Physical therapy workforce in the United States: forecasting nationwide shortages.

OBJECTIVE: To examine current and future physical therapy (PT) job surplus/shortage trends across the United States. DESIGN: Forecast models and grading methodology previously published for nursing were used to evaluate individual state PT job shortages from 2008 to 2030. SETTING: Not applicable. PARTICIPANTS: Not applicable. METHODS: The forecast model used to project PT job supply and demand accounted for changes in age and population size on the basis of estimates from the U.S. Census Bureau for each of the 50 states. PT shortages were assigned letter grades on the basis of shortage ratios (difference between demand and supply per 10,000 people) to evaluate PT shortages and describe the changing PT workforce in each state. RESULTS: On the basis of current trends, demand for PT services will outpace the supply of PTs within the United States. Shortages are expected to increase for all 50 states through 2030. By 2030, the number of states receiving below-average grades for their PT shortages will increase from 12 to 48. States in the Northeast are projected to have the smallest shortages, whereas states in the south and west are projected to have the largest shortages. CONCLUSION: These data serve to provide health professionals, policy makers, and stakeholders with a means of assessing current and future PT needs. Discussion of the issues surrounding PT shortages and ongoing assessment of supply and demand must ensue to mitigate projected shortages. Although our model has several limitations and may be oversimplified, it is the first attempt to use available, creditable data to examine both supply and demand for the entire country. Follow-up studies that use more complex modeling are needed to adequately forecast future trends beyond that accomplished in the current article. Monitoring trends over time is critical to maintain an appropriate balance between PT supply and demand that meets the population needs.

Stimulation of the expiratory muscles using microstimulators.

Respiratory complications constitute a major cause of morbidity and mortality in patients with spinal cord injury. These complications arise in part due to the loss of supraspinal control over the expiratory muscles and the resultant difficulties in clearing airway secretions effectively. The purpose of the present study is to evaluate the efficacy of lower thoracic spinal nerve stimulation using wireless microstimulators in activating the expiratory muscles. Studies were performed on nine anesthetized dogs. A thoracic laminectomy was performed on each dog,and was followed by spinal cord transection at T2. A total of 16 microstimulators (supplied by the Alfred Mann Foundation, Santa Clarita, CA) were inserted percutaneously into the bilateral intercostal nerves approximately 1 to approximately 3 cm distal to the neuroforamen from T7 to L1 in each dog. The stimulation parameters were: frequency of 20 Hz, pulse width of 200 micros, and stimulation burst of 2 s. The stimulation intensities were 3.78, 5.4, 8.1, and 10.8 mA. The pressure-generating capacity of the expiratory muscles was evaluated by the change in airway pressure (Paw) at functional residual capacity, which was produced by the microstimulators during airway occlusion. As a general trend, the expiratory pressure generated using the microstimulators increased with increasing intensity and the number of spinal nerves recruited. The maximal expiratory pressures generated from one, two, three, four, five, six, seven, and eight pairs of spinal nerves were 8.4 +/- 0.8, 12.2 +/- 1.0, 14.6 +/- 1.4, 17.8 +/- 1.8, 23.0 +/- 1.8, 27.7 +/- 2.2, 35.2 +/- 2.7, and 40.4 +/- 2.9 cmH2O, respectively. Bilateral stimulation of seven (from T8 to L1) and eight spinal nerve levels (from T7 to L1) produced the highest changes in(Paw). Stimulation of six or less spinal nerve levels resulted in significantly lower (Paw). We conclude: 1) lower thoracic spinal nerve stimulation near the neuroforamen using microstimulators produces significant expiratory pressure, 2) percutaneous placement of the microstimulators near the neuroforamen is effective in producing expiratory pressure, and 3) percutaneous placement of the microstimulators for restoring cough may potentially be used as a relatively noninvasive clinical tool for patients with spinal cord injury, or other neurological or respiratory disorders. Further studies will be needed.

California regional registered nurse workforce forecast.

OBJECTIVE: To forecast the shortage of registered nurses (RNs) of the 24 Primary Metropolitan Statistical Areas (PMSA) and Metropolitan Statistical Areas (MSA) in California. BACKGROUND: A nursing shortage prevails nationally and is most serious in the state of California. Successful interventions in the alleviation of the RN shortage will require effective resource allocation and academic program development in various regions throughout the state. While various published studies have focused on nursing workforce development at the state and even regional levels, there are no studies focused on identifying RN shortages at the PMSA or MSA (P/MSA) level. In this report, a forecasting model is developed to systematically analyze the future supply and demand of the RN workforce within each California P/MSA. METHODS: Using accessible public databases, forecasting models were constructed to project the demand and supply of RN jobs in California P/MSAs. In the demand model, population age and size were used as determinants of regionally required RN jobs. In the RN jobs (supply) model, a region's supply of RNs was the net sum of factors increasing and decreasing the regional presence of RN jobs, including RN graduations, migration, and aging of the RN workforce. The combination of these supply and demand models was used to produce regional RN shortage forecasts for future years. RESULTS: Almost all regions exhibited growing shortages by 2020 at rates ranging from 3% to 600%. Using a modified version of the grading rubric of the California Regional Registered Nurse Workforce Report Card (Lin, Lee, Juraschek, & Jones, 2006), only two regions will receive a grade above "C" in 2020. The number of "F" grades will grow to nine. CONCLUSIONS: California has the lowest RN ratio in the United States (Fletcher, Guzley, Barnhill, & Philhour, 2004; Health Resources and Services Administration, 2004a) and this RN workforce forecasting model shows that over the next 15 years, the majority of P/MSAs in California will have increasing RN shortages. This analysis has significant policy implications including the need to create specific plans to mitigate the effect of the California shortage.

Modulation of cardiovascular excitatory responses in rats by transcutaneous magnetic stimulation: role of the spinal cord.

This study investigated the efficacy of magnetic stimulation on the reflex cardiovascular responses induced by gastric distension in anesthetized rats and compared these responses to those influenced by electroacupuncture (EA). Unilateral magnetic stimulation (30% intensity, 2 Hz) at the Jianshi-Neiguan acupoints (pericardial meridian, P 5-6) overlying the median nerve on the forelimb for 24 min significantly decreased the reflex pressor response by 32%. This effect was noticeable by 20 min of magnetic stimulation and continued for 24 min. Median nerve denervation abolished the inhibitory effect of magnetic stimulation, indicating the importance of somatic afferent input. Unilateral EA (0.3-0.5 mA, 2 Hz) at P 5-6 using similar durations of stimulation similarly inhibited the response (35%). The inhibitory effects of EA occurred earlier and were marginally longer (20 min) than magnetic stimulation. Magnetic stimulation at Guangming-Xuanzhong acupoints (gallbladder meridian, GB 37-39) overlying the superficial peroneal nerve on the hindlimb did not attenuate the reflex. Intravenous naloxone immediately after termination of magnetic stimulation reversed inhibition of the cardiovascular reflex, suggesting involvement of the opioid system. Also, intrathecal injection of delta- and kappa-opioid receptors antagonists, ICI174,864 (n=7) and nor-binaltorphimine (n=6) immediately after termination of magnetic stimulation reversed inhibition of the cardiovascular reflex. In contrast, the mu-opioid antagonist CTOP (n=7) failed to alter the cardiovascular reflex. The endogenous neurotransmitters for delta- and kappa-opioid receptors, enkephalins and dynorphin but not beta-endorphin, therefore appear to play significant roles in the spinal cord in mediating magnetic stimulation-induced modulation of cardiovascular reflex responses.

California regonal regstered nurse workforce report card.

Various reports and opinion papers have offered suggestions to alleviate the national and California RN shortages. The methodology of using the report card concept for comparing the number of RN jobs per 100,000 populations regionally with the national database further highlights the severe shortage of RN's in various regions in California. This report card method may potentially be used as a planning or forecasting tool, as well as a monitoring tool to initiate workforce development strategies and projects, and to evaluate their effectiveness over time.

Functional magnetic stimulation facilitates gastric emptying.

OBJECTIVE: To evaluate the effect of functional magnetic stimulation (FMS) on gastric emptying in able-bodied and spinal cord injury (SCI) subjects. DESIGN: A prospective, nonrandomized clinical experiment. SETTING: SCI and disorder center in a Veterans Affairs medical facility. PARTICIPANTS: Five healthy, able-bodied subjects and 4 subjects with SCI. INTERVENTION: A commercially available magnetic stimulator was used; a round magnetic coil was placed along the T9 spinous process. The intensity of the magnetic stimulation was 60%, with a frequency of 20 Hz, and a burst length of 2 seconds for the gastric emptying protocol. Man Outcome Measures: Rate of gastric emptying and time required to reach gastric emptying half-time (GE(t1/2)) with and without FMS. Data fit into linear regression curve. RESULTS: Accelerated gastric emptying was achieved in both able-bodied and SCI subjects. The mean +/- standard error of mean of the GE(t1/2) at baseline and with FMS was 36+/-2.9 minutes and 33+/-3.1 minutes, respectively, for able-bodied subjects, and 84+/-11.1 minutes and 59+/-12.7 minutes, respectively, for SCI subjects. CONCLUSION: Gastric emptying was enhanced by FMS in able-bodied subjects and was greatly enhanced in SCI subjects. FMS can be a useful noninvasive therapeutic tool to facilitate gastric emptying in humans.

High intensity magnetic stimulation over the lumbosacral spine evokes antinociception in rats.

OBJECTIVES: High intensity magnetic stimulation (MS) applied over the skin can painlessly depolarize superficial and deep nerves and we aimed to evaluate the effectiveness of MS of spinal nerves in evoking a potent analgesic response. METHODS: The MS was administered to adult male Sprague-Dawley rats using a Cadwell MES-10 high-speed magnetic stimulator. A Peltier device and von Frey fibers were used to determine heat and mechanical nociceptive responses of the rats. RESULTS: A brief (5 min) course of MS over the rat's lumbosacral spine produced a long-lasting (30-40 min) and robust (80-90% maximum possible effect) hindpaw antinociceptive effect to both mechanical and heat stimuli. Spinal cord transected rats had intact hindpaw nociceptive withdrawal responses, but transection eliminated MS evoked antinociception, indicating a critical extrasegmental component in the mechanism of MS antinociceptive action. The opiate receptor antagonist naloxone (5 mg/kg, i.p.) completely blocked MS evoked antinociception, demonstrating an opioidergic mechanism for MS antinociception. The alpha(2) adrenoceptor antagonist atipamezole (5 mg/kg, i.p.) slightly reduced the MS antinociceptive response to heat and had no effect on MS antinociception for mechanical stimuli. CONCLUSIONS: These data indicate that MS can evoke a robust, long-lasting antinociceptive effect, which requires an intact supraspinal pathway and is opioidergic mediated.