conversation. I’ve already learned so much from interdisciplinary conversation after publishing this article. Question medicine…always. Engagement is how we learn and continue to grow. Cheers to you!

Keep Calm @DPT2Go

Bibliography

1. Hart, L.G., R.A. Deyo, and D.C. Cherkin, Physician Office Visits for Low Back Pain: Frequency, Clinical Evaluation, and Treatment Patterns from a U.S. National Survey. Spine, 1995. 20(1): p. 11-19.

2. Childs, J.D., T.W. Flynn, and R.S. Wainner, Low back pain: do the right thing and do it now. J Orthop Sports Phys Ther, 2012. 42(4): p. 296-9.

3. Luo, X., et al., Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States. Spine, 2004. 29(1): p. 79-86.

4. Chou, R., et al., Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med, 2011. 154: p. 181-189.

5. Pinney, S.J. and W.D. Regan, Educating Medical Students About Musculoskeletal Problems. JBJS, 2001. 83-A(9): p. 1317-1320.

6. Childs, J.D., et al., A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord, 2005. 6: p. 32.

7. Friedman, B.W., et al., Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine (Phila Pa 1976), 2010. 35(24): p. E1406-11.

8. Comer, G.C., E. Liang, and J.A. Bishop, Lack of Proficiency in Musculoskeletal Medicine Among Emergency Medicine Physicians. J Orthop Trauma, 2014. 28: p. e85-e87.

9. Freedman, K.B. and J. Bernstein, The Adequecy of Medical School Education in Musculoskeletal Medicine. JBJS, 1998. 80-A(10): p. 1421-1427.

10. Freedman, K.B. and J. Bernstein, Educational Deficiencies in Musculoskeletal Medicine. J Bone Joint Surg Am, 2002. 84-A(4): p. 604-608.

11. Truntzer, J., et al., Musculoskeletal education: an assessment of the clinical confidence of medical students. Perspect Med Educ, 2014. 3(3): p. 238-44.

12. Sneiderman, C., Orthopedic practice and training of family physicians: a survey of 302 North Carolina practitioners. J Fam Pract, 1977. 4: p. 267–350.

13. Chou, R., et al., Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med, 2007. 147: p. 478-491.

14. Choosing Wisely: An Initiative of the ABIM Foundation.  [cited 2014 December 21, 2014]; Available from: http://choosingwisely.org/.

15. Ashurst, J.V., et al., Effect of triage-based use of the Ottawa foot and ankle rules on the number of orders for radiographic imaging. J Am Osteopath Assoc, 2014. 114(12): p. 890-7.

16. Wiesel, S.W., et al., A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine, 1984. 9: p. 549-551.

17. Boden, S.D., et al., Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. JBJS, 1990. 72(3): p. 403-408.

18. Baliki, M.N., et al., Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. J Neurosci, 2006. 26(47): p. 12165-73.

19. Delitto, A., et al., Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 2012. 42(4): p. A1-A57.

20. Savage, R.A., G.H. Whitehouse, and N. Roberts, The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J, 1997. 6(106-114).

21. Matzin, E., et al., Adequacy of Education in Musculoskeletal Medicine. J Bone Joint Surg Am, 2005. 87-A(2): p. 310-314.

22. Lynch, J.R., et al., Important demographic var- iables impact the musculoskeletal knowledge and confidence of academic primary care physicians. J Bone Joint Surg Am, 2006. 88(7): p. 1589-1595.

23. Day, C.S., et al., Musculoskeletal medicine: an assess- ment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med, 2007. 82: p. 452-457.

24. Queally, J.M., et al., Deficiencies in the education of musculoskeletal medicine in Ireland. Ir J Med Sci, 2008. 177(2): p. 99-105.

25. Al-Nammari, S.S., B.K. James, and M. Ramachandran, The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom. JBJS, 2009. 91-B(11): p. 1413-1418.

26. Menon, J. and D.K. Patro, Undergraduate orthopedic education: Is it adequate? Indian J Orthop, 2009. 43(1): p. 82-86.

27. Bernstein, J., G.H. Garcia, and J.L. Guevara, Progress Report: the prevalence of required medical school instruction in musculoskeletal medicine at decade’s end. Clin Orthop Relat Res, 2011. 469: p. 895-897.

28. Facts in Brief.  [cited 2014 December 21, 2014]; Available from: http://www.boneandjointburden.org/highlights/FactsinBrief.pdf.

29. Hooyman, N.R. and H. Asuman Kiyak, Social Gerontology: A Multidisciplinary Perspective. Seventh ed. 2005, United States of America: Pearson.

30. Lawrence, R.C., et al., Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum, 1998. 41: p. 778-799.

31. Loney, P.L. and P.W. Stratford, The prevalence of low back pain in adults: a methodological review of the literature. Phys Ther, 1999. 79(4): p. 384-396.

32. Tintinalli, J.E., Emergency Medicine. JAMA, 1996. 275(23): p. 1804-5.

33. ABPTRFE: American Board of Physical Therapy Residency and Fellowship Education.  December 21, 2014]; Available from: http://www.abptrfe.org/home.aspx.

34. Deyle, G.D., Direct access physical therapy and diagnostic responsibility: the risk-to-benefit ratio. J Orthop Sports Phys Ther, 2006. 36(9): p. 632-4.

35. Fritz, J.M., et al., Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976), 2012. 37(25): p. 2114-21.

36. Fritz, J.M. and R.S. Wainner, Examining Diagnostic Tests: An Evidence-Based Perspective. Phys Ther, 2001. 81(9): p. 1546-1564.

37. Fritz, J.M. and S.Z. George, Identifying Psychosocial Variables in Patients with Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther, 2002. 82(10): p. 973-983.

38. Fritz, J.M., J.A. Cleland, and J.D. Childs, Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther, 2007. 37(6): p. 290-302.

39. Childs, J.D., et al., A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Stud. Ann Intern Med, 2004. 141(12): p. 920-930.

40. Borkan, J.M., et al., A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities. Spine, 1998. 23(18): p. 1992-1996.

41. Daker-White, G., et al., A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health, 1999. 53: p. 643-650.

42. Plummer, L., et al., Physical Therapist Practice in the Emergency Department Observation Unit: A Descriptive Study. Phys Ther, 2014.

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Concussion & Nutrition Series Part II

Concussion and Nutrition Series Part II: Effects of a High Fat, Low Carbohydrate Diet on Brain Metabolism

By Jenna Larsen, M.S.

With respect to nutrition and concussion, there isn’t concrete evidence that there is one type of diet or panacea to aide with concussion symptoms due to the multi-system nature of this injury. 

The intention behind this article is not to propose that you, as a healthcare provider, prescribe a defined diet to concussion patients or even to recommend it as an alternative therapy. Simply, it is to encourage you to consider the evidence behind the idea that (1) what we eat affects the body; and (2) nutrition may be more powerful in healing than many of us have been taught to believe.

The ketogenic diet.

What is it? Who is it prescribed for? And why has this prescribed diet continually intrigued me as it correlates to concussion patients. The ketogenic diet was developed to mimic starvation and has been used and studied for almost an entire century [1]. It is a high-fat diet in which carbohydrates are all but eliminated (less than 50g per day). For reference, there are 27g of carbohydrates in a banana. It is presently most commonly used to control epileptic seizures especially in children [1-3]. More recently, researchers have some evidence that the diet may be effective for improving traumatic brain injury (TBI) outcomes as well [14].

Let’s take a look at how the ketogenic diet works. The brain craves carbohydrates. Whenever they are available, the brain will use them for energy- before breaking down fats and certainly before breaking down protein. When a patient is on a ketogenic diet, carbohydrates aren’t available. The brain settles and breaks down fats instead, converting triglycerides into fatty acids and ketone bodies– the ketone bodies are then used to make ATP and fuel the brain cells. In fact, they may even be a more efficient source of energy than glucose [1]. But how might this translate to protecting the brain?

Ketone bodies were found to prevent neuron cell death in a variety of studies through many different mechanisms [1]. Most of them used animal models so the effectiveness in humans requires more investigation. However, ketogenic diets are highly effective in treating epilepsy [4], so we do know that the brain is most certainly affected by the diet.

We also know that processes in TBI associated neuronal death include energy (ATP) depletion, reactive oxygen species (ROS) production, and inflammation. Since ketone bodies are an alternative source of energy, they are thought to lessen the harmful effects of energy depletion that occur with injury. Multiple studies have shed light on their ability to increase the cell’s resistance to oxidation, inflammation and programmed cell death [5-10]. One caveat is that the diet may be more effective in children – adherence is easier and younger brains are better at transporting and utilizing ketone bodies [11-13].

If the ketogenic diet has so much fat, you may be wondering about health-related consequences. Over the long term, it was actually found to decrease the level of triglycerides and LDL cholesterol while increasing HDL cholesterol. On the contrary, gastrointestinal disturbances are common and children on the diet may be at slightly higher risk for stunted growth, bone fractures and kidney stones. Supplements are prescribed by a medical professional to counter deficient micronutrients [13].

There are a lot of unknown variables with respect to this diet in humans living with TBI. Do short periods on the diet lead to long-term benefits or are the effects reversible? Should the diet be administered right after the injury? What time window is most effective? Are low glucose levels necessary or could you administer ketone bodies without the need to restrict carbohydrates?

A better understanding might provide insights into therapeutic approaches that eliminate the need for strict adherence to diet that is difficult to maintain. Ideally, the ketogenic diet could inform scientists developing a drug that is effective in treating TBI.

Presently, the best course of action a healthcare professional can take with regards to nutrition is to prescribe patients with TBI an increased intake of fruits and vegetables in conjunction with their present course of treatment. Fruits and vegetables are full of flavonoids and antioxidants which have been found to have positive impacts on concussion outcomes and are a more feasible alternative to carbohydrate restriction. See Concussion and Nutrition Series Part I: Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods for a comprehensive review.

Until next time,

Jenna

References:

1. Gasior M, Rogawski MA, and Hartman AL. Neuroprotective and disease-modifying effects of the ketogenic diet. Behav Pharmacol. 2006 Sep 17(5-6):431-439

2. Kossoff EH, Rho JM (2009) Ketogenic diets: evidence for short- and long-term efficacy. Neurotherapeutics 6(2):406–414

3. Neal EG1, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial.Lancet Neurol. 2008 Jun;7(6):500-6.

4. Veech RL. The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis, ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism. Prostaglandins Leukot Essent Fatty Acids. 2004;70:309–319.

5. Ziegler DR, Ribeiro LC, Hagenn M, Siqueira IR, Araujo E, Torres IL, et al. Ketogenic diet increases glutathione peroxidase activity in rat hippocampus. Neurochem Res. 2003;28:1793–1797.

6. Sullivan PG, Rippy NA, Dorenbos K, Concepcion RC, Agarwal AK, Rho JM. The ketogenic diet increases mitochondrial uncoupling protein levels and activity. Ann Neurol. 2004;55:576–580.

7. Stamp LK, James MJ, Cleland LG. Diet and rheumatoid arthritis: a review of the literature. Semin Arthritis Rheum. 2005;35:77–94.

8. Cullingford TE. The ketogenic diet; fatty acids, fatty acid-activated receptors and neurological disorders. Prostaglandins Leukot Essent Fatty Acids. 2004;70:253–264.

9. Hu ZG, Wang HD, Qiao L et al. The protective effect of the ketogenic diet on traumatic brain injury-induced cell death in juvenile rats.Brain Inj. 2009 May;23(5):459-65.

10. Rafiki A, Boulland JL, Halestrap AP, Ottersen OP, Bergersen L. Highly differential expression of the monocarboxylate transporters MCT2 and MCT4 in the developing rat brain. Neuroscience. 2003;122:677–688.

11. Vannucci SJ, Simpson IA. Developmental switch in brain nutrient transporter expression in the rat. Am J Physiol Endocrinol Metab. 2003;285:E1127–E1134.

12. Pierre K, Pellerin L. Monocarboxylate transporters in the central nervous system: distribution, regulation and function. J Neurochem. 2005;94:1–14.

13. Duchowny MS. Food for Thought: The Ketogenic Diet and Adverse Effects in Children. Epilepsy Curr. Jul 2005; 5(4): 152–154.

14. Institute of Medicine Report: Nutrition and Traumatic Brain Injury- Improving Acute and Subacute Health Outcomes in Military Personnel by the Committee on Nutrition, Trauma and the Brain Food and Nutrition Board. Accessed June 23, 2014. http://www.iom.edu/Reports/2011/Nutrition-and-Traumatic-Brain-Injury.aspx

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#SoMe

Social Media and Medicine (#SoMe): How to Use Technology to Increase Knowledge Translation and Self-Directed Learning Processes

PT2Go SoMe Cartoon

History Behind Article:

We’re clinicians that live and practice in exponentially different ways with one seemingly universal commonality: We’re busy. 

Factually, we lose attention and retention with initial memory formation between 20-40 minutes via axonal projections from the hippocampus to the cerebral neo-cortex [1]. Learning requires modification from some of the most basic synaptic interfaces at the dendritic level. The dynamic nature of these dendritic spines are important for neuro plasticity and our ability to take on new information [2].

After formal education and residency, we are expected to remain clinically competent and synaptically sharp in a world inundated with information, tasks, and projects. I have earned the title of Doctor- now how do I maintain this perceived clinical acuity and sharpness that my peers and patients expect of me independently? 

In graduate school and residency we’re handed information. It is easy to take for granted the work and effort it takes to be caught up on the latest research and trends in medicine. More importantly, how to stay passionate while minimizing frustration levels with streamlining and accessing seemingly endless amounts of information. What’s relevant? Did I just waste 20 minutes reading an article that was pointless?

As stated in my original blog post, I hope to share my passion and authentic curiosity for medicine as well as facilitate passionate conversation with the intention of creating better clinicians and self-directed learners.

In an effort to guide you through my process, I will share the educational, social media and research pearls that have set me up for success and kept my synapses firing in 2014.


What To Expect:

At any given time we have an abundance of external distractions inundating us with pings, alerts, scrolls, vibrations, etc. I’m fairly certain in grad-school, I answered my remote control working on my thesis, quieting my puppy, avoiding Facebook notifications…

Sound familiar???

This leads us to the key question of this article: How do I quiet the external noise and organize myself professionally in order to become a better clinician? (And still lead a socially productive life!)

Below you will find my organizational process incorporating my present (and ever-changing) incorporation of using Social Media and Medicine to increase knowledge translation and self-directed learning processes with the intent of becoming a better doctor.

Apps and Programs I Use:

1. Feedly
2. Twitter
3. EndNote
4. Pomodoro Technique® Timer


 

Feedly

History: 

During the 10 years of my formal pedagogical career I  asked one question throughout every single college or university I attended: How do you receive new information and organize your research/medical content? 

After years of disorganized manilla folders, lost papers, and bookmarks strewn across various web browsers, I learned about Feedly. 

Feedly Pearls: 

Feedly is a news aggregator with a beautiful User-Interface (UI) for iOS, Android, and your computer that allows you to process, receive, and sift through information in a very intuitive and minimalistic way.

Feedly allows you to organize nearly everything on the internet from peer reviewed journals, podcasts, blogs, news sites, and YouTube Channels in a list, card, or magazine view.  

Feedly organizes topics with Categories. Categories are essentially folders if you would like to think about Feedly as a desk with drawers. Take the time to organize your Categories and then add your favorite journals, podcasts, etc. 

The beauty of the product is that everything gets delivered to you instead of you having to seek out the information in piece meal. I equate it to going to Blockbuster or the Movie Theater back in the 1990’s and now everything is streamed and filtered to you via NetFlix, Amazon Prime, Hulu, etc via the cloud. I personally take 30-60 minutes on the weekend and sit with a cup of tea on my balcony and sift through incoming information and news streams. 

I can sift from 20 to 100’s of different titles scrolling through ~5-10 pieces at a time on my iPhone or iPad (my preferential viewing style). My goals are to move through all of the content that I have in my Categories and get to Zero. Anything I see along the way that interests me, I hit Save For Later. When I get down to Zero, I then go back into my Saved For Later Category and then take the time to meaningfully go through the content that I have found interesting.

Any journal articles, podcasts, or blog posts that I deem worth keeping, I immediately store them in EndNote (see below), my Web-Browser folders or Evernote. If something is too long, I have a “Read Later” folder in both my EndNote and Web-Browser that I sit down with at a later time before I decide if I want to keep said article of interest. 

[For cohesive integration of Feedly, Twitter, and Endnote see below]

Feedly Screenshot Category in BJSM Mac View
Screenshot of Feedly on MacBook Air


picstitchScreenshots of Feedly on iPhone

Summative Feedly Pearls: 

1. Set up your Feedly on your computer

2. Find what you know

3. When you are comfortable, branch out and search broader topics of interest

4. Read and sift through articles on your iPhone/iPad or Android device taking advantage of the excellent UI

5. Work in 20 minute goal oriented time frames 

Twitter 

History:

There are endless possibilities for how to use Twitter. 

My friends in media have used Twitter for years to promote themselves and their brands. It wasn’t until recently that I became aware of a select few of my friends and colleagues using it for medicine. I started noticing that most professional organizations, hospitals, journals and conferences were also on Twitter. 

If you don’t enter the space of Twitter cautiously and well planned, it can feel like you are standing on one leg, in New York City traffic, juggling ultrasound heads while trying to catch clinical and educational pearls thrown at you by the medical community…that are lit on fire (i.e.-It can be very intimidating). 

The key question is: how can we streamline this and make it efficient so it’s not overwhelming?

The answer is to integrate yourself into Twitter in bite-sized digestible pieces.

Twitter Pearls: 

My #1 Twitter Pearl = Create Lists. 

Lists allow you to organize people, organizations and topics into smaller cohorts. 

For example:

By clicking on my Twitter handle @DPT2Go and clicking on my Lists page you can subscribe to anything that I’ve made public (Medical Organizations, PT’s, Rehab Medicine, Medicine, Medical Organizations, Journals, etc). As you create more connections with people whom you follow, you essentially create this entangled web of people, places and organizations that provide you with seemingly unlimited access to experiential or voyeuristic learning opportunities.

It’s O.K. to sit back and not tweet/participate. Saving informational pieces in your Favorites is completely fine. In fact, it took me a few years to start Tweeting!

In an effort to save time searching, you can subscribe to other peoples lists as well.

If you aren’t sure where to start or where to look, I recommend the Symplur Hashtag Project specifically relating to healthcare.

Hashtags group tweets into topics so they can easily be searched later on. Popular hashtags include #PT, #DPT, #MedEd, #FOAMed, #SoMe, #Healthcare, #DPTStudent, #Hospital, etc. Conferences also create hashtags for themselves and change yearly. 

Getting overwhelmed with Twitter/Feedly: 

Because there are seemingly endless amounts of things on Twitter and Feedly, here are a few suggestions to get you set up efficiently:

1. Set specific goals for yourself when you signup. 

2. Begin with searching and following organizations and journals that you know. e.g.: JAMA, Journal of Orthopedic and Sports Physical Therapy (JOSPT), American Physical Therapy Association (APTA), Academic Medicine, JNNT, Cochrane Reviews, PeDro etc

3. Search more global things like “Medicine” “Rehab Medicine” “Sports Medicine”, “Insert Specialty Here”, etc

4. Work in 20 min increments (See Pomodoro Technique below). It’s easy to get lost for hours syphoning through endless possibilities and connections. And remember, that’s all we really have meaningful attention for anyway…

The more gradual you enter this space of Twitter the higher likelihood of retention, maintaining interest, and knowledge transfer will occur for long term and meaningful use. Process the information at your own pace. Review it. Review it again. And find a process that works specifically for YOU. 

An example of how I’ve organized some of my lists below:

Twitter Home Screen Shot Skitch

Twitter Skitch Screenshot Lists

Summative Twitter Pearls: 

1. Twitter is essentially a microblog that allows you to communicate in 140 character bits of information

2. Create your Twitter Handle keeping the above in mind so people can reply to or include you in Tweets without compromising the 140 character limit

3. Create lists + Organize yourself early

4. Start your search with what you know

5. Branch out and search broader topics when you are comfortable

6. Remember to always be respectful and mindful of your professional presence. Seriously, the Library of Congress archives every single tweet. Read more here if you’re interested

7. Choose to be an educational voyeur or interact and engage with the Twitter community. Either way-Have fun and learn!


EndNote:

History:

Every institution I have been a part of during my educational journey has literally handed out EndNote for free. It is supposed to be the platinum package of commercial reference management software. I literally had hundreds of dollars of software handed over to me during a decade and didn’t use it.

I equate it to being handed a piece of Grade-A organic grass fed steak sans utensils or a means of cooking it. I had NO idea how to use it and the bigger issue early on in education…I didn’t really care to.

As a novice learner, I was literally inundated with so much data that I really only cared to learn to differentially diagnose X and treat Z.

The UI is not the most intuitive and past versions, to be blunt, could’ve been designed by a novice coder. However, they have spruced a few things up at Thomson Reuters to make things more intuitive and useful for the clinician on-the-go. 

I am going to discuss EndNote; however, there are a few other notable players in the reference storage, PDF annotation, and citation management game (See Table 1 for comparison).

I continue to stick with EndNote because it’s what I have always used; however, I think Papers 3.0 has some serious potential with respect to cost, UI, and cross-platform access; however, until they can improve on their cloud storage and glitchy updates I’ll continue to use EndNote.

Ref Management Table

(Table 1: Reference Management Software Comparison)

EndNote Pearls:

Organize EARLY.

I have thousands of articles that I’ve accumulated over the years. I recently started from scratch and began organizing things I need and want in my present library.

Arrange your “My Groups” (similar to Categories in Feedly and Lists in Twitter) on the left part of the screen under My Library

EndNote Screenshot

EndNote Screenshot Skitch

For the most part, EndNote is very intuitive. If importing PDF’s from PubMed, WorldCat, a specific journal you have access, etc- it will migrate most data over for you. There are some instances where it won’t do that.

My advice is manually import the relevant data right away. Bare necessities: Title, Journal, Year, Author(s), Pages, Volume and PubMed ID. The PubMed ID is preferential; however, I would much rather copy and paste “24658701” than a full title, author(s), journal, etc. 

EndNote Web Screenshot

The beauty of EndNote X7 is My EndNote Web which allows you to access your files on-the-go complete with annotations, highlights, etc. There are very few times I am without my laptop, however, it does make file access and citation management very easy especially during travel. 

Summative EndNote Pearls:

1. Organize and setup groups right away

2. Make sure important data is migrated in with article. If not, do it manually ASAP

3. Annotate and highlight directly in EndNote allowing you to search via My EndNote Web and iPad later


Pomodoro®Timer:

The Pomodoro Technique is a time management method developed in the late 80’s by Francesco Cirillo. Essentially the technique breaks things down in to 25 minute intervals assigned to a task list that you create implementing short breaks in between each ‘Pomodori’. 

I use a Pomodoro Timer on my phone. Essentially it is just a fancy timer, but it has helped me immensely with regard to breaking up larger tasks into smaller ones and decreasing distractibility. In other words, I don’t get distracted by email pings, Facebook notifications, Twitter alerts, my dogs, etc while I am working on the task at hand. I simply wait until the 5 minute break allotted to me.

So simple and highly necessary when I am in the middle of a project!

Pomodoro


 

Putting It All Together:

Twitter Feedly EndNote Cartoon Slide

Initially, this can all seem quite daunting; however, I can’t imagine practicing without having  integrated social media and technology into my educational process. The initial time and energy spent to organize, integrate and utilize these multiple services early-on will reap tremendous rewards for the you as a self-directed-forever learner.

Good luck in your educational journey  and continue to stay hungry, engaged and passionate!

Cheers,

Jessica

Twitter Handle: @DPT2Go

Email: Jessica at PT2Go dot Co

Disclosures: None

References:

1. Squire LR, Zola-Morgan S. The medial temporal lobe memory system. Science. 1991;253(5026):1380-1386.

2. Bhatt DH, Zhang S, Gan WB. Dendritic spine dynamics. Annu Rev Physiol. 2009;71:261-82. 

 3. http://library.med.utah.edu/WebPath/TUTORIAL/LEARN/LEARN16.html (Accessed May 24, 2014).

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Welcome To PT2Go!

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Greetings Folks! 

My name is Jessica Schwartz and I’d like to take a moment to introduce you to PT2Go!

You can find the mission statement here; but first, I’d like to share how PT2Go has organically developed over the last several years. 

Conceptually, I thought of this intellectual space of PT2Go as I entered Orthopaedic Residency in 2010. During residency, I learned to truly appreciate the multidisciplinary communication, candor and enthusiasm across all aspects of medicine. After 10 years of formal education and 3 degrees later, I can honestly say that I was never a great self-directed learner.

During residency, I learned how to reason and think differently. In my first 3 months of intensive learning and direct supervised practice, I had become a completely different clinician than I was the day I walked across the stage at graduation and donned that famous doctoral hood. Despite the lack of sleep, buckets of coffee, and stress of having one too many things on my plate at any given time it was an honor and a joy to have learned and grown clinically with my class of residents. 

After graduation from residency, I had a dilemma. I didn’t have someone telling me what to learn, how to learn, and there was no standing on the firing block for weekly peer review and feedback.

I had become incredibly efficient at work and I had rejuvenated my long lost social life with family and friends, but there was something missing. The work, life…learning balance. Where would I fit the time in for learning? How would I do it on my own? How would I do it efficiently?

THIS is where PT2Go comes in. 

My goal is to promote the field of Physical Therapy in a collaborative and multidisciplinary way. I hope that by sharing some of my own self-directed learning experiences: the good, the bad, and the ugly (and believe you me I’m talking ugly!) I can assist in fostering interdisciplinary connections and conversations similar to the connections I made during my time as a resident. 

Here is what you can expect*:

    • • High Yield Evidenced Based information that you can attain on-the-go
    • • International and domestic contributors providing thought provoking and energetic guest pieces 
    • • Opinion (Op-Ed) articles that may push the envelope, foster passionate conversation, and encourage thinking outside of the box
    • • Tips on how to use and integrate Social Media and Medicine (#SoMe) for the Millennial and Generation X Learner
    • • A series on my own Post-Concussive-Syndrome experience. The Dichotomy of The Doctor Becoming The Patient: A Shared Experience of Personal Moments with an Evidenced Based Twist
    • • Concussion Story: A collaborative space for survivors and health care professionals to gain insight into the lives of their patients
    • • Links to Clinical Prediction Guidelines and tips on how to access the information we need in the clinic in real time
    • • A holistic approach to food and nutrition in medicine: taking care of ourselves, food and environmental responsibility, and how it relates to our patients 
    • • Collaborative Case Studies

And much, much, more… 

So cheers to you for coming on this self-directed learning experience with me. I hope to share my passion and authentic curiosity for medicine as well as facilitate passionate conversation with the intention of creating better clinicians and self-directed learners all around the world. 

Enthusiastically,

Jess

Note*: Initial 3-5 blog postings will be primarily related to Concussion

PS-  As promised, I did say Evidenced Based right? My first blog post is written is in a story based format. Here are some links establishing the power of storytelling in medicine and business:

    1. Calman, K. (2001). “A study of storytelling, humour  and learning in medicine.” Clin Med 1: 227-229.
    2. Becker, K. A. and K. Freberg (2014). “Medical student storytelling on an institutional blog: A case study analysis.” Med Teach 36(5): 415-421.
    3. Schwartz, M. R. (2012). “Storytelling in the digital world: achieving higher-level learning objectives.” Nurse Educ 37(6): 248-251.
    4. Stephens, G., et al. (2010). “Speaker–listener neural coupling underlies successful communication.” Proc Natl Acad Sci U S A. 107(32): 14425-14430.
    5. Scott, S., et al. (2013). “Protocol for a systematic review of the use of narrative storytelling and visual-arts-based approaches as knowledge translation tools in healthcare.” Syst Rev 2: 1-7.
    6. Hensel, W. and T. Rasco (1992). “Storytelling as a method for teaching values and attitudes.” Acad Med 67(8): 500-504.
    7. Diagnosis Goes Low Tech By Dinitia Smith Published October 11, 2003. Accessed May 8, 2014.  http://www.nytimes.com/2003/10/11/arts/diagnosis-goes-low-tech.html
    8. Lead with a Story: A Guide to Crafting Business Narratives That Captivate, Convince, and Inspire Truth by Paul Smith. Accessed May 8, 2014.  http://www.leadwithastory.com/
    9. The Power of Story Telling as seen in PT In Motion Published July 7, 2011. Accessed May 8, 2014. http://stephaniestephens.com/wp-content/uploads/2011/07/0312_PTM_Storytelling_MedRes4.pdf
    10. George, D. R., et al. (2014). “How a creative storytelling intervention can improve medical student attitude towards persons with dementia: A mixed methods study.” Dementia (London) 13(3): 318-329.
    11. Cavazza, M. and F. Charles (2013). “Towards Interactive Narrative Medicine.” Stud Health Technol Inform 184: 59-65.