Utility of Embedding a Physical Therapist in a United States National Park: A Pilot Program.

Facilitators and Barriers to Implementation of a Transcutaneous Electrical Nerve Stimulation Intervention in a Pragmatic Clinical Trial

Fibromyalgia Transcutaneous Electrical Nerve Stimulation in Physical Therapy Study (FM TIPS): an embedded pragmatic clinical trial in physical therapy clinics

National Park Service (NPS) units have seen a significant increase in visitation in recent years. From 2014 to 2016, Grand Teton National Park (GTNP) experienced a 17% increase in recreational visits. Managing for increased use, driven partially by new and novel types of recreation activities, is a growing issue of concern for the NPS. This study uses a qualitative approach to examine how emerging activity types paired with increased visitor use in GTNP’s popular String and Leigh Lakes (SLL) area may lead to outcome interference among park visitors. An influx of novel uses, such as paddleboarding, to an area that is already popular for a myriad of recreation activities, including canoeing, picnicking, and day hiking, adds a layer of complexity to the management of the lakes. This increase in visitation and activity diversity, combined with limited vehicle access and parking, is creating an environment in which crowding and displacement of visitors is occurring. Using the recreational opportunity demand hierarchy (RODH) and an outcomes-focused management (OFM) framework, this study explores visitor activities, settings, and motivations, as well as possible outcome-interfering variables that may interfere with benefit-achievement. To inform this effort, 62 semi-structured interviews were compiled using a random-sampling technique in the SLL area during the summer of 2017. Data were analyzed using a blind coding technique and results suggest that conflict, crowding, and displacement are possible outcome-interfering variables that can be targeted in future research and monitoring efforts in the SLL area and beyond. The results also indicate that visitors react rationally to previous recreational outcomes. Additionally, we examine how our results can address common critiques of OFM. Finally, we propose a new iteration of the RODH, the rational recreation demand hierarchy (RRDH), in which outcomes direct future recreational decisions. The findings of this study and the updated outcomes-focused framework provide a variety of implications to managers. These include the management of outcomes and outcome-interfering variables as indicators of quality, a means of conceptualizing how outcome-achievement influences future decision-making concerning recreational activities and settings, and the treatment of protected area visitors as rational decision makers. Additionally, this study provides a vignette of how increased visitation, a phenomenon widely reported across US national parks, influences visitor experience. Subscribe to JPRA

The effects of introduced exotic species in natural environments are becoming important issues in conservation biology and natural resource management and recent scientific literature reveals increasing concern regarding the spread of invasive exotic plant species (Allen, 1996; Vitousek et al. 1996; Walker and Smith, 1997). Ecological consequences of these species include increased competition for space, water, and nutrients with native plants (which could result in a decrease in biodiversity), decreased forage quality for native ungulates, and changes in the microenvironments where the establishments took place (Woods, 1997). Sheley et al (1998) list several ecologically and economically detrimental impacts of exotic species. The National Park Service recognizes the need to protect ecosystems from exotic species (National Park Service, 1997) through management based on the ability to predict species distributions and spread, and monitoring in areas that are most susceptible to invasion. Recommended strategies for preventing the spread of exotic species include developing an early warning system to identify and eradicate new infestations of exotic plants in National Parks, and continued inventory and monitoring of exotic plants (National Park Service, 1997). These strategies will be based on assessment of the distribution and spread of exotic plants (National Park Service, 1997) using remote sensing and Geographic Information Systems (GIS) technologies for mapping and monitoring exotic plants, and models to predict the invasiveness and spread of exotic plants. In Grand Teton National Park (GTNP), exotic species are a great concern for park managers (National Park Service, 1997). Of the 1000 species of flowering plants within GTNP, there are also four (possibly five) rare plants that may be threatened as a result of competition with exotics (Wyoming Rare Plant Technical Committee, 1994): Draba borealis (Boreal draba), Epipactis gigantea (Giant helleborine), Lesquerella carinata var. carinata (Keeled bladderpod), Lesquerella paysonni (Payson's bladderpod), and possibly Draba densifolia var. apiculata (Rockcress draba). The continued survival of these sensitive plants in GTNP increases the need for management of exotic plants. GTNP has implemented a classification system for exotic plant species that consists of three priority levels (GTNP, 1997a). Priority 1 species are designated as "noxious" since they are capable of invading natural ecosystems and disrupting or displacing native vegetation. Currently, there are thirteen exotic plant species with a Priority 1 status within GTNP (Table 1 ).

Anthropogenic climate change is altering ecological and human systems globally, including in United States (US) national parks, which conserve unique biodiversity and resources. Yet, the magnitude and spatial patterns of climate change across all the parks have been unknown. Here, in the first spatial analysis of historical and projected temperature and precipitation across all 417 US national parks, we show that climate change exposes the national park area more than the US as a whole. This occurs because extensive parts of the national park area are in the Arctic, at high elevations, or in the arid southwestern US. Between 1895 and 2010, mean annual temperature of the national park area increased 1.0 °C ± 0.2 °C century−1 (mean ± standard error), double the US rate. Temperature has increased most in Alaska and its extensive national parks. Annual precipitation of the national park area declined significantly on 12% of national park area, compared to 3% of the US. Higher temperatures due to climate change have coincided with low precipitation in the southwestern US, intensifying droughts in the region. Physical and ecological changes have been detected and attributed mainly to anthropogenic climate change in areas of significant temperature increases in US national parks. From 2000 to 2100, under the highest emissions scenario (representative concentration pathway [RCP] 8.5), park temperatures would increase 3 °C–9 °C, with climate velocities outpacing dispersal capabilities of many plant and animal species. Even under the scenario of reduced emissions (RCP2.6), temperature increases could exceed 2 °C for 58% of national park area, compared to 22% of the US. Nevertheless, greenhouse gas emissions reductions could reduce projected temperature increases in national parks by one-half to two-thirds.

The purpose of this study was to evaluate the knowledge and the use of Transcutaneous Electrical Nerve Stimulation (TENS) by Nigerian physical therapists. A cross sectional study design was carried out among Nigerian physical therapists. Eighty-six physical therapists participated in this study and data were collected using a structured and validated questionnaire. Copies of the questionnaires were distributed by hand and by mail (with self addressed envelopes) to various hospitals, clinics, universities that offer physical therapy services/programmes across Nigeria. Data were analyzed using descriptive statistics. Academic staff constituted 10.5% while 89.5% were clinicians. First degree holders constituted 61.6% while 38.4% had postgraduate degrees. Majority of physical therapists, 90.7% use TENS, 83% of those who use TENS are aware of the different types of TENS; 98.72% use TENS for 30 minutes or less, 48.7% use it for 15 minutes or less. The frequency commonly use is between 1-30 Hz and about 12.8% of those using this frequency believed that TENS relieves pain through the pre-synaptic inhibition, endogenous pain control, and direct inhibition of abnormally excited nerve and restoration of afferent input. Furthermore, 12.8% calibrated their TENS devices. Only 6.4% have published TENS related papers in the last five years while 29.5% have attended TENS related seminar in the past. Majority, 88.5% considered TENS to be cost effective. This study concluded that TENS is widely used among Nigerian physical therapists and tend to have adequate knowledge of TENS and its application in the management of pain.

Author(s): Gonzalez, Patrick | Abstract: Human-caused climate change has exposed the US national park area to more severe increases in heat and aridity than the country as a whole and caused widespread impacts on ecosystems and resources. Reducing carbon dioxide emissions from cars, power plants, and other human sources would reduce future risks. Since 1895, annual average temperature of the area of the 419 national parks has increased at a rate of 1.0 ± 0.2oC (1.8 ± 0.4oF) per century, double the rate of the US as a whole, while precipitation has declined significantly on 12% of national park area, compared with 3% of the US. This occurs because extensive areas of national parks are located in extreme environments. Scientific research in national parks has detected numerous changes that analyses have attributed primarily to human-caused climate change. These include a doubling of the area burned by wildfire across the western US, including Yosemite National Park, melting of glaciers in Glacier Bay National Park, a doubling of tree mortality across the western US, including Sequoia National Park, a loss of bird species from Death Valley National Park, a shift of trees onto tundra in Noatak National Preserve, sea level rise of 42 cm (17 in.) near the Statue of Liberty National Monument, and other impacts. Without emissions reductions, climate change could increase temperatures across the national parks, up to 9oC (16oF) by 2100 in parks in Alaska. This could melt all glaciers from Glacier National Park, raise sea level enough to inundate half of Everglades National Park, dissolve coral reefs in Virgin Islands National Park through ocean acidification, and damage many other natural and cultural resources. Adaptation measures, including conservation of refugia in Joshua Tree National Park and raising heat-resistant local corals in Biscayne National Park, can strengthen ecosystem integrity. Yet, reducing greenhouse gas emissions from human activities is the only solution that prevents the pollution that causes climate change. Energy conservation and efficiency improvements, renewable energy, public transit, and other actions could lower projected heating by two-thirds, reducing risks to our national parks.

Transboundary movement of wildlife results in some of the most complicated and unresolved wildlife management issues across the globe. Depending on the location and managing agency, gray wolf (Canis lupus) management in the US ranges from preservation to limited hunting to population reduction. Most wildlife studies focus on population size and growth rate to inform management, but relatively few examine species biological processes at scales aside from that of the population. This is especially important for group‐living species such as the gray wolf, for which the breeding unit is the social group. We analyzed data for gray wolf packs living primarily within several US National Park Service units (years of data): Denali National Park and Preserve (33 years), Grand Teton National Park (23 years), Voyageurs National Park (12 years), Yellowstone National Park (27 years), and Yukon‐Charley Rivers National Preserve (23 years). We identified two gray wolf biological processes that differed from population size – namely, pack persistence and reproduction – and determined that while human‐caused mortality had negative effects on both, pack size had a moderating effect on the impacts of mortality.

Beginning in 1979, a detailed survey of the macro lepidopteran fauna began in Grand Teton National Park. The three year survey, supported by UW-NPS funding, includes the following objectives: 1. Formulation of a synoptic list and voucher specimen collection of all macro lepidopteran species inhabiting Grand Teton National Park. Prior to this study, very little was known concerning the important lepidopterans or their ecology within Wyoming ecosystems and virtually nothing of scientific value had been published on the lepidopterans of the national parks in Wyoming. 2. Determination of Pleistocene "relict" or "marker" species which have survived in Grand Teton National Park. The data obtained from these "relict" species can be used in the aging and the determination of rates of species evolution within the ecosystems of the park. Related studies in Rocky Mountain National Park and elsewhere in Colorado, Wyoming and Utah (Bagdonas, 1976; Bagdonas, et al. 1977a, 1977b, 1977c, 1977d, 1978a, 1978b, 1978c, 1979a, 1979b, 1979c, 1979d, 1979e, 1979f; Bagdonas, 1980a, 1980b; Bagdonas et a1. 1980c, 1980d, 1980e, 1981, 1982a, 1982b, 1982c, 1982d,) have indicated many lepidopteran species in the Rocky Mountains are survivors of the Pleistocene glacial and interglacial periods. 3. Determination of relative abundances, habitat preferences, seasonal flight periods, life histories, and other ecological data of Grand Teton macro lepidopterans. This data will be used toward the completion of a book for the National Park Service on the butterflies and moths of the Grand Teton National Park, and with expanded studies, also, those of Yellowstone National Park.

Background: Quadriceps muscle contracture (QC) that develops because of orthopedic interventions in the distal femur, proximal tibia or knee joint is a difficult process and may require a new series of orthopedic surgeries. However, despite everything, the prognosis is considered poor. The use of various physical therapy methods in musculoskeletal system and pain control is becoming more common in veterinary practice. This study aimed to investigate the effectiveness of transcutaneous electrical nerve stimulation (TENS), therapeutic ultrasound (TU) and low-level laser therapy (LLLT) applications in the treatment of QC in 1 cat and 6 dogs. Materials, Methods & Results: The study was conducted on 6 dogs and 1 cat diagnosed with QC. All animals had undergone previous surgery. TENS+TU+LLLT was applied to the animals in the study for physical therapy for 3 or 4 weeks. The findings of the study were found to be extremely satisfactory, in terms of opening the muscle contracture and regaining the use of the leg. After each case was examined clinically, the relevant extremity was evaluated orthopedically. The hip-knee joint, femur, tibia and surrounding soft tissues were examined. Quadriceps femoris muscle (QFM) tension, knee and knee joint range of motion, QFM atrophy, pain, hip joint function, abduction and adduction ranges were examined. In addition, the patient's history and the development of the disease were noted to determine the etiology. Additionally, craniocaudal and mediolateral X-ray images of the extremity were taken. The diagnosis of quadriceps contracture was made based on clinical examination findings. Physical therapy was then planned with TENS, TU and LLLT sequences. When the cases were evaluated, it was understood that some of them were caused by faulty/insufficient and malpractice practices (4 cases), while some (3 cases) developed QC due to the patient's inability to use their extremities. In all cases, the knee joint was stiff, and it was very difficult to move the joint. The quadriceps muscles were stiff and atrophied. No problems or difficulties were experienced in the implementation of physical therapy procedures. In the animals that the owner showed interest, it was noticed that the knee joint gap and contracture started to decrease after the 2nd session and the recommended passive movements were performed at home. In the other patients, there was a significant relief at the end of the 1st week. At the end of the 3rd week, the animal was able to use its extremities clinically and the owner was satisfied. No case required surgical treatment for QC. Discussion: Treatment options for QC, which often develops after incorrect or poor/insufficient orthopedic interventions, are limited even today. The patient remains in a situation that can lead to amputation of the relevant extremity. In addition, it is known that strain or hyperflexion movements during physical therapy will cause ruptures or fractures at the point where the muscle attaches to the tibia. In our study, different physical therapy applications such as TENS, TU and LLLT were used in combination without applying any force or pressure to the region. Of course, different doses and durations than the ones we chose could have been chosen, but the patient owner constantly stated that the patient's pain was relieved in our applications. In addition, it was clearly seen that the muscle contraction began to resolve significantly at the end of the 1st week of treatment and the knee joint range of motion began to increase. As a result, it should be known that in cases where QC develops, with effective physical therapy in the early period, the patient can regain his/her former health and surgery will not be necessary. Keywords: cats, dogs, low level laser therapy, LLLT, transcutaneous electrical nerve stimulation, TENS, therapeutic ultrasound, TU.

Serum samples from 295 employees of Great Smoky Mountains National Park (GRSM), Rocky Mountain National Park (ROMO), and Grand Teton National Park with adjacent Bridger-Teton National Forest (GRTE-BTNF) were subjected to serological analysis for mosquito-borne bunyaviruses. The sera were analyzed for neutralizing antibodies against six orthobunyaviruses: La Crosse virus (LACV), Jamestown Canyon virus (JCV), snowshoe hare virus (SSHV), California encephalitis virus, and Trivittatus virus (TVTV) belonging to the California serogroup and Cache Valley virus (CVV) belonging to the Bunyamwera serogroup. Sera were also tested for immunoglobulin (Ig) G antibodies against LACV and JCV by enzyme-linked immunosorbent assay (ELISA). The proportion of employees with neutralizing antibodies to any California serogroup bunyavirus was similar in all three sites, with the prevalence ranging from 28% to 36%. The study demonstrated a seroprevalence of 3% to CVV across the three parks. However, proportions of persons with antibodies to specific viruses differed between parks. Participants residing in the eastern regions had a higher seroprevalence to LACV, with 24% (18/75) GRSM employees being seropositive. In contrast, SSHV seroprevalence was limited to employees from the western sites, with 1.7% (1/60) ROMO and 3.8% (6/160) GRTE-BTNF employees being positive. Seroprevalence to JCV was noted in employees from all sites at rates of 6.7% in GRSM, 21.7% in ROMO, and 15.6% in GRTE-BTNF. One employee each from ROMO (1.7%) and GRTE-BTNF (1.9%) were positive for TVTV. This study also has illustrated the greater sensitivity and specificity of plaque reduction neutralization test compared to IgG ELISA in conducting serosurveys for LACV and JCV.

Background: Over 1.2 million women undergo Cesarean delivery each year in the United States, accounting for approximately 30% of deliveries. In the United States, women are prescribed opioids for pain management in both the inpatient stay and upon discharge home following Cesarean delivery. Non-pharmacological therapy for postsurgical incision pain, such as Transcutaneous Electrical Nerve Stimulation (TENS), may be effective to reduce the quantity of opioids provided to new mothers after birth to manage postoperative pain after Cesarean delivery. Little is known about the use and effectiveness of TENS in inpatient postpartum care. The purpose of this review was to explore the use and effectiveness of TENS to decrease pain and opioid consumption after Cesarean delivery during the inpatient hospital stay. Methods: A systematic review was initially attempted, but the literature was scarce and heterogeneous. A scoping review was therefore pursued to better understand the research landscape of TENS for the reduction of pain and opioid consumption after Cesarean delivery. A literature search was conducted in 2018 and updated in 2022 using PubMed and CINAHL databases. Search terms included: “TENS,” “transcutaneous electrical nerve stimulation,” “electrical stimulation,” “Cesarean,” “analgesia,” “incisional pain,” “postpartum,” and “opioids.” Peer-reviewed studies published between 2010 and 2022, in English, with female human subjects were included. Studies investigating the effects of TENS on incisional pain in postpartum individuals after Cesarean delivery were included. Exclusion criteria were animal studies, those not in English, qualitative studies, and nonintervention studies. Results: Nine studies were identified that utilized TENS to reduce pain in women with acute Cesarean incisional pain during the first 72 hours after surgery. Studies that compared TENS plus usual care to usual care alone found statistically significant reductions in pain. Electrode placement consisted of 2 or 4 electrodes placed within 5 cm of the incision. High frequency TENS (>75 Hz) was more effective to reduce pain than low frequency TENS. TENS was provided for 2 to 4 days either continuously or at 30-minute intervals. Two of the 9 studies utilized TENS and measured opioid consumption and reported conflicting findings. Discussion: TENS can be used to complement the usual care provided in the postpartum inpatient hospital stay and has been shown to reduce pain within the first 72 hours using a high-frequency (>75 Hz) setting for 30-minute intervals. Physical therapists are an underutilized resource within the United States’ postpartum health care model. Factors such as the opioid epidemic in the United States, prevalence of Cesarean delivery, and the routine prescription of opioid medications in usual care contribute to the critical need for scalable non-pharmacological therapies like TENS to reduce acute postsurgical pain and promote patient mobility.

Fibromyalgia is characterized by chronic widespread pain that is often exacerbated by movement that interferes with daily activities. Development of effective treatments for movement-evoked pain is essential for improving function for individuals with fibromyalgia. To evaluate whether the addition of transcutaneous electrical nerve stimulation (TENS) to outpatient physical therapy improves fibromyalgia-associated movement-evoked pain. The Fibromyalgia TENS in Physical Therapy (FM-TIPS) study was a cluster-randomized clinical trial of participants with fibromyalgia at 28 outpatient PT clinics from 6 health care systems. Between February 1, 2021, and September 31, 2024, 958 participants were screened, 459 participants enrolled, and 384 completed baseline data collection, with final data collected in March 2025. Clinics were randomized to PT plus TENS (PT-TENS) and PT-only groups. Data were captured on days 1, 30, 60 (primary end point, randomized phase), 90, and 180. Participants in the PT-only group received TENS after day 60 (extension phase). TENS was applied to the upper and lower back with instructions to use 2 hours daily with parameters of modulating frequency of 2 to 125 Hz for 100 to 180 microseconds at a strong but comfortable intensity. The primary outcome was a change in movement-evoked pain (scale of 0-10, with 0 indicating no pain and 10 indicating worst pain imaginable) from baseline to day 60 rated during a 5-times sit-and-stand task using a linear mixed-effects model. In addition, patient-reported improvement based on the Patient Global Impression of Change score and patient-reported adverse events were assessed. A total of 384 FM-TIPS participants (mean [SD] age, 53 [15] years; 351 [91%] female) completed baseline data collection (modified intention-to-treat), with 191 individuals in PT-TENS group and 193 in PT-only group. Movement-evoked pain at day 60 during TENS treatment was significantly lower in the PT-TENS group compared with the PT-only group (group mean difference, -1.2; 95 CI, -1.6 to -0.7; d = 0.46). A dose-response effect for TENS was observed, with more participants in the PT-TENS group reporting improvement on the Patient Global Impression of Change (120 [72%] vs 86 [51%], P = .001) and a 30% or greater reduction in movement-evoked pain in responder analysis (66 of 161 [41%] vs 22 of 169 [13%]; P < .001). At day 180, 217 respondents (81%) found TENS helpful and 147 (55%) used TENS daily. There were no serious adverse events, and 109 of 358 (30%) experienced minor adverse events during the entire 6 months of the study. In this cluster randomized clinical trial of TENS in fibromyalgia, TENS meaningfully reduced movement-evoked pain and remained effective for 6 months. This study's results suggest that TENS is a safe, inexpensive, and readily available treatment for fibromyalgia. ClinicalTrials.gov Identifier: NCT04683042.

Physical Therapist Training Challenges for an Embedded Pragmatic Trial: Fibromyalgia TENS in Physical Therapy Study

Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological intervention that provides an electrical current through the skin to produce analgesia. The primary purpose of this study is to examine if the addition of TENS to routine physical therapy improves movement-evoked pain in individuals with fibromyalgia in a physical therapy clinical setting. Fibromyalgia TENS in Physical Therapy Study is a phase III embedded pragmatic clinical trial funded through the National Institutes of Health Helping to End Addiction Long-Term Initiative. This trial will utilize a randomized cluster design that includes more than 110 physical therapists in 24 to 30 physical therapy clinics within 6 health care systems and 7 states. Clinics will be randomized to TENS or No-TENS, stratified by health care system and clinic size. The plan is to enroll 600 participants, with all participants completing physical therapy as prescribed by their physical therapist. Participants at TENS clinics will utilize TENS for a minimum of 2-hour per day while at the physical therapy clinic and at home when active. The primary outcome is reduction in movement-evoked pain from baseline to day 60 on an 11-point numeric rating scale when participants sit and stand 5 times (Sit and Stand Test). Secondary outcomes include resting pain and fatigue, pain interference, fibromyalgia disease activity, movement-evoked fatigue, multidimensional assessment of fatigue, rapid assessment of physical activity, patient global impression of change, and common data elements shared across studies supported through the Helping to End Addiction Long-Term Initiative. The findings from this study will provide effectiveness data on TENS for individuals with fibromyalgia for health care policymakers, clinicians, and insurers. Data from this study will also inform future pragmatic trials for nonpharmacological interventions and chronic musculoskeletal pain conditions.