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PM & R : the Journal of Injury,... Oct 2023To expand access to comprehensive rehabilitation services among veterans with cancer by increasing cancer rehabilitation referrals in a Veterans Affairs (VA) hospital.
OBJECTIVE
To expand access to comprehensive rehabilitation services among veterans with cancer by increasing cancer rehabilitation referrals in a Veterans Affairs (VA) hospital.
DESIGN
A rapid cycle improvement approach based on the Institute of Healthcare Improvement's Model for Improvement was used to assess and optimize the cancer rehabilitation referral process. In this quality improvement project, our cancer rehabilitation workgroup developed an electronic screening tool within the VA electronic patient record system to streamline cancer rehabilitation referrals. Providers could complete an optional Cancer Rehabilitation (CaRe) Screen that consisted of 12 questions related to patient symptoms and function. If the screen was positive, a nonvisit electronic consult was automatically generated and sent to a physiatrist for review. The physiatrist would then triage patients to appropriate services including physiatry, physical therapy, occupational therapy, speech therapy, rehab psychology, and other rehabilitation services.
RESULTS
A total of 90 referrals were placed between 2019-2021. A total of 84% of the patients referred were male, 73% were white. The top cancer types referred were lung (27%), blood (23%), gastrointestinal (12%), and prostate (10%). There were 19 referrals in 2019, 13 in 2020, and 58 in 2021. The electronic screening tool was implemented in mid-2021. Advanced practice providers placed 48% of consults. Of the referrals placed in 2021, 13% of consults were initiated through the electronic screening tool. The most common rehabilitation-related referrals placed after initial cancer rehabilitation triage included physical therapy (n = 47, 35.1%), physiatry (n = 28, 20.9%), and occupational therapy (n = 24, 17.9%).
CONCLUSIONS
Implementing an electronic screening tool can streamline cancer rehabilitation referrals and increase access to cancer rehabilitation services for Veterans with cancer. Ongoing work is required to refine the referral process and educate providers and patients on the importance of cancer rehabilitation in the cancer care continuum.
Topics: Humans; Male; Female; United States; Veterans Health; Quality Improvement; Referral and Consultation; Veterans; Continuity of Patient Care; United States Department of Veterans Affairs; Neoplasms
PubMed: 36695293
DOI: 10.1002/pmrj.12949 -
Hand (New York, N.Y.) Aug 2023There is increased interest in ultrasound (US) for the diagnosis of cubital tunnel syndrome (CuTS). We hypothesize that ulnar nerve cross-sectional area (CSA) correlates...
BACKGROUND
There is increased interest in ultrasound (US) for the diagnosis of cubital tunnel syndrome (CuTS). We hypothesize that ulnar nerve cross-sectional area (CSA) correlates with disease severity and electrodiagnostic studies (EDX).
METHODS
ARetrospective review was performed at a tertiary medical center. One hundred seventeen patients (166 ulnar nerves) were evaluated. Maximum CSA at 3 points around the elbow (proximal, groove, and distal) and EDX results (American Board of Electrodiagnostic Medicine-certified physiatrist's interpretations) were collected.
RESULTS
US was positive (CSA > 0.1 cm) in 95/117 cases (81.20%) versus 84/117 (71.79%) positive for EDX. CuTS patients treated surgically had significantly greater (0.13 cm, standard deviation [SD] 0.038) preoperative CSA than non-operative patients (0.10 cm, SD 0.033) ( = .003). CSA increased as EDX increased in severity; mild (0.116 cm, SD 0.031), moderate (0.121 cm, SD 0.035), and severe (0.163 cm, SD 0.047) with a significant difference between the mild and severe groups ( = .001) and between the moderate and severe groups ( = .01). Significant differences were seen between patients with positive US and EDX studies compared to those with negative US and EDX in the average physical function scores (57.26, SD 8.57 versus 43.18, SD 7.70; < .001); average sleep scores (50.14, SD 9.53 versus 56.62, SD 7.31; = .02); average physical function scores (43.04, SD 8.68 versus 57.08, SD 6.34; < .001) and average depression scores (49.10, SD 10.88 versus 45.043, SD 7.06; = .02).
CONCLUSIONS
US is a reliable tool for diagnosis and surgical decision-making for CuTS.
TYPE OF STUDY/LEVEL OF EVIDENCE
Diagnostic/III.
PubMed: 37533402
DOI: 10.1177/15589447231187081 -
PM & R : the Journal of Injury,... May 2024Physical medicine and rehabilitation (PM&R) physicians are trained to perform interventional procedures using local anesthetics (LAs) to reduce pain and enhance function...
INTRODUCTION
Physical medicine and rehabilitation (PM&R) physicians are trained to perform interventional procedures using local anesthetics (LAs) to reduce pain and enhance function and quality of life. LA administration is not benign and one potential complication is local anesthetic systemic toxicity (LAST). Anesthesiologists also perform interventions with LAs; however, training on LAST may differ between medical specialties.
OBJECTIVE
To investigate if a gap exists in the knowledge of LAST between physiatry and anesthesiology physicians.
DESIGN
Prospective cross-sectional survey study.
SETTING AND PARTICIPANTS
All residents, fellows, and attendings of the anesthesiology and PM&R departments at a single academic medical center.
OUTCOME MEASURES
The primary outcome measures include participants' self-reported exposure to LAST education and comfort with their LAST knowledge as recorded on a Likert scale, as well as the percentage of correctly answered knowledge-based questions on the topic.
RESULTS
Fifty-eight physicians including 28 PM&R and 30 anesthesiology physicians (24 attending and 34 trainees) participated. Anesthesiology trainees and attendings exhibited greater overall perceived knowledge of LAST (trainees U = 43, p < .001; attendings U = 9, p < .001), with greater exposure to LAST education (trainees U = 16.5, p < .001; attendings U = 12, p < .001). Assessment of responses to knowledge-based questions on LAST revealed a statistically significant knowledge gap between PM&R and anesthesia trainees (t = 6.62, p = <.001) as well as between attending groups (t = 3.25, p = <.01).
CONCLUSION
This study reveals a distinction in both the subjective and objective knowledge of LAST between PM&R and anesthesiology physicians at a single academic institution. This suggests that there is opportunity for further assessment of the education on LAST among physiatrists and residents in training.
Topics: Humans; Cross-Sectional Studies; Prospective Studies; Anesthetics, Local; Anesthesiology; Clinical Competence; Female; Male; Physical and Rehabilitation Medicine; Internship and Residency; Surveys and Questionnaires; Adult
PubMed: 37883117
DOI: 10.1002/pmrj.13093 -
Frontiers in Surgery 2024Spine surgery is a prevalently performed procedure. Some authors have proposed an age-related surge in surgical and general complications. During spine surgery, patients...
Spine surgery is a prevalently performed procedure. Some authors have proposed an age-related surge in surgical and general complications. During spine surgery, patients are placed in positions that are not physiologic, would not be tolerated for prolonged periods by the patient in the awake state, and may lead to complications. Understanding these uncommon complications and their etiology is pivotal to prevention and necessary. The patient is a 76-year-old woman referred to the outpatient department of neurosurgery in February 2022 by her physiatrist with a chief complaint of chronic low back pain and numbness over the left leg. Lumbar spine magnetic resonance imaging revealed degenerative disc disease and posterior disc bulging at the levels of L2/3∼L5/S1 with compression of the thecal sac. After receiving anti-inflammatory medication, nerve block and caudal block, her symptoms persisted. She was referred to a neurosurgeon for surgical intervention. We diagnosed spinal stenosis with left L3 and L4 radiculopathy, and elective decompression surgery was scheduled a few days later. We performed discectomies at L2/3 and L3/4 and left unilateral laminectomy at L2 and L3 for bilateral decompression. Following an uneventful surgery, the patient was extubated, and her left leg pain improved, but pain over the right outer calf with drop foot developed. A second lumbar MRI the next day revealed no evidence of recurrent disc herniation or epidural hematoma. Then, she received nerve conduction velocity and needle electromyogram on postoperative day 2, and the studies indicated right common peroneal nerve entrapment neuropathy. After medication with steroids and foot splint use, right leg pain improved. However, weak dorsiflexion of the right ankle persisted. We referred this patient to a physiatrist and OPD for follow-up after discharge. Perioperative peripheral nerve injury (PPNI) is most commonly caused by peripheral nerve ischemia due to abnormal nerve lengthening or pressure and can be exacerbated by systemic hypotension. Any diseases affecting microvasculature and anatomical differences may contribute to nerve injury or render patients more susceptible to nerve injury. Prevention, early detection and intervention are paramount to reducing PPNI and associated adverse outcomes. The use of intraoperative neuromonitoring theoretically allows the surgical team to detect and intervene in impending PPNI during surgery.
PubMed: 38410409
DOI: 10.3389/fsurg.2024.1329860 -
Physical Medicine and Rehabilitation... Aug 2024The focus of this article is on the acute management of traumatic brain injury. The article focuses on the classification of traumatic brain injury, general acute... (Review)
Review
The focus of this article is on the acute management of traumatic brain injury. The article focuses on the classification of traumatic brain injury, general acute management of traumatic brain injury, the role of the physiatrist on this team, and lastly, behavioral and family considerations in the acute care setting. The article includes a focus on physiologic systems, strategies for the management of various aspects of brain injury, and consideration of factors associated with the continuum of care. Overall, the article reviews this critical period of brain injury recovery and provides a primer for the physiatrist.
Topics: Humans; Brain Injuries, Traumatic
PubMed: 38945645
DOI: 10.1016/j.pmr.2024.02.002 -
Healthcare (Basel, Switzerland) Feb 2024This study aims to describe a local community expert's perspective on the identification of and access to children's health assets and to gather proposals to promote...
This study aims to describe a local community expert's perspective on the identification of and access to children's health assets and to gather proposals to promote children's health and well-being within their community. The health asset approach is essential for health promotion, and there is evidence of its benefits to individuals' or communities' health when this approach is observed. Children's health assets are gaining increasing interest, but the literature that captures the perception of professionals working with children is scarce. Qualitative research designed with Delphi methodology was carried out with the participation of 25 professionals working in a neighbourhood with children and families. The participants stated that this neighbourhood was a good environment for the healthy and happy growth of children but pointed out that there were inequities. They emphasised the importance of economic and physical security and feeling loved. The absolute best aspects of the neighbourhood according to these experts were its support networks, mutual help, educational and health services, and green spaces, and the most deficient aspects were the possibility of a hopeful future and emotional support within the family unit. Poverty and/or the scarcity of economic resources were identified as the main barriers to accessing health assets. Special difficulties in access to health for migrant and Roma children were also identified. The panel of experts made concrete action proposals. It was recommended to support resources and services that already exist in their community. The experts prioritised work with families, education, working in conjunction with vulnerable groups, community participation, and networking.
PubMed: 38470616
DOI: 10.3390/healthcare12050506 -
Rehabilitacion 2023The profile of the patient who most frequently suffers lower limb amputations is usually an elderly patient with high comorbidity. Physiatrists need objective tools in... (Review)
Review
The profile of the patient who most frequently suffers lower limb amputations is usually an elderly patient with high comorbidity. Physiatrists need objective tools in the assessment of these patients that predict the results of prosthetic programs to increase patient safety and efficiency of prosthetic rehabilitation programs. Given the need to update scientific knowledge in this field, we have carried out a review of the literature with the aim of defining a proposal for tools that facilitate decision-making in the indication of prosthetic rehabilitation in these patients. A bibliographic search strategy has been carried out using the scientific databases PubMed, Web of Science, Scopus and Cochrane Library. The quality of the selected articles has been assessed according to the tools proposed by CASPe.
Topics: Humans; Aged; Artificial Limbs; Amputation, Surgical; Comorbidity; Lower Extremity
PubMed: 36739682
DOI: 10.1016/j.rh.2023.100785 -
Journal of Pediatric Rehabilitation... 2024Conjoined twins are identical twins joined in utero and are a rare phenomenon. This report discusses a case of female thoraco-omphalo-ischiopagus tripus conjoined twins....
Conjoined twins are identical twins joined in utero and are a rare phenomenon. This report discusses a case of female thoraco-omphalo-ischiopagus tripus conjoined twins. The twins were separated at age two, and once medically stable, spent one month in inpatient rehabilitation to improve their sitting balance and gross motor skills. This was followed by outpatient physical therapy. The twins initially had customized ZipZac seats, which they were able to wheel independently. After six months of therapy, the girls began walking with posterior walkers and prostheses. The hemipelvectomy prosthesis included a customized thoracolumbosacral orthosis component and was directly attached to a non-articulated pylon. A manual-locking hip joint was added to accommodate sitting. An articulated ankle-foot orthosis was used for the intact leg. Care of formerly conjoined twins requires comprehensive care from a multidisciplinary team involving, but not limited to, a physiatrist, orthopaedic surgeon, physical therapist, and orthotist/prosthetist. Complex congenital limb deficiencies are often a major undertaking for the rehabilitation team as continuous treatment and management are needed throughout the patient's lifetime due to growth, development, and evolving physical demands. Anatomic variations must be examined on a case-by-case basis but often include limb deficiencies, orthopedic abnormalities, and organ comorbidities.
Topics: Humans; Twins, Conjoined; Female; Treatment Outcome; Physical Therapy Modalities; Child, Preschool
PubMed: 38393928
DOI: 10.3233/PRM-220121 -
American Journal of Physical Medicine &... Aug 2023Physiatrists are at elevated risk of burnout, a work-related exhaustion syndrome resulting from chronic stress associated with emotionally draining work demands. The...
Physiatrists are at elevated risk of burnout, a work-related exhaustion syndrome resulting from chronic stress associated with emotionally draining work demands. The high reported rate of burnout in physical medicine and rehabilitation led the Association of Academic Physiatrists Chair Council to convene a workgroup to address burnout among academic physical medicine and rehabilitation physicians. The council recognizes that leaders of departments are accountable for all organizational stakeholders, including faculty, trainees, and staff. Department leaders are expected to understand and effectively manage the drivers of burnout among stakeholders. The workgroup identified several opportunities, including identifying and disseminating effective burnout mitigation across US academic medical center physical medicine and rehabilitation programs. As a result, in 2019, a work group conducted a survey of US academic physical medicine and rehabilitation program leaders to ascertain the use of strategies for reducing physician burnout. With the aim of identifying, educating, and advancing the development of effective interventions to address burnout among academic physical medicine and rehabilitation departments, the Association of Academic Physiatrists Chair Council advocates for increased education and utilization of effective strategies aimed at promoting physician well-being across organizational levels (national, organizational, work unit, and individual).
Topics: Humans; Burnout, Professional; Physicians; Medicine; Physical and Rehabilitation Medicine; Physiatrists; Surveys and Questionnaires
PubMed: 37026874
DOI: 10.1097/PHM.0000000000002245 -
PM & R : the Journal of Injury,... Nov 2023Sleep health is linked to pain, function, and global health. Unfortunately, sleep health may not be consistently addressed as a part of musculoskeletal care.
BACKGROUND
Sleep health is linked to pain, function, and global health. Unfortunately, sleep health may not be consistently addressed as a part of musculoskeletal care.
OBJECTIVE
To describe the frequency of sleep health documentation and intervention by musculoskeletal physiatrists. Additionally, patient-reported outcome measures were compared between patients with and without sleep impairment. We hypothesized that sleep health is documented and addressed in less than half of initial patient encounters and that patients with a sleep impairment have worse patient-reported outcomes scores compared to those without sleep impairment.
DESIGN
Retrospective study.
SETTING
Tertiary orthopedic hospital.
INTERVENTIONS
None.
MAIN OUTCOME MEASURES
Frequency of provider documentation of sleep health, frequency and characteristics of sleep health intervention provided, and Patient-Reported Outcome Measurement Information System (PROMIS)-10 mental health and physical health scores.
RESULTS
Initial visits for a musculoskeletal condition of 39,452 patients from January 1, 2020 to October 1, 2022 were included. Documentation of sleep health was found in 33.0% (13,002/39,452) of patients. Of those with sleep health documentation, 59.2% (7697/13,002) were classified as having a sleep impairment. Only 19.0% of patients were provided with sleep-related education or other intervention. Patients with a sleep impairment had worse PROMIS-10 mental health and physical health scores (p < .001), as compared to those without a sleep impairment.
CONCLUSIONS
Patients with sleep impairment had worse mental and physical health scores than those without sleep impairment, and only 19.0% received sleep health intervention. These data suggest that sleep impairment is common in patients presenting for evaluation of a musculoskeletal condition, and advanced provider education and tools to help patients improve their sleep health are needed.
PubMed: 37916613
DOI: 10.1002/pmrj.13100