PM&R

What's on the Horizon: The Rehabilitation Hospitalist

M. Elizabeth Sandel — 2012-01-01

The year was 1982, the second year of my residency training in physical medicine and rehabilitation (PM&R). I was evaluating the first patient with a spinal cord injury I had ever cared for in the emergency department of Thomas Jefferson University Hospital. Three residents arrived at the bedside after the trauma alert, one each from the departments of rehabilitation medicine, orthopedics, and neurosurgery, and one attending physician, John F. Ditunno Jr, MD, chair of the Department of Rehabilitation Medicine. The examination of the patient was carefully completed, and decisions were made about surgery and rehabilitation based on the evaluation. The PM&R resident and the attending physician communicated with the patient and the family. This was the beginning of lifetime care for this patient, in the intensive care unit, the medical-surgical unit, the inpatient rehabilitation hospital, and then ambulatory care, provided through the Delaware Valley Spinal Cord Injury Model Systems Program at Thomas Jefferson University and Magee Rehabilitation Hospitals, funded through the National Institute on Disability and Rehabilitation Research (NIDRR). No one was called a hospitalist back in that era, but I think the role we in PM&R played is consistent with that label.

Relationship Between Disability and Health-Related Quality of Life and Caregiver Burden in Patients With Upper Limb Poststroke Spasticity

2011-12-26

Objective: To evaluate the relationship between disability and both health-related quality of life (HRQoL) and caregiver burden in patients with upper limb poststroke spasticity. Design: Multicenter open-label study. Setting: Thirty-five sites in North America. Participants: Patients (N = 279) with upper limb poststroke spasticity. Methods: Post hoc analyses of data from an open-label study were performed to estimate HRQoL and caregiver burden at study baseline across levels of disability in 4 problem domains: hygiene, dressing, limb posture, and pain. Disability severity in these areas was determined by using the 4-point Disability Assessment Scale rated by the physicians. Main Outcome Measurements: HRQoL measured by the patient-reported EuroQol 5 Dimensions questionnaire and the Stroke-Adapted Sickness Impact Profile and caregiver burden. Results: At study baseline, increasing disability in the hygiene, dressing, and pain domains of the Disability Assessment Scale was associated with diminishing HRQoL scores (P < .002) measured by the EuroQol 5 Dimensions. By using the Stroke-Adapted Sickness Impact Profile, greater disability scores in all problem domains were significantly associated with higher overall dysfunction scores (P ≤ .05). Within the physical dimension of the Stroke-Adapted Sickness Impact Profile, significant associations also were observed in all domains. At baseline, caregiver burden was significantly related to increasing levels of hygiene and dressing domain severity (P ≤ .05). Caregiver assistance requirement increased from approximately 9.0-28.2 hours per week in the hygiene domain and 3.3-32.1 hours per week in the dressing domain as disability increased from “none” to “severe.” Conclusions: In patients with upper limb poststroke spasticity, increasing disability in the hygiene, dressing, and pain domains of the Disability Assessment Scale were associated with diminishing HRQoL. Furthermore, these patients required caregiver assistance proportionally related to the severity of their disability in the hygiene and dressing domains.

Enoxaparin Versus Tinzaparin for Venous Thromboembolic Prophylaxis During Rehabilitation After Acute Spinal Cord Injury: A Retrospective Cohort Study Comparing Safety and Efficacy

Christina M. Marciniak, Jenny Kaplan, Leah Welty, David Chen — 2012-01-01

Objective: To compare the safety and efficacy of 3 low-molecular-weight heparin (LMWH) treatments (enoxaparin, 40 mg once daily, with an alternative LMWH, tinzaparin, 3500 or 4500 units once daily) for the prevention of venous thromboembolic events (VTEs) after acute spinal cord injury (SCI). Design: Retrospective, chart review study. Setting: Acute inpatient rehabilitation facility. Participants: Patients admitted to acute rehabilitation within 3 months of either a traumatic or nontraumatic SCI during a 15-month time frame and who received either enoxaparin or tinzaparin for VTE prophylaxis. Main Outcome Measures: Symptomatic VTE incidence and bleeding events during acute rehabilitation. Results: A total of 140 participants who met inclusion criteria were admitted at a median of 15 days after an acute SCI. Before admission to rehabilitation, 23.6% were not on any VTE prophylaxis, 55.7% were on enoxaparin, 17.1% were on unfractionated heparin, 1.4% were on treatment doses of a LMWH, and 2.1% did not have documentation available regarding type of prophylaxis before admission. No patients were receiving tinzaparin before admission. During rehabilitation, 68 participants received prophylaxis with enoxaparin, whereas 14 and 58 participants received tinzaparin 3500 or 4500 units, respectively. Symptomatic VTE developed in 14 patients during rehabilitation, including 4 developing pulmonary emboli. Compared with patients receiving tinzaparin 3500 units, both those receiving enoxaparin had significantly reduced odds of VTE (odds ratio [OR] 0.12; 95% confidence interval [95% CI] 0.02-0.65)] and those receiving tinzaparin 4500 units had significantly reduced odds of VTE (OR 0.18; 95% CI 0.03-0.93). After we adjusted for age, previous pharmacologic prophylaxis, and etiology for the SCI (traumatic vs nontraumatic) via propensity scores, pharmacologic prophylaxis with enoxaparin remained protective for VTE compared with tinzaparin 3500 units (adjusted OR 0.15; 95% CI 0.02-0.93). The use of prophylaxis before admission with enoxaparin compared with no prophylaxis was associated with decreased risk of VTE during rehabilitation (adjusted OR 0.20; 95% CI 0.04-0.88); however, this association was no longer significant when we adjusted for prophylaxis during rehabilitation. The etiology for the SCI and the presence of an inferior vena cava filter were not associated with VTE. One patient receiving enoxaparin required transfer for a bleeding event, and no patients had greater than a 1-g decrease in hemoglobin during the rehabilitation stay. Conclusions: VTE was more prevalent in participants receiving tinzaparin 3500 units than in participants who received tinzaparin 4500 units or enoxaparin. Bleeding events were low with the use of LMWH for prophylaxis during acute rehabilitation. Although the use of prophylaxis before rehabilitation may be protective of VTE events, after we adjusted for VTE prophylaxis during rehabilitation, type of previous prophylaxis was not found to be significantly protective of VTE events during rehabilitation.

A Hidden Reservoir of Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococcus in Patients Newly Admitted to an Acute Rehabilitation Hospital

Ronald P. Rabinowitz, Joseph A. Kufera, Michael J. Makley — 2012-01-01

Objective: To find hidden reservoirs of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) via active surveillance cultures for MRSA and VRE in newly admitted patients. Design: A prospective, cohort, screening study. The period of surveillance was 3 months in the winter of 2006-2007. Setting: A freestanding academic and community rehabilitation hospital. Participants: A total of 540 consecutive patients admitted to a freestanding rehabilitation hospital. Methods: All of the patients were screened for MRSA and VRE upon admission to the hospital. Main Outcome Measure: The number of new patients identified with either MRSA or VRE colonization. Results: A total of 540 patients were screened, of whom 42 (7.8%) had pre-existing MRSA status, 8 (1.5%) had pre-existing VRE status, and 10 (1.9%) had a history of positive results for both MRSA and VRE. Of the 480 patients without pre-existing positive cultures, admission swabs were positive for MRSA in 37 patients (7.7%), swabs were positive for VRE in 33 patients (6.9%), and swabs for both MRSA and VRE were newly positive for 7 patients (1.5%). Therefore 16% of the patients without a history of MRSA or VRE had a new finding of MRSA or VRE. Regression analysis revealed that prior bacteremia was a risk factor for MRSA; diabetes mellitus and a history of pneumonia and trimethoprim-sulfamethoxazole use were risk factors for VRE. Conclusion: We found a 16% incidence of a hidden reservoir of multiple drug-resistant organisms in patients admitted to rehabilitation hospitals. We believe that all patients admitted to a rehabilitation facility should be screened for MRSA and VRE.

The Ligamentum Flavum at L4-5: Relationship With Anthropomorphic Factors and Clinical Findings in Older Persons With and Without Spinal Disorders

2011-11-18

Objective: To examine the relationship between ligamentum flavum thickness and clinical spinal stenosis. Design: A validation study. Setting: Clinical research laboratory. Patients: A total of 119 subjects from the Michigan Spinal Stenosis Study (MSSS). Methods: Two new measurement techniques were compared by use of magnetic resonance images of 4 asymptomatic subjects by 2 examiners. The technique with the best interrater reliability was then used to measure the ligamentum flavum at L4-L5 in 119 subjects in the MSSS who, on the basis of clinical examination without imaging, were thought to have lumbar stenosis, mechanical back pain, or no pain. These findings were related to other radiologic findings, demographics, clinical severity, and electrodiagnostic findings. Main Outcome Measurements: Perpendicular on the inside of the spinal canal from the deepest point of concavity of the lamina to the edge of the ligament. Results: The ligamentum flavum width measurement had high interrater (r = 0.774) and intrarater (r = 0.768) reliability. In 28 asymptomatic volunteers, ligamentum flavum width averaged 5.72 ± 0.95 mm, with the left side significantly thinner than the right (t = 2.117, P = .044), and thicker ligaments with age (r = 0.653, P < .001). Asymptomatic persons whom radiologists thought had stenosis had thicker ligaments (t = 2.273, P = .032). Persons with clinical stenosis (n = 48) and mechanical pain (n = 43) had ligament thickness similar to that of asymptomatic volunteers. Among patients with clinical stenosis, ligamentum flavum thickness did not relate to symptom severity (pedometer and laboratory ambulation tests, Pain Disability Index, and visual analog scale for pain). Most neurophysiological findings had no relationship with ligamentum flavum width, except the presence of limb fibrillation potentials related to a thinner ligament (t = 2.915, P = .004). Conclusions: The measurement technique is standardized for the ligamentum flavum for future use. Although the ligamentum flavum appears to get thicker with age, other factors, including clinical diagnosis, pain, and function, do not appear to relate to the ligamentum flavum width.

Clinical and Spatiotemporal Gait Effects of Canes in Hip Osteoarthritis

2011-11-17

Objective: To investigate the effects of cane use on spatiotemporal gait parameters, pain, and function in adults with hip osteoarthritis (OA). Design: Prospective observational study. Setting: An academic tertiary Veterans Affairs Healthcare Center. Participants: Thirteen adults with symptomatic hip OA and 13 healthy adults. Methods: We undertook gait analysis in all subjects with an optoelectronic camera system. Pain, stiffness, and physical function in subjects with hip OA were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Main Outcome Measurements: Baseline spatiotemporal measures of unaided gait were obtained for healthy subjects. Baseline and 4-week spatiotemporal gait parameters were assessed for hip OA subjects while they walked with and without a cane. Participants with hip OA completed the WOMAC at baseline and after 4 weeks of cane use. Results: At baseline when walking unaided, the subjects with hip OA (age range 60-75 years) had a significantly slower gait velocity, shorter affected limb stride length, and longer double-stance time compared with healthy control subjects. When walking with a cane, they had a reduction in gait velocity (P < .05) caused by a decrease in cadence (P < .05) compared with walking unaided. After 4 weeks of cane use, the participants with hip OA demonstrated significant improvements in gait velocity (P < .05) and double-stance time (P < .05) when walking with a cane in comparison with baseline data. There was no improvement in pain and function after 4 weeks of cane use, a period in which only approximately 60% of the hip OA subjects used the cane 6 or more times per week. Conclusions: Initial use of a cane led to decreased gait velocity and cadence in people with hip OA compared with walking unaided. This difference in gait velocity diminished after they practiced walking with the cane. Inconsistent use of the cane may have contributed to the lack of improvement in the subjects' hip OA pain and function.

Ultrasound Applications in Electrodiagnosis

Andrea J. Boon, Jay Smith, C. Michel Harper — 2012-01-01

This review article discusses the current scope of high-resolution diagnostic ultrasound in the diagnosis of neuromuscular disease, both as a complementary tool to electrodiagnosis and in some cases as a stand-alone imaging modality. Indications, limitations, potential for research, and training and credentialing are discussed. Indications include needle guidance for nerve conduction studies and needle electromyography, diagnosis of nerve entrapment, diagnostic muscle imaging via grayscale analysis, and dynamic real-time imaging, including sonopalpation, to provide additional diagnostic information. The role of neuromuscular ultrasound in research is discussed, including the need to evaluate the sensitivity, specificity, positive and negative predictive value, and cost-effectiveness of these techniques when they are used alone or in combination. Training and credentialing are reviewed, specifically noting the challenge of the lack of formal training programs and the relatively long, flat learning curve of diagnostic ultrasound.

Electrosonodiagnosis: Neuromuscular Diagnosis Raised to the Power of 2

Gary Goldberg, Marko Bodor — 2012-01-01

The publication of the review article “Ultrasound Applications in Electrodiagnosis” by Boon et al [] in this issue of PM&R represents an important milestone in the development of ultrasonography as an important emerging tool for neuromuscular diagnosis. As with electrodiagnosis, ultrasonography of nerve and muscle significantly extends the ability of the clinician to examine the integrity of nerve and muscle but in a different and highly complementary manner.

Does Brain Injury or a Brain Disease Constitute a Sort of “Death”?

2012-01-01

“His wife as he knows her is gone,” the caller said to Pat Robertson of the 700 Club,” and the friend is “bitter at God for allowing his wife to be in that condition, and now he's started seeing another woman.”

Fitting an Older Patient With Medical Comorbidities With a Lower-limb Prosthesis

Richard A. Frieden, Anureet K. Brar, Alberto Esquenazi, Thomas Watanabe — 2012-01-01

Physiatrists are aware of the increased energy cost of ambulation with a prosthesis. They also know that risk factors for amputation include some of the same medical conditions that make this increased energy cost more difficult to accommodate. Advanced age may also be seen as a potential barrier to successful ambulation with a prosthesis as well as a return to independent living. This is an increasingly relevant consideration given that the number of older people is increasing. It is often not clear when an older patient with certain medical comorbidities would be a candidate for functional ambulation with a prosthesis. The following case and discussion highlight some of the variables that should be considered when making this determination.

Thoracic Outlet Syndrome—Postural Type: Ultrasound Imaging of Pectoralis Minor and Brachial Plexus Abnormalities

Benjamin M. Sucher — 2012-01-01

Thoracic outlet syndrome (TOS) is a controversial diagnosis that sometimes is referred to as disputed or nonspecific neurogenic TOS because diagnostic test results typically are negative or inconclusive []. A review of the pathomechanics and associated dysfunctional body habitus suggests that use of the term “postural TOS” is more appropriate for this common type of presentation []. Postural TOS is thus recommended in cases without objectifiable neurologic or vascular abnormality. In contrast, the less-common type of TOS involves compromise of the neurovascular bundle (NVB), which includes the brachial plexus (BP), the axillary or subclavian artery, and the axillary or subclavian vein []. Compression in all types of TOS may occur superiorly at the interscalene space, the costoclavicular space, or beneath the pectoralis minor muscle (PMM). The PMM location is recognized as a common and important site of compression in both the postural and nonpostural types of TOS [].

Cervical Transforaminal Epidural Injection in the Management of a Stinger

Daniel Leung, Jared S. Greenberg, P. Troy Henning, Anthony E. Chiodo — 2012-01-01

A “stinger,” otherwise known as a “burner,” is a transient, reversible peripheral nerve injury of the upper limb caused by injury to the cervical spine and shoulder. This injury usually occurs during participation in contact sports []. Stingers are considered to be under-reported by athletes and are most common in American-style football, hockey, gymnastics, and wrestling []. In a study of collegiate American-style football players, Levitz et al [] reported that stingers occur in 50%-65% of these athletes during the course of their career; they also reported high rates of recurrence. Mechanisms of injury include traction, compression, and direct blows []. Traction injuries result from ipsilateral shoulder depression and contralateral neck flexion, effectively resulting in traction on the nerve root and/or brachial plexus.

Manifestations of Rheumatoid Arthritis: Epidural Pannus and Atlantoaxial Subluxation Resulting in Basilar Invagination

Adam L. Schreiber — 2012-01-01

Atlantoaxial instability results from cartilaginous destruction, periarticular erosions, and ligament and tendon attenuation. Instability affects 19%-70% of patients, and basilar invagination from vertical odontoid subluxation through the foramen magnum occurs in 38% of patients. This phenomenon occurs twice as often in women than men, whose age at diagnosis typically ranges from 30-50 years. Along with bony compression, the pannus further decreases the space available for the cord by 3 mm or more in approximately 66% of patients (). The earliest and most common symptom of cervical subluxation is pain radiating up into the occiput with associated headaches. Episodes of medullary dysfunction that represent severe but less common patterns of progressive myelopathic symptoms provide an even more grim prognosis. When cervical myelopathy is established, 50% of these patients die within 1 year.

Lower Extremity Weakness After Childbirth: A Case of Preserved Nerve Conduction Studies, Axonal Involvement, and Good Recovery

Dennis N. Nutini, Jeffrey S. Fine — 2012-01-01

Although uncommon, the prompt and definitive identification of obstetric-related neuropathies poses a challenge to clinicians. Benefits of early identification include etiologic determination, interventions to limit functional impairment, and prognostication for recovery. A postpartum lumbosacral root and lower extremity nerve injury incidence of 0.92% has been described []. The complex innervation of the pelvic musculature and the numerous neural structures traversing the pelvis often complicate the clinical picture. This clinical pearl highlights that, even in the setting of diagnostic uncertainty, early physiatric intervention can minimize functional impairments and provide prognostic perspective.

Update on Accountable Care Organizations

Gregory Worsowicz — 2012-01-01

Since the publication of the article “What are the Implications of Accountable Care Organizations for Physical Medicine and Rehabilitation Practices?” in the November 2011 issue of PM&R, the Centers for Medicare and Medicaid Services (CMS) has issued the final rule for the Medicare Shared Savings Program Initiative that covers Accountable Care Organizations (ACOs). The final rule published in the November Federal Register contains what many consider significant changes to the initially proposed rule []. Because these modifications result in reduced burden and cost for groups to participate, there may be a renewed interest for many groups to form or enroll in an ACO.

Academy News

2012-01-01

Your Academy continues to recognize the importance musculoskeletal ultrasound can play in patient care and the value it can add to your practice. To help you fully prepare for integrating the technology into your practice, the Academy is proud to offer you: Diagnostic and Interventional Musculoskeletal Ultrasound of the Lower Extremity, February 10-12, 2012 in Las Vegas, NV.