PM&R RSS feed: Current Issue. PM&R is the official scientific journal of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) . It is a monthly, peer reviewed, scholarly publication that advances education and impacts the specialty of physical medicine and rehabilitation through the timely delivery of clinically relevant and evidence-based research and review information. Topics covered include acute and chronic musculoskeletal disorders and pain, neurologic conditions involving the central and peripheral nervous systems, rehabilitation of impairments associated with disabilities in adults and children, and neurophysiology and electrodiagnosis. PM&R emphasizes principles of injury, function, and rehabilitation, and is designed to be relevant to practitioners and researchers in a variety of medical and surgical specialties and rehabilitation disciplines. Submission of manuscripts is encouraged from physiatrists, physicians, and researchers in related disciplines, and other multidisciplinary rehabilitation professionals. The content of PM&R includes articles that are contemporary and important to both research and clinical practice. The various sections of the journal highlight original research including clinical trials and outcomes studies, clinically relevant translational science, comprehensive and focused review articles, case presentations, point/counterpoint debates and commentary, ethical legal topics, practice management updates, editorial and opinion pieces, images, clinical pearls, emerging issues, and publication-related letters to the editor. http://www.pmrjournal.org/?rss=yesElsevier Inc.en © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. PM&R1934-148244April 2012 © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.pmrjournal.org/article/PIIS1934148212001232/abstract?rss=yesIn the mid 1990s, the specialty of physical medicine and rehabilitation (PM&R) was not as well known as it now is in Korea. Many of my colleagues and I believed that the acknowledgment and appreciation of PM&R was limited because it was (is) not based on a single organ system or tissue type (such as other popular specialties, eg, ophthalmology or neurology) but rather on a philosophy or strategy (namely, comprehensiveness, holistic approach, and goal-directed rehabilitation). So, we debated about the issue of changing our name from physiatrists to “physicians for brain, spinal cord, peripheral nerve, muscle and bone.” I found comfort in noting similar phraseology from the American Academy of Physical Medicine and Rehabilitation (AAPM&R) home page, “PM&R physicians are nerve, muscle, bone and brain experts …” [].What Is on the Horizon? Adding a New Item to Our List: Mechanical Connective Soft TissueSun G. Chung10.1016/j.pmrj.2012.03.001PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Invited Perspective247251http://www.pmrjournal.org/article/PIIS1934148211014237/abstract?rss=yes Objective: To evaluate exercise recommendations in patients newly diagnosed with fibromyalgia. Design: A retrospective chart review. Setting: A public university rheumatology clinic. Patients: Patients newly diagnosed with fibromyalgia (N = 122). Main Outcome Measurements: Frequency and type of exercise recommendations. Results: The mean (standard deviation) age of these patients with fibromyalgia was 45 ± 12 years; 91% were women. Exercise was recommended as part of the documented treatment plan in 47% of these patients (57/122); only 3 patients had a documented contraindication for exercise. Aquatic exercise was most frequently recommended (56% [32/57]), followed by combined aquatic-aerobic exercise (26% [15/57]), and, infrequently, aerobic exercise only (5% [3/57]); only 7% of these patients (4/57) were referred for physical therapy. The primary method of communication was verbal discussion (94% [54/57]). Conclusions: Although there is well-documented evidence that exercise is beneficial for patients with fibromyalgia, we found that less than half of patients with newly diagnosed fibromyalgia in our study were provided recommendations to initiate an exercise program as part of their treatment plan. Further investigation of these findings are warranted, including evaluation of other university and community rheumatology practices as well as that of other physicians caring for patients with fibromyalgia. However, our findings indicate that there appears to be an opportunity to provide more specific and practical education regarding the implementation of an exercise regimen for patients with newly diagnosed fibromyalgia. Physiatrists may be particularly well suited to manage the exercise component of patients with fibromyalgia because of their specialized training in exercise prescription. Exercise Recommendations in Patients With Newly Diagnosed FibromyalgiaBrad Wilson, Horace Spencer, Patrick Kortebein10.1016/j.pmrj.2011.11.012PM&R 4, 4 (2012)2012-03-09PM&R2012-03-0944S1934-1482(11)X0019-9Original Research252255http://www.pmrjournal.org/article/PIIS1934148212001475/abstract?rss=yesThese follow-up questions were directed to the author by a PM&R senior editor and are meant to stimulate further clinical insight. Sr. Editor: Your descriptive study identified that fewer than half of the patients newly diagnosed with fibromyalgia were advised to exercise as part of treatment recommendations by the physician (a rheumatologist). Did you find that number surprising?Ask the AuthorsHeidi Prather, Patrick Kortebein10.1016/j.pmrj.2012.03.014PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Ask the Authors256256http://www.pmrjournal.org/article/PIIS1934148211013682/abstract?rss=yes Objective: To determine which patient characteristics are closely associated with a positive response to a brief interdisciplinary fibromyalgia treatment program (FTP). Design: A prospective cohort study. Setting: FTP at a tertiary medical center. Participants: A total of 536 patients with a confirmed diagnosis of fibromyalgia who underwent the FTP and completed the Fibromyalgia Impact Questionnaire (FIQ) at baseline and 6-12 months after treatment. Interventions: A brief 1.5-day interdisciplinary FTP, which included evaluation with a registered nurse and a physician for a diagnosis or confirmation of fibromyalgia, fibromyalgia education, interactive self management session, and physical and occupational therapy. Main Outcome Measurements: The responder definition was an improvement of 14% or more in the FIQ total score from their baseline to 6-12 months after treatment. Results: Mean (standard deviation) age of our patients was 50.3 ± 13.0 years; 515 women (96%) and 23 men (4%). Two hundred forty-eight patients (46%) met the responder definition at 6-12 months follow-up. In an univariate analysis, younger age (P = .008), college or higher education (P = .02), fewer tender points (P = .048), and higher FIQ depression subscore (P = .02) significantly predicted positive response. In a multivariate analysis, these factors all remained statistically significant. In addition, a positive abuse history became significant (P = .03). There was no significant association for gender, duration of symptoms, marital status, employment, smoking status, or 3 numeric rating scale pain scores. Conclusions: Patients with younger age, more years of education (with college or graduate degree), higher baseline FIQ depression score, lower tender point count, and absent abuse history experience greater benefit from a brief FTP. Predictors of Clinical Outcome in Fibromyalgia After a Brief Interdisciplinary Fibromyalgia Treatment Program: Single Center ExperienceTerry H. Oh, Tanya L. Hoskin, Connie A. Luedtke, Toby N. Weingarten, Ann Vincent, Chul H. Kim, Jeffrey M. Thompson10.1016/j.pmrj.2011.10.014PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Original Research257263http://www.pmrjournal.org/article/PIIS193414821101286X/abstract?rss=yes Objective: To assess whether clusters of patients with hip fracture and with distinct initial recovery trajectories (IRT) could be identified by using practice-based evidence data and to examine the validity of these data. Design: Analysis of multisite prospective observational cohort study database. Setting: Eighteen skilled nursing and inpatient rehabilitation facilities. Patients: Patients with hip fractures (N = 226) treated with joint replacement and admitted to skilled nursing or inpatient rehabilitation facilities, subset (n = 85), with telephone follow-up results approximately 8 months after rehabilitation discharge. Patients' ages were 76.8 ± 11.4 years; the majority were women (78%) and white (87%). Methods: Measurements included medical severity by using the Comprehensive Severity Index and functional levels by using Functional Independence Measure (FIM). The IRT was calculated for each patient as the rate of change in function from the time of surgery to rehabilitation admission. We used cluster analysis to partition patients into subsets that shared common IRT scores. Validity was explored by comparing subgroups across patient characteristics and treatment patterns. Significance was defined as P ≤ .05. Main Outcomes Measurements: IRT grouping, Comprehensive Severity Index, FIM, discharge location, living location at follow-up. Results: We identified 3 patient clusters with differentiated IRT scores: group 1: 4.96 ± 2.45 (range, 0.4-8.6) FIM point change per day; group 2: 12.42 ± 2.51 (range, 8.9-17.0); group 3: 26.80 ± 13.78 (range, 17.5-70.0). Clinical group validation was established from statistically different Comprehensive Severity Index scores on admission; FIM scores at admission, discharge, and follow-up; and discharge and 8-month living settings. Calculation of IRT recovery curves by using FIM scores and associated time in days through logarithmic regression curves confirmed each group's IRT remained distinct through rehabilitation and follow-up. Conclusions: The IRT concept appears to be valid in patients with hip fracture who were treated with hip arthroplasty, and may assist in evaluating and comparing the effectiveness of postacute rehabilitation services. Initial Recovery Trajectories Among Patients With Hip Fracture: A Conceptual Approach to Exploring Comparative Effectiveness in Postacute CareHarriet U. Aronow, Phoebe Sharkey, Hilary C. Siebens, Susan D. Horn, Randall J. Smout, Gerben DeJong, Michael C. Munin, Craig S. Radnay10.1016/j.pmrj.2011.10.002PM&R 4, 4 (2012)2012-01-16PM&R2012-01-1644S1934-1482(11)X0019-9Original Research264272http://www.pmrjournal.org/article/PIIS1934148211012810/abstract?rss=yes Objective: To provide a cost-effectiveness analysis of dysphagia screening in the acute poststroke period with use of a videofluoroscopic swallowing study, a clinical bedside swallowing evaluation, or a combined approach. Design: Decision-analysis model. Methods: A decision-analysis model was used with information derived from multiple data sources, including meta-analyses and other relevant clinical studies. Univariate and probabilistic sensitivity analyses were performed. Main Outcome Measures: The analysis assessed direct medical costs of pneumonia. Strategies were compared on the basis of an incremental cost-effectiveness analysis, with effectiveness measured in quality-adjusted life-years. Results: The strategy of having each patient undergo a videofluoroscopic swallowing study for dysphagia was more effective and less costly than the strategies of clinical bedside swallowing evaluation alone or a combined approach. The model was most influenced by the reduction in the risk of pneumonia attributable to the treatment of mild/moderate and severe dysphagia, the effectiveness of treatment with clinical bedside swallowing evaluation, the baseline probability of pneumonia, and the cost of a videofluoroscopic swallowing study. Conclusions: A videofluoroscopic swallowing study is cost-effective and often saves costs compared with a clinical bedside swallowing evaluation alone or a combined approach. Research aimed at improving the understanding of the effectiveness of treatment for dysphagia in the prevention of aspiration pneumonia and resulting mortality would improve the model. A Cost-Effectiveness Analysis of Screening Methods for Dysphagia After StrokeRichard D. Wilson, Evan C. Howe10.1016/j.pmrj.2011.09.006PM&R 4, 4 (2012)2011-12-26PM&R2011-12-2644S1934-1482(11)X0019-9Original Research273282http://www.pmrjournal.org/article/PIIS1934148212000238/abstract?rss=yes Objective: To assess the accuracy of bedside swallow evaluation (BSE) compared with videofluorosopic swallow study (VFSS) in diagnosing dysphagia in individuals with tetraplegia due to spinal cord injury (SCI). Design: A prospective diagnostic accuracy study according to STAndards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Setting: A county hospital with acute inpatient SCI unit. Patients: Thirty-nine subjects with SCI and tetraplegia were enrolled. All of the subjects underwent BSE, and 26 subjects completed the VFSS. Methods: Individuals with SCI underwent a BSE followed by a VFSS within 72 hours of the BSE. The subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS. Main Outcome Measures: Sensitivity, specificity, and positive and negative predictive values were calculated by using VFSS as the criterion standard. Results: Fifteen subjects (38%) were diagnosed as having dysphagia based on the BSE results. Among the subjects who completed the VFSS, 11 were diagnosed with dysphagia (42%) and 4 were diagnosed with aspiration (10%). Of the 26 subjects who completed both BSE and VFSS, only 1 subject was diagnosed differently compared with BSE (3.8%). Different diet recommendations were made in 4 cases after VFSS versus BSE. Different liquid recommendations were made in 8 cases after VFSS versus BSE. Sensitivity of BSE was 100% (95% confidence interval [CI], 71.5%-100%), specificity was 93.3% (95% CI, 68.1%-99.8%). A positive predictive value of BSE was 91.7% (95% CI, 61.5%-100%), and the negative predictive value was 100% (95% CI, 76.8%-100%). Conclusions: Dysphagia is present in approximately 38% of individuals with acute tetraplegia. Because only one of the 21 subjects was diagnosed differently based on VFSS, we believe that BSE is an appropriate screening tool for dysphagia for individuals with cervical SCI. However, VFSS provided additional information on diet and liquid recommendations, so there appears to be an important clinical role for the VFSS. Diagnostic Accuracy of Bedside Swallow Evaluation Versus Videofluoroscopy to Assess Dysphagia in Individuals With TetraplegiaKazuko L. Shem, Kathleen Castillo, Sandra Lynn Wong, James Chang, Ming-Chih Kao, Stephanie A. Kolakowsky-Hayner10.1016/j.pmrj.2012.01.002PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Original Research283289http://www.pmrjournal.org/article/PIIS1934148212000330/abstract?rss=yes Objective: To examine recovery of functional status for white, black, and Hispanic patients who have had a stroke from the time of admission to inpatient medical rehabilitation to 12 months after discharge. Design: A longitudinal study that used information from the Stroke Recovery in Underserved Population database, a prospective observational study of persons with stroke who received inpatient medical rehabilitation services during 2005-2006. Setting: Eleven inpatient rehabilitation facilities located across diverse regions of the United States, including California, Florida, Iowa, Illinois, Kentucky, New Jersey, New York (2), Texas (2), and Washington, DC. Participants: A total of 990 adults aged 55 years or older who had a stroke and were admitted to 1 of 11 inpatient medical rehabilitation facilities in the United States were interviewed at 4 time points, including admission to and discharge from an inpatient medical rehabilitation facility and 3 and 12 months after discharge. Interventions: Not applicable. Main Outcome Measure: Functional status as measured by the Functional Independence Measure (FIM). Results: For the total sample, FIM ratings increased from admission to discharge and from discharge to 3-month follow-up, with little recovery occurring between 3 and 12 months. In random effects mixed models, at 3-month follow-up, both black and Hispanic patients had lower FIM ratings than did white patients. At 12-month follow-up, black and white patients were similar; however, Hispanic patients continued to have lower FIM ratings compare with white patients. Racial/ethnic group, age, length of stay, and medical comorbidities were significant predictors of total FIM ratings over the 4 time points. Conclusions: Persons 55 years and older who have had a stroke, regardless of race/ethnicity, appear to benefit from inpatient medical rehabilitation. Most functional status gains occur during inpatient medical rehabilitation and continue in the first few months after discharge, with little change afterward. Recovery of Functional Status After Stroke in a Tri-Ethnic PopulationIvonne-M. Berges, Yong-Fang Kuo, Kenneth J. Ottenbacher, Gary S. Seale, Glenn V. Ostir10.1016/j.pmrj.2012.01.010PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Original Research290295http://www.pmrjournal.org/article/PIIS193414821200130X/abstract?rss=yesI first encountered a patient with conversion disorder about 20 years ago. I was a new attending physician, and the woman was admitted to my inpatient rehabilitation service with a diagnosis simply of “quadriplegia.” The diagnosis of an underlying conversion disorder was ingeniously cinched by a video that documented normal movement during sleep. But, during her waking hours, she was as disabled as if she had had a spinal cord injury, that is, she was unable to move, she was dependent in her self–care, and she was still subject to the problems of immobility.“Why Can't I Move, Doc?” Ethical Dilemmas in Treating Conversion DisordersKristi L. Kirschner, Geoffrey R. Smith, Ryan M. Antiel, Philip Lorish, Frederick Frost, Richard A.A. Kanaan10.1016/j.pmrj.2012.03.008PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Ethical-Legal Feature296303http://www.pmrjournal.org/article/PIIS1934148212001505/abstract?rss=yesA 55-year-old man presents to a pain clinic upon referral from his primary care physician. His symptom is axial low back pain. His pain started approximately 1 year earlier without a specific inciting event. He denies radiation of pain into the lower extremities. There is no bowel or bladder involvement. There is no directional preference. He reports pain “all the time,” with minimal specific exacerbating or relieving factors. There is no medical-legal involvement. His medical history is significant for hypertension, hypercholesterolemia, obesity, and sleep apnea. He is a divorced father of 2 adult children. He is self-employed local truck driver, and his job also involves some loading and unloading of boxes, although he describes the weight of the boxes as “light.” He notes a decreased capacity to complete job-related activities but states that the pain medication (sustained-release oxycodone, 80 mg twice a day) allows him to work with minimal discomfort.The Appropriateness of Long-term Opioids to Treat Chronic Back PainMichael Saulino, Adam Schreiber, Thomas Watanabe10.1016/j.pmrj.2012.03.017PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Point/Counterpoint304311http://www.pmrjournal.org/article/PIIS1934148211014444/abstract?rss=yesPulmonary aspiration in patients with brain lesions may result from dysfunction of the swallowing process or gastroesophageal reflux. Inadequate protection of the airway from oral secretions such as saliva may also induce aspiration. Chronic pulmonary aspiration of saliva can lead to substantial respiratory morbidity, including unexplained lung disease or recurrent pneumonia, and is an important issue in the rehabilitation unit. In particular, patients with neurologic disease who are in a long-term bedridden state can be at greater risk for development of chronic salivary aspiration and pulmonary complications []. In contrast to aspiration during the swallowing process, continuous secretion of saliva and its aspiration are difficult to control, even through modification of food consistency or cessation of oral feeding.Salivagram After Gland Injection of Botulinum Neurotoxin A in Patients With Cerebral Infarction and Cerebral PalsyHea-Woon Park, Won-Yub Lee, Gi-Young Park, Dong-Rak Kwon, Zee-Ihn Lee, Yun-Woo Cho, Sang-Ho Ahn, Dong-Kyu Lee10.1016/j.pmrj.2011.12.008PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Case Presentations312316http://www.pmrjournal.org/article/PIIS1934148212000251/abstract?rss=yesEwing sarcoma is a malignant “round blue cell” tumor, with a peak incidence between the ages of 10 and 25 years. It is aggressive, with a 5-year mortality related to age []. We describe 2 cases of back and leg pain caused by Ewing sarcoma in adult patients who presented to an outpatient musculoskeletal clinic.Ewing Sarcoma Causing Back and Leg Pain in 2 PatientsStephan M. Esser, Jennifer Baima10.1016/j.pmrj.2011.12.013PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Case Presentations317321http://www.pmrjournal.org/article/PIIS1934148212000780/abstract?rss=yesIn their randomized controlled trial that compared prolotherapy injections with corticosteroid injections for lateral epicondylosis, Carayannopoulos et al [] made commendable efforts toward methodologic rigor. Both patients and injectors were blinded to the solution type; improvement between groups on primary and secondary outcomes was not significantly different, and the trial results reported like outcomes for these 2 injection types. However, we are concerned that overly strict adherence to one aspect of methodologic rigor (blinding) has led to the use of a nonstandard prolotherapy protocol that limited the possibility of detecting a positive relationship between prolotherapy and lateral epicondylosis, which, in turn, may have led to conclusions that do not go far enough regarding both these results and considerations for future research.Can Double Blinding Distort Results in Randomized Controlled Trials?Michael J. Yelland, Leanne Bissett, David Rabago, Jeffrey Patterson10.1016/j.pmrj.2012.02.013PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Letters to the Editor322323http://www.pmrjournal.org/article/PIIS1934148212001438/abstract?rss=yesWe would like to thank Drs Yelland, Rabago, Patterson, and Bissett for an insightful and clinically relevant response to our study titled “Prolotherapy Versus Corticosteroid Injections for the Treatment of Lateral Epicondylosis: A Randomized Controlled Trial” []. We do agree that, when designing clinical trials, one should weigh the merits of real-life treatment scenarios versus the “artificiality” of criterion standard design that classically carries the requirements of double-blinding, randomization, and use of the placebo control. No one study can achieve such perfection that would satisfy both ends of the desired spectrum. We are surely aware that, by limiting the number of injection treatments in the prolotherapy arm of our study, this might have led to less of a clinically robust response when compared with that in the steroid arm. Recognizing that the act of needling itself can produce a therapeutic effect and that our original goal was to compare clinical efficacy between 2 different injectables, proliferant solution, and steroid, an intergroup equilibration in the number of treatment sessions was required [].ReplyAlec L. Meleger, Joanne Borg-Stein10.1016/j.pmrj.2012.03.010PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Letters to the Editor323323http://www.pmrjournal.org/article/PIIS1934148212001591/abstract?rss=yesThe American Board of Physical Medicine and Rehabilitation is administering the Sports Medicine Subspecialty Exam in July 2012. Planning to sit for the exam? Your Academy offers the following resources to help you prepare.Academy News10.1016/S1934-1482(12)00159-1PM&R 4, 4 (2012)2012-04-01PM&R2012-04-0144S1934-1482(11)X0019-9Departments324327