Next generation of anatomy apps for learning and patient education here NOW!!

Regular readers of the blog may remember the previous post on anatomy applications (apps) back in June last year, when I presented my top 5 anatomy apps on the Apple apps store for both learning anatomy and educating patients.

For those of you who need a quick reminder, apps from the Apple store are computer programs that work on several Apple-platform mobile devices including iPads, iPhones and the iPod touch, with certain apps and features within apps being available only on certain devices, limited only by hardware and next generation development issues. For example, the iPad 2 has an integrated camera whereas the first generation device had none. The value of anatomy apps lies both within clinician and patient education.

The next generation of anatomy apps are now available from 3D4Medical, running on both first and second generation iPads. There are updates for both of the Skeletal System and Muscle System Pro Nova apps (now in their 3rd editions), and new dedicated apps for the hip joint, knee joint and shoulder joint which include the complete anatomy of these regions including musculoskeletal anatomy, nervous system and vascular anatomy.

I am pleased to say that there has been a significant improvement to the existing apps which were already excellent in quality. Now, they are simply outstanding in many ways. The quality of the visuals has not gone unnoticed by Apple themselves who have showcased some of the apps on their latest TV adverts. The images really are stunning when seen on the iPad.

Both Skeletal and Muscle System Pro Nova III apps come with a new interface which allows for simpler navigation. Images can be more easily manipulated than before for different viewing angles allowing for simpler rotation, single finger-swipe cuts for coronal, saggital and transverse views, and a double-tap zoom feature. This allows you to get to the images you really want to see much quicker than before. There is a hint feature to help you to get to grips with the new graphical interface features which can be turned off once you get used to these. Pin Media labels are more extensive, and these are now spoken to allow users to hear the correct pronunciation of each anatomical feature.

The pin labels themselves now come with additional media, such as animations of anatomical movements or further images. There are also linked public notes which allows for users to read notes made by other users of the apps in the public domain. The images can be easily annotated, and shared with patients or other people who may wish to view them by email and social media via twitter and Facebook.

The new dedicated apps are perhaps the ones of most interest to clinicians, for the first time including all of the relevant anatomy of the regions to give a clear picture of the entire anatomy from surface to bone. The clarity of images within these apps is outstanding, and the animations are especially helpful for explaining how certain muscles produce certain movements to patients. Structures such as the subacromial bursa in the shoulder can easily be visualised, and when combined with the animations showing movement at the shoulder joint, it is much easier than before to explain to patients how impingement of this structure can occur under the subacromial arch.

You can check out the new features in the Knee Pro Nova video below (will only show on standard site).

Having used the earlier apps during my patient consultations as an educational tool, I have now started to use these new apps and have found them easier to use both in the consulting room and at the training ground than the previous incarnations. Patients seem to gain a better understanding of the anatomy relevant to their injuries or conditions when seeing the visuals, and the multimedia content really helps to bring functional anatomy to life.

Perhaps future additions to the series might include videos specifically related to pathologies. Examples might be video image of an inflamed bursa impinging under the subacromial arch, a ruptured anterior cruciate ligament in real time, or the dynamic anatomy of a snapping hip. For now, however, these apps give clinicians an extremely powerful set of tools for patient education, and for learning anatomy.

For further information on 3D4Medical’s new apps, see the 3D4Medical website, or check out videos of the other apps on youtube via these links :

Shoulder Pro

Hip Pro

Skeletal System Pro III (Nova Series)

Muscle System Pro III (Nova Series)

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PRP – magic bullet, or damp squib?

I’m guessing that not many of you will have seen the Academy Award-nominated biographical movie ‘Dr Ehrlich’s Magic Bullet’ starring Edward G Robinson. It outlines part of the career of the famous German scientist  Dr Paul Ehrlich, who popularised the concept of the ‘magic bullet’ therapy for the treatment of specific diseases. The film focuses on arsphenamine, ‘compound 606,’ and Ehrlich’s cure for syphylis.

The concept of the ‘magic bullet’ is rather older however, dating back at least to the 1800’s and deriving from the histochemical staining of tissues. It was Ehrlich’s opinion that, if a chemical could be found that targeted a pathogen, then a toxin could be delivered along with that chemical and hence a ‘magic bullet’ would be created that would destroy the pathogen leading to the elimination of a disease state. The concept was later realised following the discovery of monoclonal antibodies for which Köhler, Milstein and Jerne shared a Nobel Prize in 1984.

So-called ‘targeted therapies’ do not necessarily destroy their target as such, but may act to cause some form of modification, for example to a cell membrane via second messenger cascades or within the cell nucleus itself, leading to alterations in cellular genetic expression which then lead to a sequence of events that ultimately results in healing or an improvement in clinical symptoms.

Platelet-rich plasma (PRP) has been perhaps the most widely investigated preparation of late. PRP contains a number of growth factors including PDGF, IL-8, and CTGF, which have a number of different effects on different cells. Many of these actions are poorly understood, despite much basic science research, yet this has not prevented the clinical application of PRP for tendinopathies which is perhaps not surprising given the search for effective therapies for tendinopathies and the drive for ‘cutting-edge’ therapies in Sports Medicine.

However, when one stops to consider the knowledge gaps we have concerning the pathophysiology of tendinopathies, and our lack of understanding of the complex interactions involved in cellular healing mechanisms, then perhaps one may not be surprised to see the heterogeneity of results from clinical trials using PRP in the treatment of these conditions. The three main theories for the genesis of tendinopathy, namely overuse, overload and thermal stress, are still open to debate and there is a very wide range of possible actions of PRP on tendinopathic tendons.

Well-conducted clinical trials such as this one by de Jong et al on PRP for achilles tendinopathy, and systematic reviews such as this one by de Vos and colleagues ,have failed to find a positive clinical effect when using PRP use for the treatment of tendinopathies.

In this month’s systematic review in CJSM on the use of PRP in Sports Medicine as a new treatment for tendon and ligament injuries, Taylor and colleagues concluded that, despite several possible theoretical advantages to the use of PRP, there are very few well-conducted prospective studies and clinical trials available with which to inform clinical practice.

The recent IOC consensus paper on the use of PRP in sports medicine published in BJSM also highlighted the limited amount of basic science research, the paucity of well-conducted clinical studies on PRP, and the heterogeneity of methodological issues between different studies making comparisons of clinical effects difficult to judge. The IOC group’s recommendation was that clinicans should proceed with caution in the clinical use of PRP.

The debate is on as to whether there is a true lack of efficacy of PRP in the treatment of tendinopathies, or whether we simply need more well-designed clinical research.

What do you think? Where do we need to focus our research efforts? Should we forget the idea of ‘targeted therapies’ such as PRP and ‘magic bullets’ for tendinopathies?

CJSM would like to hear your views.

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When Anatomy meets Technology – Learning and Educating with Anatomy Apps

With over 108 million iPhone sales since 2007 and rising, together with 60 million iPod touch sales and 25 million iPads, there is a now a huge global userbase for applications (Apps) on these devices with over 425,000 Apps in total available in the App store.  Android-capable mobile phones are also growing in popularity, and these have their own applications for use on these devices.

An App store search using ‘anatomy’ reveals 372 iPhone and iPod touch compatible anatomy Apps, together with 170 dedicated iPad anatomy Apps. Some of these show images of anatomy, some are ‘flash cards’ and some have integrated quizzes.

Anatomy apps can be useful for both learning anatomy and for using as an educational tool in  a patient consultation. Given the portability of the iPhone, iPod touch and iPad, it is easy to use these Apps in the clinic, at the training ground, or whilst on tour with teams, and most of the Apps do not require internet access to function once they have been downloaded.

Some of the better Apps have the ability to add notes and annotations to diagrams, and to view structures from multiple angles with magnification. Whilst the detail is sometimes limited, there is often more than enough to be able to use an App to help to explain the relevant structures to patients in order to improve their understanding of their injuries, and indeed to learn some of the anatomy that a Sports Physician might need. However, the extensive detail is often lacking, so there is room for improvement.

Here are my ‘Top 5’ Anatomy Apps currently available in the App store :

1) Pocket Body – The Interactive Human Body (iPad / iPod Touch / iPhone) (App store link here)

This App by eMedia Interactive LTD has a 9-layer graphic of the human body, with 4 views (anterior, left lateral, posterior and right lateral), and the images magnify up nicely without significant pixellation. Muscles, bones, tendons, vessels and nerves are all shown. Pins are attached to most of the muscles, and a quick press reveals the origin, insertion, key relations, functions, and innervation and vascular supply. In addition, some clinical notes are shown although these are somewhat limited in scope and not always accurate. It is possible to add your own notes, and to edit these. Many of the pins attached to nerves are red, and indicate the structures but give no additional detail although you can add your own notes and indeed can add your own pins on the model.

There are 3 different quizzes available – a ‘locate pins’ quiz, an MCQ, and a flash card type quiz and these can be set to examine any particular region. In addition, there is the ability to take a screenshot of an image and to share the image by email, post on your Facebook page or link to Twitter, or save to your device. This is a great App for learning the basics of musculoskeletal anatomy, and for showing relevant structures to patients.

2) Muscle System Pro II (Nova Series) and Skeletal System Pro II (Nova Series) (iPad / iPod Touch / iPhone) (App store links here – muscle & skeletal)

These are 2 separate Apps by 3D4 Medical, and show some really quite beautiful images, with the ability to view from many different angles. The image pins link to information boxes. The information on muscles shows origin, insertion, action, innervation and vascular supply. There is also the ability to add your own notes. Individual structures can be shown such as different bones, with excellent quality images when fully magnified, and with much anatomical detail. There are quizzes, although these are somewhat easy for anyone except novices. The images are probably the best available on these devices and are particularly impressive on the iPad, and these can be shared by email or social networking applications.

3) Muscle Trigger Points (iPod Touch / iPhone / iPad) (App store link here)

This App by Real Bodywork acts as a reference for common muscle trigger points. There is information on over 70 muscles and 100 different trigger point patterns, with information on the action of the relevant muscles and on the referral pain patterns. There is a 3D model which rotates in 2 animations to anterior and posterior images showing the different muscles, and muscles can be viewed individually from a list, or by choosing ‘zones.’ Real Bodywork provide a number of other anatomy Apps in addition to the Muscle Trigger Point App, including a ‘Learn Muscles’ App, a muscle and bone anatomy 3D for iPad, and skeletal anatomy 3D quiz and reference.

4) Instant Anatomy Lectures, Flash Cards, A/V Lectures and MCQ Apps (iPad / iPod Touch / iPhone / Android) (App store link here)

Robert Whitaker has been offering a number of excellent resources from his Instant Anatomy series for a number of years now. These originally started with books, going on to CD ROMs, and now a series of Apps. There are podcasts of anatomy lectures, video podcasts, and flash card Apps. This series of Apps offers some quite wonderful learning material, especially for the novice, and a great way to learn anatomy. The diagrams are easy to understand, although are more suited to learning than to explaining structures and pathology to patients. Some of the Apps are free on the App store, offered as ‘tasters’ with limited information, so you can try them out for yourself. Highly recommended for medical students and those re-engaging with anatomy after a while.

5) Aspects of Anatomy (iPad / iPod Touch / iPhone) (App store link here)

This App was developed by my one of my former anatomy teachers at University College, London, Professor Peter Abrahams, who is now Professor of Anatomy at Warwick University. He is also one author of the excellent ‘Essentials of Clinical Anatomy’ text. It consists of a series of 38 short (3-8 minute) lectures on a number of plastinated specimens, together with some related clinical information on related topics such as Colles fracture. In addition, imaging modalities are included, together with ‘spot’ quizzes (don’t I remember those during my Anatomy finals!) and clinically relevant MCQs. This is a wonderful resource for medical students and those revisiting anatomy.

CJSM would be interested to hear about your favourite Anatomy Apps, and how you use them in your clinical practice.

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