Back to the iPad – explaining spinal conditions to your patients using iSpineCare

Regular blog readers will recall previous posts describing a range of different anatomy applications for the iPhone and iPad, useful for both learning anatomy and for patient education. A particular favourite of mine thus far has been the 3D4Medical series of Apps discussed in a previous blog post, describing anatomy and pathology of various joints in the body, but these have not included an app designed specifically to cover just anatomy and pathology of the spine to date.

Anatomate-Apps (anatomical animation applications) is a Australian Company founded in 2009  by Dr John Hart, in order to develop iTunes applications designed by clinicians involved in the assessment and treatment of patients with spinal conditions, for use as patient education tools.

The over-riding idea is that patients who are given visual and spoken information in the form of interactive digital media during the consultation may experience an improved quality of care overall, as they are better informed about their condition(s) in a way that they can easily understand, and can then go on to make better informed decisions about their subsequent care.

Whilst there are some patients and clinicians such as myself who undoubtedly welcome these applications for use during the consultation, there are other patients and clinicians who will prefer a more traditional approach. Nevertheless, it is hard to argue against the view that the use of applications designed for patient education on the new iDevices is likely to significantly increase in the future, and I for one am using these more and more in my patient consultations to good effect.

iSpineCare is the first spinal anatomy and patient education application for iDevices that I have come across with such a comprehensive and accurate description of spinal anatomy and pathology. Constituting a hefty download at around 1.7GB of information on iPhone or iPad, the application consists of a main menu with folders relating to cervical and lumbar spinal anatomy, movements, and pathologies together with a folder of conservative care options and an exercise library folder.

Navigating through the different sections is easy and quick, and takes you to a context-specific menu which contains links to a series of movies which can be paused, rewound, or fast-forwarded to different points of interest, together with an image library of key stills from the movies allowing for prolonged discussion around particular points of interest. In addition, a pdf document linked to each movie is presented giving a more detailed explanation of different topics.

Another bonus is the availability of medical imaging alongside the individual movies. This section contains a series of x-rays, CT scans and MRI scans and has interactive labels  and reports to help to explain the images further to patients. This section may also be useful for junior clinicians to assist with learning about spinal pathology from a visual perspective.

The quality of the images and in particular the movies is outstanding, with crystal-clear animations allowing for easy recognition of the relevant spinal anatomy and pathologies. Some of the movies have voice-overs explaining salient points, whereas others are animation-only allowing for the clinician to talk the patient through the particular points of interest important for that individual patient to be aware of and focus on during the consultation. In addition, there is a section where particular images can be added to a list of the user’s favourite movies allowing for quick access to a particular user’s most often-used animations.

Another section of movies under the folder ‘Conservative Care’ offers a number of movies describing back-safe ways of performing everyday duties such as gardening, shopping and typing. There are also movies offering advice on a variety of lifestyle topics.

Finally, there is an ‘Exercise Library’ folder with several sub-folders offering animations describing a series of exercises for different purposes including cervical flexibility exercises and core stability exercises.

The overall package is very slick, well thought-out, and accurate in the descriptions of spinal pathologies and anatomical features. Stand-out points are the quality of the animations and the wide range of animations available. An internet connection is not necessary for the app to run, as all of the animations are downloaded embedded within the main app.

Anatomate-Apps also offers other similar applications describing spinal surgery (iSpineOperations) and pain management (iSpinePainManagement), and there are some smaller-sized applications offering information focussed on some particular aspects of spinal pathologies and operations for those who don’t need the larger apps.

As a Sport and Exercise Medicine Physician, I would have liked a little more emphasis on some of the conditions more commonly seen in my patient population including symptomatic spondylolysis, and cervical ‘stingers’ and ‘burners.’  However, most common pathologies are well represented and I can see iSpineCare and iSpinePainManagement becoming an important part of my clinical practice in the future.

Anatomate-Apps are available on the iTunes Apps store, and a video review of iSpineCare highlighting some of its features is available from the App show iPad edition on the link below.

Gearing up for the London 2012 Olympiad – Games Makers at the ready

With less than 8 weeks to go before the opening ceremony of the 2012 Olympiad, London’s preparation for the forthcoming Olympics is moving into the final stages.

There have been a large number of test events so far, two of which I have had the personal privilege of being involved with whilst providing medical cover – namely archery and swimming. The torch relay is well underway, and the media attention in the UK is starting to reach fever pitch.

During the Games, there will be 30 days of competition and around 10 million tickets will be sold. 15,000 athletes will be competing in 46 different sports in a total of 805 events. There will be over 4,000 technical officials, and almost 10,000 team officials on duty.

Of the team delivering the Games, there will be approximately 6,000 staff from the London Organising Committee of the Olympic and Paralympic Games (LOCOG) and more than 125,000 contractors from more than 100 organisations in addition to the volunteer work-force.

A large part of the preparations for the Games is the training of London’s 70,000 or so volunteers, known as the Games Makers. Indeed, volunteers were used for the first time at the Games in 1948 when London was the host City for the second time.

As a member of the medical workforce, I have been required to attend both role-specific training, and venue specific training in order to prepare me for the work ahead as a medical Games Maker volunteer. Role-specific training focuses on some of the generic aspects of the Games Maker role. This includes information about the background to the Games, the venues and the athletes, and offers advice about aspects of the role where Games Makers can make a real difference in delivering a memorable Games to all of our visitors from around the World.

Venue-specific training focuses on the aspects of the individual roles particular to certain venues. Most of the sporting events will take place in the Olympic Park which houses nine venues in total, but there will be other events in different London venues and up and down the Country as well. Competition venues in the Olympic Park include the BMX tract, Water Polo Arena, Velodrome, Copper Box, Riverbank Arena, Basketball Arena, Eton Manor and the Aquatics Centre.

Further afield but still within London, events will take place at Earls Court, Greenwich Park, the Mall, Hampton Court Palace, Horse Guards Parade, Hyde Park, Lord’s Cricket Ground, Wimbledon, the Royal Artillery Barracks, the ExCel Centre, Wembley Arena, North Greenwich Arena, and last but not least Wembley Stadium where I will be assisting in providing medical cover for the football (soccer) events.

Competition venues outside London will include Brands Hatch, Eton Dorney, Hadleigh Farm, Weymouth and Portland, and the Lee Valley White Water Centre.

In addition to the competition areas, there are many other important non-competition venues being used for the Games including Heathrow Airport, St Pancras International Rail Station, the International Broadcast Centre and the Olympic and Paralympic Village that will host 17,000 athletes and team officials during the Olympic Games, and 6,000 athletes and team officials during the Paralympic Games.

Things have largely gone smoothly with the preparations so far, and next weekend I will be collecting my Games Maker uniform and accreditation. There is a real feeling of excitement with the Games just around the corner. Given that the last Games in London was held over 60 years ago, it’s unlikely that I will be able to be involved in a Games taking part in my home City again in my lifetime, and I feel lucky, proud and privileged to be able to make a contribution as a Games Maker in London this time around.

Perhaps of even more importance than my contribution to the Games as a Sport and Exercise Medicine Physician is that of working towards ensuring the success of the Olympic Legacy for health for our Nation. This is the first time that a deliberate and co-ordinated action to attempt to achieve a Legacy for improving the Health of the host Country has been attempted in relation to the Games – this is something that excites me even more than the Games itself. I’ll have more to say about the Olympic Legacy for Health in a future blog post.

Statistics re: 2012 Olympiad taken from the 2012 Games Maker Workbook, pictured

Olympic Torch picture by John Candy at Wikimedia Commons

Olympic Stadium picture at Wikimedia Commons

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Neuropsychological tests in sport-related concussion – are they worthwhile?

The article by Shrier in the current edition of CJSM revisits the issue of neuropsychological testing in the setting of sport-related concussion, and poses some searching questions in relation to the use of these tools in the diagnosis and management of sport-related concussion. In particular, he asks ‘…do the results of neuropsychological testing change patient management or provide other clinical benefit to the patient?’ and ‘Is there sufficient evidence to mandate it (neuropsychological testing) as standard of medical care?’ (Shrier, 2012).

Whilst it is clear that sport-related concussion is a hot topic in Sports Medicine, with an ever-increasing literature on the subject, and following three expert consensus panellist group meetings since 2001, controversy surrounding the diagnosis, management, and return to play protocols continues to rage amongst academics and clinicians alike.

In his article, Shrier concentrates on the application of neuropsychological tests to the sport-related concussion setting. Whilst it is accepted that neuropsychological tests alone are not adequate to confirm the diagnosis and dictate the ongoing management of concussion, they are currently widely used in the rehabilitation and return-to-play setting as a part of an overall neuropsychological assessment for players in elite sport suffering from a concussion – especially in hockey, and college football.

Shrier points out that neuropsychological tests are designed to give an objective assessment of brain function, but that ‘the objective in concussion management is to measure brain injury’ and points out that ‘brain injury is only one cause of decreased brain function,’ mentioning that there are several other factors that may affect brain function such as the presence or absence of other injuries or mood disorders (Shrier, 2012). The author does not point out exactly when he means by ‘brain function,’ however, nor discusses in detail any of the other multidimensional tools that may be used to assess this such as EEG and fMRI.

There are clearly limitations in using neuropsychological tests in the setting of sports-related concussion related to the issues Shrier points out in his article. However, it is important to remember that it is the application of these tests in the overall clinical context that perhaps assists the practitioner in making an informed and reasoned judgement as to whether impairment in brain function is likely to be secondary to concussion.

Further on in the article, Shrier goes on to argue that neuropsychological tests have ‘minimal value for an individual athlete and does not support mandating (their) use,’ (Shrier, 2012) and then examines the arguments for using the tests related to asymptomatic athletes at rest, athletes who are asymptomatic at rest but symptomatic on exertion, and athletes who are asymptomatic on exertion.

Whilst there is still academic debate surrounding the clinical usefulness of neuropsychological tests in the setting of sport-related concussions, doubt must also be levelled at their applicability and cost-effectiveness, a point also argued by Shrier in his conclusion. He also mentions that there are not enough neuropsychologists with appropriate expertise available to be able to warrant mandatory neuropsychological testing on a population level for them to be considered as standard of care, which is certainly true.

In his conclusion, Shrier argues that ‘NP testing provides only a small increase in prognostic information and does not change the management of athletes who are symptomatic at rest or with exercise,’ and points out that ‘There is no evidence that abnormal NP testing is associated with increased risk of further injury or delayed recovery in athletes who are asymptomatic at rest and exertion.’ (Shrier, 2012). 

The Concussion in Sport group, however,  in their last consensus statement mentioned that ‘the application of neuropsychological testing in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation.’ (McCrory et al, 2009).

No doubt Shrier’s article will fuel much continuing academic debate on the use of neuropsychological tests in the setting of sport-related concussion.

Are you using these tests as part of your overall concussion management programme?

CJSM would like to hear your thoughts on the debate.

References

1) Shrier i. 2012. Neuropsychological testing and Concussions: A Reasoned Approach. CJSM 22(3): 211-213

2) McCrory  P et al. 2009. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. CJSM 19(3): 185-200

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The Larks and the Owls – chronotypes and desynchronosis. Time for an individual approach with MEQ-SA analysis?

The practical management article in this month’s edition of the Clinical Journal of Sport Medicine by Charles H Samuels highlights a difficult problem facing athletes and their support staff that is commonly encountered during air travel, that of the issue of jet lag. Samuels makes the point about the difference between travel fatigue and jet lag (desynchronosis), defining the former as a  constellation of physical, psychological and environmental factors that impact over time on an athlete’s capacity to recover and perform, and the latter being defined as a number of symptoms occurring following travel between time zones.

The key to the understanding of these concepts lies within the study of Chronobiology – the field of biological science that examines cyclical phenomena in living organisms and their adaptation to solar and lunar rhythms. Human beings are normally diurnal creatures, usually being active in the day and sleeping at night. However, as many night and shift-pattern workers will attest, many of us are required to adapt to different patterns of activity and sleep as part of our everyday lives. Some of us are able to cope with these pattern shifts better than others, whereas extremes of sleep-activity outside the normal range may cause a person difficulty in participating in normal work, school and social activities.

Flight travel over different time zones presents a challenge for the individual as the body seeks adjusts its circadian rhythms to these different  zones. A number of different modalities may be used in order to prevent athletes developing jet-lag, including the use of melatonin, preflight adjustment to travel, timed light exposure and avoidance, and changes in training schedules. However, it is interesting to observe that some individuals seem to suffer from jet lag more than others, and that there is variability in the efficacy of preventative and treatment strategies for desynchronosis amongst athletes.

Why is it that some of us seem to cope better with time zone changes and shift pattern working? Perhaps the answer lies in an individual’s chronotype.

Sleep researchers refer to ‘Larks’ as individuals who naturally wake up in the morning, contrasting with the ‘Owls’ who wake up and go to sleep late. These groups are also described as being comprised by individuals with ‘morning-ness’ and ‘evening-ness’ tendencies. Most people lie somewhere in between. However, there are some interesting differences between the groups with some researchers going as far as to suggest that disease processes may be directly influenced by morning-ness and evening-ness. This news feature in Nature, published in 2009, discusses some of these concepts in greater detail for those readers who may be interested to know more.

Horne & Ostberg in 1976 presented a self-assessment morningness-eveningness questionnaire and this has been modified by others to produce an MEQ-SA. Those of you who may wish to objectively assess your lark-ish and owl-ish tendencies can find the modified MEQ-SA questionnaire and scoring table here. 

It is unclear which factors contribute to an individual’s chronotype, as there seems to be no clear correlation to gender, ethnicity, or socio-environmental factors. However, perhaps chronotype variation may go some way to explaining why there is such variability in the effect of different preventative strategies for jet-lag between individuals. If so, then the assessment of an individual’s chronotype may form an important part of an overall primary preventative strategy for travelling athletes and support staff, which may be best conducted as part of an individual approach rather than a team approach.

Unfortunately, there is currently a paucity of literature on chronotype analysis in elite athletes in relation to jet-lag prevention representing an opportunity for further research in this area.

Are any readers using chronotype analysis as part of a jet-lag prevention strategy? CJSM would like to know.

References –

Samuels, Charles H. 2012. Jet Lag and Travel Fatigue: A Comprehensive Management Plan for Sport Medicine Physicians and High-Performance Support Teams. Clin.J.Sport Med. 22(3): 268-273

Phillips, Melissa Lee. 2009. Of owls, larks and alarm clocks. Nature 458 

Horne JA & Ostberg O.1976. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int. J. Chronobiol. 4(2):97-110 

 

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