PM&R

From Novice to Expert: Obstacles and Opportunities for Residency Programs

Teresa L. Massagli — 2010-02-01

Physical medicine and rehabilitation (PM&R) residency programs have a duty to the public to educate physicians who will practice competently and independently and to their residents to help them become lifelong learners who will maintain their expertise. In pursuit of these goals, residency programs and their directors are enabled, and at times impeded by, local resources and national regulatory requirements. Some of the challenges and changes facing residency programs and the field include the demographics of the trainees, the environment of teaching, the evolution toward fellowship training, and preparation for engaging in maintenance of certification (MOC). Although my experiences have been informed by my work as residency program director (PD) at the University of Washington, as a director of the American Board of PM&R, and as a member of the Accreditation Council of Graduate Medical Education (ACGME) PM&R Review Committee, the opinions expressed herein are my own.

(In Search of) Excellence in Physiatry: What Can We Learn From Our Patients

William Micheo — 2010-02-01

The idea for this Presidential Address came about after reading some of the excellent work published by Dr. Julie Silver, our invited plenary speaker, on healing, recovering from illness, and learning from patients (see page 94 in this issue). Although there is limited scientific literature on this topic, I firmly believe that if we are going to achieve excellence in medical care we need to partner with our patients.

Prescriptions for Optimal Healing

Julie K. Silver — 2010-02-01

As a physiatrist, I spend a lot of time explaining to people what I do. I hear from colleagues that they are in the same predicament. My sister, a pediatrician, doesn't have this problem. People instantly understand the job description of a pediatrician without any explanation. For better or worse, I generally begin by saying that I help people to heal physically from injuries and illnesses. I often expand this by remarking that physical and emotional healing typically go together—the better individuals feel physically, the better they feel emotionally, too.

Antibiotic Prescribing for Acute Respiratory Infection and Subsequent Outpatient and Hospital Utilization in Veterans With Spinal Cord Injury and Disorder

2010-02-01

Objective: To assess the association between antibiotic prescribing for acute respiratory infection (ARI) and subsequent health-care utilization in veterans with spinal cord injury and disorder (SCI/D).Design: Retrospective cohort of veterans with SCI/D.Setting: Veterans Affairs medical facilities that provide outpatient care.Patients: Veterans with SCI/D with a diagnosis of acute bronchitis or upper respiratory infection during an outpatient visit between fiscal year 2006 and 2007 that did not result in same-day hospitalization.Independent Variable: Receipt of a new antibiotic prescription occurring within 3 days before or after an ARI visit.Main Outcome Measure: Subsequent outpatient visit or hospitalization within 30 days of the index ARI visit.Results: A total of 1277 patients were identified with ARI; 53.2% were prescribed an antibiotic. An outpatient clinic visit within 30 days of the index ARI visit occurred in 47.0% of patients. Receipt of an antibiotic prescription was not associated with a subsequent outpatient visit. However, in those with certain chronic respiratory conditions (cough, shortness of breath, bronchitis not specified as acute or chronic, and allergic rhinitis), those prescribed antibiotics were less likely to return for an outpatient visit than those not prescribed antibiotics (adjusted relative risk =0.77, 95% confidence interval = 0.61-0.97); no association was observed in those patients without these conditions. A total of 7.9% of patients were hospitalized within 30 days and did not differ by prescribing group. The 30-day mortality rate was 0.6%.Conclusions: Certain chronic respiratory conditions in veterans with SCI/D may be risk factors for increased health-care utilization and potentially poor outcomes if a patient is not treated with antibiotics for ARI. However, in those without these conditions, those with ARI who were prescribed antibiotics have similar utilization to those not prescribed antibiotics. These data suggest that in the absence of chronic respiratory conditions, antibiotic use for ARI can be curbed in this population that is at high risk for respiratory complications.

Risk Factors for Plantar Fasciitis Among Assembly Plant Workers

2010-02-01

Objective: The objective of this study was to determine the relative contributions of work activity (time spent standing, walking, or sitting), floor surface characteristics, weight, body mass index, age, foot biomechanics, and other demographic and medical history factors to the prevalence of plantar fasciitis.Design: A cross-sectional observational study design was used.Setting: The study site was an automobile engine assembly plant.Participants: Full-time employees of the assembly plant who had been working at least 6 months.Assessment of Risk Factors: The independent variables included baseline demographics, medical history, ergonomic exposures, psychosocial factors, discomfort ratings, shoe characteristics, and foot biomechanics.Main Outcome Measurements: The dependent variable was the finding of plantar fasciitis on physical examination.Results: The study demonstrated that forefoot pronation on physical examination, high metatarsal pressure on the gait assessment, increasing time spent standing on hard surfaces, increased time spent walking, medium tenure at the plant, and an increased number of times getting in and out of the vehicle (for the truck/forklift drivers) increased the risk of presenting with plantar fasciitis. Rotation of shoes during the work week was found to reduce the risk of presenting with plantar fasciitis. Increased supervisor support showed a trend toward reducing the prevalence of plantar fasciitis.Conclusions: Plantar fasciitis is relatively common in the manufacturing setting. These findings suggest several options for primary and secondary prevention strategies. Shoe rotation may be an effective strategy that may be used as either a primary or secondary strategy. The use of shoe orthoses with a medial longitudinal arch and metatarsal pad may be used as a preventive or treatment strategy. Work stations that decrease the percentage of time walking or standing on hard surfaces (eg, allowing workers to alternate between sitting and standing postures or providing cushioning mats for concrete surfaces) may lower the risk for plantar fasciitis.

Implementation of Peer Review into a Physical Medicine and Rehabilitation Program and its Effect on Professionalism

Jaclyn Bonder, Douglas Elwood, Jeffrey Heckman, Austin Pantel, Alex Moroz — 2010-02-01

Objective: To examine the effects of implementing a peer review evaluation system on residents' attitudes and perceptions of professionalism, a core competency of the Accreditation Council for Graduate Medical Education (ACGME), in a Physical Medicine and Rehabilitation (PM&R) program.Design: Four classes of residents were divided prospectively into a control and an intervention group. All residents were asked to complete a survey regarding their attitudes and perceptions on both peer review and professionalism. Only 2 of these classes participated in a newly adopted peer review evaluation system, after which time all participants were again asked to fill out the surveys.Setting: Residents were from a PM&R residency program at an urban tertiary care medical center.Participants: All residents who completed the entire survey preintervention and postintervention were included.Methods: The intervention was the introduction of peer review into residents' evaluation assessments. All residents filled out a survey with questions relating to peer review and professionalism before and after this intervention.Main Outcome Measurements: Outcomes include understanding how residents perceive various attributes of professionalism, peer review, and the interconnection of the 2.Results: Data analysis using SPSS was performed using survey scores for 46 residents preintrodution and postintroduction of a peer review evaluation system. Analysis revealed that residents who participated in the peer review process were more likely to agree that certain aspects of daily patient care, behaviors, and concepts were components of professionalism. However, they continued to believe that residents are ultimately not responsible for their colleagues' professionalism and that peer review might be harmful to a residency program.Conclusion: This study introduces an interesting dichotomy. Peer review clearly influences resident outlook on professionalism and yet there is a high suspicion regarding its implementation. If appropriately implemented, peer review may be a potent method of enhancing the education of this ACGME requirement.

Reliability of Gait Performance Tests in Individuals With Late Effects of Polio

Ulla-Britt Flansbjer, Jan Lexell — 2010-02-01

Objective: To assess the reliability of 4 gait performance tests in individuals with late effects of polio.Design: An intrarater (between occasions) test-retest reliability study.Settings: University hospital.Participants: Thirty men and women (mean age 63 ± 6.4 years) with clinically and electrophysiologically verified late effects of polio.Intervention: Not applicable.Main outcome measures: The Timed “Up & Go” test, the Comfortable and the Fast Gait Speed tests, and the 6-Minute Walk test were assessed 7 days apart. Reliability was evaluated with the intraclass correlation coefficient (ICC2,1), the mean difference between the test sessions (d̄), and the 95% confidence intervals for d̄, the standard error of measurement (SEM and SEM%), the smallest real difference (SRD and SRD%) and the Bland & Altman graphs.Results: Test-retest agreements were high (ICC2,1 0.82−0.97) and measurement errors generally small. The standard error of measurement (SEM%), representing the smallest change that indicates a real (clinical) improvement for a group of individuals, was small (4%−7%). The smallest real difference (SRD%), representing the smallest change that indicates a real (clinical) improvement for a single individual also was small (12%−21%).Conclusion: These commonly used gait performance tests are highly reliable and can be recommended to evaluate improvements in various aspects of gait performance in groups of individuals as well as single individuals with late effects of polio.

Electromyographical Assessment of Passive, Active Assistive, and Active Shoulder Rehabilitation Exercises

Timothy L. Uhl, Tiffany A. Muir, Laura Lawson — 2010-02-01

Objective: To determine the electromyographical (EMG) activation levels of shoulder musculature during early rehabilitation exercises to regain active range of motion.Design: Descriptive.Setting: University clinical research laboratory.Participants: Ten asymptomatic volunteers (age, 25 ± 5 years; height, 171 ± 7 cm; weight, 78 ± 15 kg).Intervention: Fine-wire (supraspinatus and infraspinatus) and surface (anterior deltoid, upper trapezius, lower trapezius, and serratus anterior) electrodes recorded EMG activity from each muscle during 12 therapeutic exercises completed during a single testing session in random order.Main Outcome Measure: EMG root mean squared amplitude normalized to a percentage of maximum voluntary contraction (% MVC).Results: Passive exercises generated the lowest mean EMG activity (<10%) for all muscles studied. The standing active shoulder elevation exercises generated the greatest mean EMG activity with an upper boundary of 95% CI (40% MVC). Overall the active-assistive exercises generated a small (<10%) increase in muscle activity compared with the passive exercises for the supraspinatus and infraspinatus muscles, which was not a significant increase (P > .05).Conclusion: This electrophysiological data in normal volunteers suggest that many exercises used during the early phase of rehabilitation to regain active elevation do not exceed 20% MVC. Progression from passive to active-assisted can potentially be performed without significantly increasing muscular activation levels exercises. Upright active exercises demonstrated a consistent and often a statistically significant increase in muscular activities supporting that these exercises should be prescribed later in a rehabilitation program.

The Role of the Lumbar Multifidus in Chronic Low Back Pain: A Review

Michael D. Freeman, Mark A. Woodham, Andrew W. Woodham — 2010-02-01

Low back pain (LBP), a highly prevalent problem in society, is often a recurrent condition. Recent advances in the understanding of the biomechanics of LBP have highlighted the importance of muscular stabilization of the “neutral zone” range of motion in the low back. The lumbar multifidus muscles (LMM) are important stabilizers of this neutral zone, and dysfunction in these muscles is strongly associated with LBP. The dysfunction is a result of pain inhibition from the spine, and it tends to continue even after the pain has resolved, likely contributing to the high recurrence rate of LBP. Persisting LMM dysfunction is identified by atrophic replacement of multifidus muscle with fat, a condition that is best seen on magnetic resonance imaging. Muscle training directed at teaching patients to activate their LMM is an important feature of any clinical approach to the LBP patient with demonstrated LMM dysfunction or atrophy.

Physiatric Practice Management: Lessons From the Field

Gregory M. Worsowicz — 2010-02-01

The focus of physiatric training is to prepare physicians with the clinical skills to deliver appropriate medical care to their patients. Consequently, physiatrists may be well equipped for the clinical aspect of their practice, but uncomfortable or unprepared for the business aspects of health care. It is not uncommon to hear physicians report on-the-job training or learning by the trial-and-error method when it comes to practice management. These methods may not provide sustainable results for some of the challenges faced by many medical practices today. In a Medical Group Management Association (MGMA) survey of practice managers, some of the top challenges identified were maintaining physician compensation, dealing with operating costs that are increasing faster than revenue, selecting and implementing a new electronic health record system, managing uncertain Medicare fee rates, negotiating contracts, hiring and retaining quality staff, and participating in the Medicare Physician Quality Reporting Initiative [].

High-Intensity Exercise for Patients in Cardiac Rehabilitation After Myocardial Infarction

Matthew N. Bartels, Gerald W. Bourne, Jeffrey H. Dwyer, M. Elizabeth Sandel — 2010-02-01

Mrs. R is a 62-year-old woman with a history of diabetes, hypertension, hyperlipidemia, smoking, and obesity who was admitted 6 weeks ago with acute onset of substernal chest pain while climbing stairs. She had an acute myocardial infarction (MI) with ST-segment elevation on her cardiogram and was emergently taken for cardiac catheterization. Drug-eluting stents were placed in the first diagonal and second obtuse marginal arteries. She is now taking clopidogrel bisulfate, beta blockade, and aspirin and has been counseled regarding lifestyle modifications. Her insurance has approved her for only 18 sessions of outpatient cardiac rehabilitation (CR), and she is planning to make her annual migration south for the winter in 8 weeks.

Metastatic Crohn Disease in a Spinal Cord Injury Patient Without Gastrointestinal Manifestation

Nicholas Ketchum, Farhad Sepahpanah — 2010-02-01

A case is presented of cutaneous metastatic Crohn disease (CD) manifesting in a spinal cord injury (SCI) patient as multiple perianal, perigenital, and periostomal cutaneous ulcerations and a chronic anocutaneous fistula without any gastrointestinal (GI) involvement.

Chronic Nonunion in a Patient With Bilateral Supracondylar Distal Femur Fractures Treated Successfully With Twice Daily Low-Intensity Pulsed Ultrasound

Zeeshan Waseem, Michael Ford, Khalid Syed, John Flannery — 2010-02-01

A 77-year-old woman was involved in a motor vehicle accident and sustained an open comminuted left distal femur fracture and a closed right distal femur fracture. She initially underwent irrigation and debridement of the open left distal femur wound, open reduction, internal fixation (ORIF) of the left distal femur fracture with an LCP (locking condylar plate), and ORIF of the right distal femur fracture with the LISS (less invasive stabilization system) plate. Early failure and instability of the right LISS plate from proximal screws disengaging from the femoral shaft was found 11 days later. This required revision surgery with removal of the LISS plate and fixation with an LCP. Eight months later, as a result of right distal femur nonunion, she underwent removal of hardware including the LCP, takedown of pseudoarthrosis, and repeat ORIF of the right distal femur with a new LCP and right iliac crest autologous bone graft. The left femur was not healing, but overall bone position was maintained with no overt hardware failure, thus delaying nonunion determination. Ultimately, 14 months from the time of her accident, as a result of fracture of the proximal femoral screws and infection of hardware, she underwent irrigation and debridement, left distal femur removal of hardware, takedown of nonunion, and refixation with a new, longer LCP and new, nonlocking and locking screws.

Sacral Insufficiency Fracture: A Masquerader of Diskogenic Low Back Pain

David S. Cheng, Richard J. Herzog, Gregory E. Lutz — 2010-02-01

A 63-year-old man presented with a 3-week history of low back pain. At its onset, the patient indicated the pain originated in the left hip. However, at the time of visit, the pain was isolated to the left buttock. The pain was described as a deep ache without radiation, weakness, or numbness, and was worse in the morning. On a scale of 1 to 10 with10 being the worst pain experienced, the pain ranged from 3 to 8 in severity. Pain was exacerbated by activity and relieved with rest and ibuprofen. Patient denied recent trauma, citing that the pain began after he started a vigorous walking program.

Academy News

2010-02-01

The popular AAPM&R Study Guide will be delivered next month in the March issue of PM&R. Don't forget to look for the purple cover to find your copy of this year's Study Guide.

Journal Based CME

2010-02-01