The Inverted Case Study Technique: changing the traditional case-study approach to prioritize physiological mechanisms over correct diagnosis and treatment.

The traditional case study has been used as a learning tool for the past 100 years, and in our program, graduate physiology students are presented with a real-world scenario and must determine the diagnosis and treatment of the patient. We found that students defaulted to memorization of disease with treatment and bypassed gaining an understanding of the mechanistic physiology behind disease and treatment. To adjust our student's approach, we developed a novel way to enhance student learning. To accomplish this shift from memorization to physiological mastery, we created the Inverted Case Study. This approach diverges from the traditional model in that students are given the diagnosis and treatment beforehand and are tasked with explaining the actual physiology of the case. In this way, students can no longer rely on the memorization of symptoms-disease-treatment but rather gain a solid understanding of the physiological mechanisms of the disease since that is the focus of the Inverted Case Study Technique. The Inverted Case Study approach is an effective approach to apply and hone critical thinking skills.NEW & NOTEWORTHY This article presents a novel approach to century-old learning techniques that enhances students' self-reported learning and also their attitudes toward learning mechanistic physiology and increases their perception of preparedness for professional school.

Autogenic biofeedback training improves autonomic responses in a participant with cervical motor complete spinal cord injury- case report.

STUDY DESIGN: Single-subject case design OBJECTIVE: To evaluate the Autogenic Feedback Training Exercise (AFTE) on autonomic nervous system responses. INTRODUCTION: AFTE combines specific autogenic exercises with biofeedback of multiple physiological responses. Originally developed by the National Aeronautics and Space Administration (NASA), AFTE is used to improve post-flight orthostatic intolerance and motion sickness in astronauts. Individuals with cervical or upper thoracic spinal cord injury (SCI) often present symptoms of autonomic dysfunction similar to astronauts. We hypothesize that AFTE challenges nervous system baroreflex, gastric and vascular responses often impaired after SCI. METHODS: Using a modified AFTE protocol, we trained a hypotensive female participant with cervical motor complete (C5/6-AIS A) SCI, and a male non-injured control participant (NI) and measured blood pressure (BP), heart rate (HR), gastric electrical activity, and microvascular blood volume before, during and after AFTE. The participants were instructed to complete breathing and imagery exercises to help facilitate relaxation. Subsequently, they were instructed to use stressful imagery and breathing exercises during arousal trials. RESULTS: Both participants completed 8 sessions of approximately 45 min each. Microvascular blood volume decreased 23% (SCI) and 54% (NI) from the beginning to the end of the stimulation cycles. The participant with SCI became progressively more normotensive and improved levels of gastric electrical activity, while the NI participant's changes in HR, gastric electrical activity, and BP were negligible. CONCLUSIONS: AFTE may offer a novel non-pharmacologic intervention to minimize symptoms of dysautonomia in people with SCI.

Active learning assignment: Legos and coins to explain glucose metabolism.

This article describes an assignment used in an undergraduate Advanced Exercise Physiology course for seniors. Students' backgrounds in chemistry varied from adequate to almost nonexistent. This presented several challenges for teaching and students' understanding of aerobic oxidation of a glucose molecule. This article presents an assignment for an active-learning team-based approach in the classroom and the adapted version for virtual learning. Students in active, team-based learning were asked to create a short video of glucose oxidation using Lego bricks, coins, or other toys to represent the glucose molecule, the by-products, and the enzymes involved in each pathway. During virtual learning, the assignment was modified to create a video independently in both synchronous and asynchronous course sections. Based on students' responses to an instructor-developed survey on their perceptions of the assignment, 71% reported that the assignment was helpful to understand glucose metabolism.

A Randomized Study on the Effects of Minds in Motion and Yoga on Motor Proficiency and Academic Skills Among Elementary School Children.

BACKGROUND: Physical activity is critical for the healthy development and well-being of children. Specifically, physical activity is associated with improvements in coordination, balance, attention, and behavior among elementary school-aged children. However, for many children, particularly those belonging to minority groups, opportunities to engage in quality physical activity programs outside school settings are limited. The purpose of this study was to examine the whether a physical activity program called Minds in Motion (MiM) The Maze before school, as compared with yoga, meets the criteria of the Comprehensive School Physical Activity Program framework as a before-school program to improve overall physical activity and academic performance among elementary school-age students. METHODS: A total of 48 children attending an urban public school with large minority representation in the Midwest were randomly assigned to MiM-The Maze or yoga. Participants were assessed on motor proficiency, behavior, balance, and academic skills before and after training. Training consisted of either yoga or MiM-The Maze 30 minutes per day before school, 5 times per week for 12 weeks. RESULTS: MiM-The Maze and yoga group students showed significant improvements in academic skills. CONCLUSIONS: MiM-The Maze is feasible and affordable before-school program to promote students' classroom behavior in elementary school students.

Physiology Understanding Week in a public middle school in Southern Indiana: exercise and health.

The Physiology Understanding (PhUn) Week is a national outreach event sponsored by the American Physiological Society. Our PhUn team conducted an event for 551 students (12.5 ± 0.9 yr old) in a middle school in Indiana. The aims of this program were to: 1) teach about the negative consequences of inactivity on cardiovascular (CV) health and overall well-being; 2) help students to determine their own CV fitness level and design their fitness plan; and 3) test the hypothesis that students who are offered daily physical education (PE) classes are able to meet the Physical Activity Guidelines for Americans. The University of Louisville PhUn team visited the school during school hours to execute the outreach program to students enrolled in Health and PE as their course elective. During the event, students were educated about CV physiology and the effects of exercise on CV fitness and metabolism. Additionally, students were asked to completed a questionnaire about their physical activity behaviors outside the school. Students were also educated about ways to increase energy expenditure by 150 METy (units of metabolism for youth) per day during 7 days. CV fitness levels were estimated by using the PACER (Progressive Aerobic Cardiovascular Endurance Run) test, and students were asked to create a plan to increase energy expenditure daily. The results showed that 53% of the students did not perform enough physical activity outside school to meet the guidelines. In conclusion, the incorporation of PE in schools is critical to cultivate healthy lifestyles and decrease the sedentarism epidemic in the U.S.

Physiology Understanding (PhUn) Week in a public Spanish-immersion elementary school in Kentucky.

The purpose of this outreach program was to promote elementary school students' understanding of human physiology and exercise science. I conducted this outreach event for 421 pre-kindergarten through grade 5 students attending a Spanish-immersion elementary school within a large, urban public school district in Kentucky. To meet the needs of the school's minority students, I delivered the Physiology Understanding (PhUn) program bilingually in both English and Spanish. The University of Louisville's PhUn team was composed of 14 undergraduate students, 5 graduate students, and 3 other faculty scientists who participated and supported me throughout the delivery of this outreach program. Elementary school students were taught about science, learned how to make scientific discoveries, and made predictions to test the hypothesis that heart rate increases with exercise. Hands-on activities and demonstrations included use of oxymeters, heart rate monitors, spirometry, blood pressure at rest and during exercise, and electromyography. We invited grade 4 and 5 students to participate in a science fair in which 32 students designed their own research projects and presented their findings during the science fair in three categories: English, Spanish, and bilingual.

Epidural stimulation with locomotor training improves body composition in individuals with cervical or upper thoracic motor complete spinal cord injury: A series of case studies.

CONTEXT: Four individuals with motor complete SCI with an implanted epidural stimulator who were enrolled in another study were assessed for cardiovascular fitness, metabolic function and body composition at four time points before, during, and after task specific training. Following 80 locomotor training sessions, a 16-electrode array was surgically placed on the dura (L1-S1 cord segments) to allow for electrical stimulation. After implantation individuals received 160 sessions of task specific training with epidural stimulation (stand and step). OUTCOME MEASURES: Dual-energy X-ray absorptiometry (DXA), resting metabolic rate and peak oxygen consumption (VO2peak) were measured before locomotor training, after locomotor training but before epidural stimulator implant, at mid-locomotor training with spinal cord epidural stimulation (scES) and after locomotor training with scES. FINDINGS: Participants showed increases in lean body mass with decreases on percentage of body fat, particularly android body fat, and android/gynoid ratio from baseline to post training; resting metabolic rate and VO2peak also show increases that are of clinical relevance in this population. CONCLUSIONS: Task specific training combined with epidural stimulation has the potential to show improvements in cardiovascular fitness and body composition in individuals with cervical or upper thoracic motor complete SCI.

Compensatory muscle activation during forced respiratory tasks in individuals with chronic spinal cord injury.

When lesions in the spinal cord occur, the neural activation of respiratory muscles is compromised (De Troyer and Heilporn, 1980; De Troyer et al., 1986, 1990; Estenne et al., 2000a) resulting in significant respiratory dysfunction (De Troyer and Heilporn, 1980; Linn et al., 2000, 2001; Yokoba et al., 2003). However the underlying mechanisms that contribute to this dysfunction remain unclear. The aims of this study were: (1) to investigate whether a correlation exists between pulmonary function and the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) examination scores for sensory and motor function; (2) to evaluate whether compensatory muscle activation plays a role in pulmonary function after spinal cord injury (SCI). We recorded Forced Vital Capacity (FVC); Forced Expiratory Volume in 1s (FEV1); and electromyography (EMG) of respiratory muscles during maximum respiratory tasks in 36 with SCI and 15 neurologically intact participants. Results indicate that pulmonary function (FVC, FEV1) was strongly correlated with motor and sensory scores from the ISNCSCI exam and maximal expiratory pressure (MEP) was also significantly related to ISNCSCI sensory scores (ρ=0.73, p<.001) and moderately, but significantly correlated to motor scores (ρ=0.41, p=.04). After SCI, there is a compensatory recruitment of accessory muscles upper trapezius during maximal inspiratory pressure (MIP) and pectoralis and latissimus dorsi during MEP that is significantly higher than in non-injured (p<.001).

Respiratory motor function in seated and supine positions in individuals with chronic spinal cord injury.

This case-controlled clinical study was undertaken to investigate to what extent pulmonary function in individuals with chronic spinal cord injury (SCI) is affected by posture. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) were obtained from 27 individuals with chronic motor-complete (n=13, complete group) and motor-incomplete (n=14, incomplete group) C2-T12 SCI in both seated and supine positions. Seated-to-supine changes in spirometrical (FVC and FEV1) and airway pressure (PImax and PEmax) outcome measures had different dynamics when compared in complete and incomplete groups. Patients with motor-complete SCI had tendency to increase spirometrical outcomes in supine position showing significant increase in FVC (p=.007), whereas patients in incomplete group exhibited decrease in these values with significant decreases in FEV1 (p=.002). At the same time, the airway pressure values were decreased in supine position in both groups with significant decrease in PEmax (p=.031) in complete group and significant decrease in PImax (p=.042) in incomplete group. In addition, seated-to-supine percent change of PImax was strongly correlated with neurological level of motor-complete SCI (ρ=-.77, p=.002). These results indicate that postural effects on respiratory performance in patients with SCI can depend on severity and neurological level of SCI, and that these effects differ depending on respiratory tasks. Further studies with adequate sample size are needed to investigate these effects in clinically specific groups and to study the mechanisms of such effects on specific respiratory outcome measures.

Quality of residual neuromuscular control and functional deficits in patients with spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: This study examined the relationship between motor control and clinical function outcomes after spinal cord injury (SCI). SETTING: University of Louisville, Louisville, KY, USA. MATERIALS: Eleven persons with SCI and 5 non-injured subjects were included in this study. METHODS: The ASIA Impairment Scale (AIS) was used to categorize injury level and severity. Multi-muscle, surface EMG (sEMG) recording, was carried out using a protocol of reflex and volitional motor tasks and was analyzed using a vector-based tool that calculates index values that relate a distribution of multi-muscle activation pattern of each SCI subject to the prototype obtained from non-injured subject group and presents overall magnitude as a separate value. Functional Independence Measure motor sub-scale, Spinal Cord Injury Independence Measure (SCIM-III), and Walking Index for Spinal Cord Injury (WISCI) scale scores were compared to neurophysiological parameters. RESULTS: AIS category and injury level correlated significantly with the WISCI and SCIM mobility sub-scales. sEMG-derived parameters were significantly correlated with SCIM and WISCI scores but only for examinations carried out 48 or more days post-injury. CONCLUSION: These results supported the hypothesis that clinically relevant function after SCI is related to the degree to which functional organization within the central nervous system is disrupted. Further, due likely to the constraints placed on the expression of functional ability by early post-injury immobilization and hospitalization, neurophysiological assessment of motor function may provide better sensitivity and reliability than can be obtained using the clinical function scales examined here within the early period after injury.

Locomotor step training with body weight support improves respiratory motor function in individuals with chronic spinal cord injury.

This prospective case-controlled clinical study was undertaken to investigate to what extent the manually assisted treadmill stepping locomotor training with body weight support (LT) can change respiratory function in individuals with chronic spinal cord injury (SCI). Pulmonary function outcomes (forced vital capacity /FVC/, forced expiratory volume one second /FEV1/, maximum inspiratory pressure /PImax/, maximum expiratory pressure /PEmax/) and surface electromyographic (sEMG) measures of respiratory muscles activity during respiratory tasks were obtained from eight individuals with chronic C3-T12 SCI before and after 62±10 (mean±SD) sessions of the LT. FVC, FEV1, PImax, PEmax, amount of overall sEMG activity and rate of motor unit recruitment were significantly increased after LT (p<0.05). These results suggest that these improvements induced by the LT are likely the result of neuroplastic changes in spinal neural circuitry responsible for the activation of respiratory muscles preserved after injury.

Respiratory motor control disrupted by spinal cord injury: mechanisms, evaluation, and restoration.

Pulmonary complications associated with persistent respiratory muscle weakness, paralysis, and spasticity are among the most important problems faced by patients with spinal cord injury when lack of muscle strength and disorganization of reciprocal respiratory muscle control lead to breathing insufficiency. This review describes the mechanisms of the respiratory motor control and its change in individuals with spinal cord injury, methods by which respiratory function is measured, and rehabilitative treatment used to restore respiratory function in those who have experienced such injury.