Patricia J. Ohtake

Exaggerated anxiety is not unique to CO2 in panic disorder: a comparison of hypercapnic and hypoxic challenges.

Current biological models of panic disorder (PD) assert that this disorder is maintained by hypersensitivity to carbon dioxide (CO2) and related asphyxia cues, which is manifested as an exaggerated suffocation alarm (D. Klein, 1993). Because suffocation can result from both increased CO2 (hypercapnia) and decreased oxygen (O2; hypoxia), this study examined respiratory responding and anxiety during 5% CO2 (a hypercapnic challenge) and 12% O2 (a hypoxic challenge) in 14 PD patients and 14 matched controls (MC). Results demonstrate that irrespective of the source of suffocation, PD patients respond with increased anxiety relative to MC participants. Significant group differences were observed in respiratory functioning, with the PD patients showing higher respiratory rates in response to both challenges. The MC sample demonstrated the expected respiratory responses to both hypercapnia and hypoxia. The findings indicate that PD patients are hypersensitive to alterations in breathing and that this reactivity is not specific to CO2.

Biomarkers in the diagnosis of aspiration syndromes.

Recognizing and managing the different types of aspiration events remain a challenging task due to the lack of distinguishing clinical or laboratory characteristics. Numerous biomarkers in serum, sputum and bronchoalveolar lavage have been studied, and their role in the recognition of aspiration remains controversial at this time. Recent animal investigations using an array of biomarkers based on distinct pathogenic features of each aspiration event have produced promising results; however, they have not been validated in humans. Newer markers are being introduced as diagnostic and prognostic tools in conditions such as community-acquired pneumonia and sepsis, but they have not been examined in aspiration. The present review summarizes the different biomarkers that have been studied in aspiration and those who might have a potential clinical use in the future.

Relationships between the anxiety sensitivity index, the suffocation fear scale, and responses to CO2 inhalation

Interest in documenting ways to predict anxious responding in panic disorder (PD) patients has proliferated recently in the literature. In the current study, two self-report measures were assessed to determine their relative utility in predicting responses to a panicogenic challenge. The Anxiety Sensitivity Index (ASI) and the Suffocation Fear Scale (SFS) were evaluated by correlating scores on these measures with reactions to inhalation of 35% carbon dioxide (CO2), assessed via anxiety ratings, panic symptom intensity, tidal volume (VT) and respiratory rate (RR). A sample of 14 PD patients and 14 matched control (MC) participants demonstrated that the relationship between ASI scores and responses to 35% CO2 were stronger than the relationship between SFS scores and responses to CO2. Specifically, both respiratory responses (VT and RR) and self-reported reactions (anxiety and symptom intensity) were significantly correlated with scores on the ASI. In contrast, scores on the SFS were significantly correlated with only one measure of respiratory change (VT). Although preliminary, these data indicate that the ASI may be a more useful tool than the SFS in predicting self-reported and respiratory responses to CO2 challenges.

The Role of Physical Therapists in Smoking Cessation: Opportunities for Improving Treatment Outcomes

Tobacco use constitutes one of the greatest threats to public health worldwide. As a preventable cause of mortality and chronic disease, tobacco use in the United States results in an estimated 443,000 deaths each year through both direct exposure and secondhand smoke.1 An additional 8,600,000 people across the nation have chronic illness due to smoking.1 As physical therapists, we must realize that tobacco use affects all areas of our practice, including cardiovascular, musculoskeletal, neurological, and integumentary health throughout the life span. In order to provide optimal care for the clients we serve, it is essential for physical therapists to screen for tobacco use and incorporate cessation strategies as part of our interventions.2 There is a substantial unmet demand and opportunity for our profession to promote tobacco cessation.2 Despite evidence that links successful cessation to counseling by health care providers, fewer than 40% of insured adults report receiving such advice.3 In addition, receiving advice from 2 or more health care practitioners more than doubles the odds of successful cessation,4 further supporting the need for physical therapists and physical therapist assistants to contribute our skills and expertise as part of the interdisciplinary health care team. Successful cessation efforts have been demonstrated by other health care professionals, including physicians, dentists, dental hygienists, nurses, and pharmacists, and are an important component of preventive medicine and population health.5 According to the US Medical Expenditure Panel Survey, in 2007, physical therapists conducted a total of 88 million ambulatory visits for approximately 9 million adults aged 18 years and over.6 The number of visits (an average of 9.6 per patient, per episode)6 and nature of our interactions, which include extended, personalized, one-on-one care, present a unique opportunity for physical therapists and physical therapist assistants to provide support for …

Tissue inhibitor of metalloproteinase-1 modulates allergic lung inflammation in murine asthma

Matrix metalloproteinases (MMPs) modulate development, inflammation, and repair in lungs. Tissue inhibitors of MMPs (TIMPs) interact with MMPs, controlling the intensity and nature of the response to injury. Absence of MMP-9, -2, and -8 activities is associated with altered lung inflammation during allergic sensitization. To test the hypothesis that the absence of TIMP-1 enhances allergic lung inflammation, airway hyperreactivity (AHR), and lung remodeling in asthma, we studied TIMP-1 null (TIMP-1 KO) mice and their WT controls using an ovalbumin (OVA) asthma model. TIMP-1 KO mice, compared to WT controls, developed an asthma phenotype characterized by AHR, pronounced cellular lung infiltrates, greater reduction in lung compliance, enhanced Th2 cytokine mRNA and protein expression, and altered collagen lung content associated with enhanced MMP-9 activity. Our findings support the hypothesis that TIMP-1 plays a protective role by preventing AHR and modulating inflammation, remodeling, and cytokine expression in an animal model of asthma.

Does electrical stimulation improve motor recovery in patients with idiopathic facial (Bell) palsy

The purpose of “Evidence in Practice” is to illustrate how evidence is gathered and used to guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated. A 35-year-old woman was referred to our clinic with the diagnosis of Bell palsy, a unilateral facial palsy of unknown etiology. The patient reported that she first noticed the problem when she awoke 2 days ago and saw that her face “was distorted and deviated towards the right side.” She stated that she was recovering from a recent respiratory tract infection and that the evening before the facial symptoms appeared, she experienced pain in the mastoid region. Upon observing the facial asymmetry, the patient was concerned that she was having a stroke. The patient saw her primary care physician who diagnosed her as having Bell palsy after having ruled out a tumor, stroke, and Lyme disease by physical examination, magnetic resonance imaging studies, and laboratory tests including blood work. The physician prescribed acyclovir and prednisolone and suggested a consultation with a physical therapist for management of her facial muscle weakness. Upon arrival in our clinic, the patient expressed great concern that her facial weakness would interfere with her work as a lawyer and indicated that she was willing to adhere to any treatment regimen that would enhance her chances of early and optimal recovery. Our examination of the patients vital signs revealed a heart rate of 76 bpm and blood pressure of 126/80 mm Hg. The neurologic examination revealed facial asymmetry at rest with drooping of the corner of the mouth and some accumulation of saliva on the left side of the mouth and a decrease in the prominence of the nasal labial fold. Sensation over the left side of the face was intact; …

Translating Research Into Clinical Practice: The Role of Quality Improvement in Providing Rehabilitation for People With Critical Illness

Our goal as health care professionals is to provide patients with the best care available. One important challenge is the slow translation of research evidence into clinical practice. It is essential that such “knowledge translation” is efficient and timely to ensure that patients receive the most effective therapies and achieve improved outcomes.1 Currently, the gap between publication of clinical research findings and their implementation into routine clinical practice is substantial2 and leads to suboptimal health care delivery.3 Alan Jette, PT, PhD, FAPTA, addressed this issue in the 43rd Mary McMillan Lecture, in which he shared his vision for the physical therapy profession to be a leader in implementing evidence-based strategies for health promotion and treatment interventions.4 One approach to facilitating the translation of research into clinical practice is the use of systematic quality improvement (QI) processes. Quality improvement attempts to change clinician behavior and, through those changes, lead to more consistent, appropriate, and efficient application of established clinical interventions, resulting in improved care and patient outcomes.5 Quality improvement is an intrinsic part of good clinical practice and is designed to bring about immediate improvements in health care in local settings.6 Quality improvement assumes that quality and safety are characteristics of health care systems, and many QI activities involve groups of clinicians, managers, and staff cooperating to improve procedures and practices.6 Quality improvement differs from human subject research in that the latter identifies new, effective therapies, whereas QI interventions are designed to enhance the real-world implementation of proven therapies, such as implementing an evidence-based practice guideline.6 To increase the reliable use of clinical research, not only does practitioner behavior need to change, but changes must occur in the culture of health care teams and organizations.7 Two very successful QI projects8– …

Advanced Glycation End Products Induce Obesity and Hepatosteatosis in CD-1 Wild-Type Mice

AGEs are a heterogeneous group of molecules formed from the nonenzymatic reaction of reducing sugars with free amino groups of proteins, lipids, and/or nucleic acids. AGEs have been shown to play a role in various conditions including cardiovascular disease and diabetes. In this study, we hypothesized that AGEs play a role in the “multiple hit hypothesis” of nonalcoholic fatty liver disease (NAFLD) and contribute to the pathogenesis of hepatosteatosis. We measured the effects of various mouse chows containing high or low AGE in the presence of high or low fat content on mouse weight and epididymal fat pads. We also measured the effects of these chows on the inflammatory response by measuring cytokine levels and myeloperoxidase activity levels on liver supernatants. We observed significant differences in weight gain and epididymal fat pad weights in the high AGE-high fat (HAGE-HF) versus the other groups. Leptin, TNF-α, IL-6, and myeloperoxidase (MPO) levels were significantly higher in the HAGE-HF group. We conclude that a diet containing high AGEs in the presence of high fat induces weight gain and hepatosteatosis in CD-1 mice. This may represent a model to study the role of AGEs in the pathogenesis of hepatosteatosis and steatohepatitis.

Rehabilitation for People With Critical Illness: Taking the Next Steps

Due to the omission of several references, the original, published editorial has been replaced by this corrected version. This special series on rehabilitation for people with critical illness (published in 2 issues—December 2012 and February 2013) presents recent advances in managing critical illness across the continuum of care, from the intensive care unit (ICU) to the community setting. The series also raises awareness of the essential role that physical therapists and rehabilitation and critical care professionals play in this growing patient population. The articles in this issue showcase important research conducted by established authors in the field, including physical therapists from across the United States and from Australia. In February 2013, articles will highlight innovative quality improvement initiatives, discuss key considerations for the profession, illustrate educational strategies, and describe novel cases. Improvements in managing the care of patients with critical illness have resulted in an increasing number of survivors.1 However, survivors of critical illness often experience “post–intensive care syndrome,”2 with long-lasting physical impairments, including muscle weakness and decreased functional ability3 and neuropsychiatric dysfunction.4 These consequences of critical illness often lead to decreased quality of life.5,6 Early intervention by physical therapists and other rehabilitation and critical care professionals is feasible and safe for patients in respiratory,7 medical,8 and surgical9 ICUs. Moreover, early rehabilitation in the ICU is associated with many short-term benefits, including decreased duration of mechanical ventilation, shorter ICU and hospital lengths of stay, shorter duration of delirium, and improved functional outcomes.8,10–12 Throughout a 1-year follow-up, early rehabilitation during the ICU stay also is associated with decreased hospital readmission and mortality rates.13 With this growing body of evidence, interest in early rehabilitation in the ICU is rapidly increasing, likely resulting in significant change from …

Tobacco Cessation Counseling Training in US Entry-Level Physical Therapist Education Curricula: Prevalence, Content, and Associated Factors

Background The US Public Health Service (USPHS) recommends tobacco cessation counseling (TCC) training for all health care professionals. Within physical therapist practice, smoking can have adverse effects on treatment outcomes in all body systems. In addition, people with physical disabilities have a higher smoking prevalence than the general population, creating a strong need for tobacco cessation among physical therapy clientele. Therefore, TCC training is an important component of entry-level physical therapist education. Objective The aims of this study were: (1) to determine need for TCC training within entry-level physical therapist education and (2) to identify potential barriers to implementation of USPHS guidelines in the academic environment. Design A descriptive cross-sectional survey was conducted. Methods Directors or academic coordinators of clinical education from entry-level physical therapist programs (N=204) were surveyed using an online instrument designed specifically for this study. Data regarding program and faculty characteristics, tobacco-related training content, and faculty opinions toward TCC in both physical therapist practice and education were analyzed descriptively. Results The response rate was 71%. A majority (60%) of programs indicated inclusion of tobacco-related training, most commonly 1 to 2 hours in duration, and of these programs, 40% trained students in the implementation of USPHS clinical guidelines for TCC. Limitations Data analyses were constrained by limited or missing data in some areas. A single faculty member completed the survey for each program. Conclusions There is a need for TCC training in entry-level physical therapist education. Inclusion may be facilitated by addressing perceived barriers toward TCC as a component of physical therapist practice and promoting the relevance of TCC as it relates to intended outcomes of physical therapy interventions.