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Helping trainees in physical medicine and rehabilitation improve their skills as practitioners, learners, and educators and better prepare for the ongoing process of professional development throughout their medical careers, is the aim of this book.
9 781936 28783311 West 42nd Street New York, NY 10036 www.demosmedical.comRecommended Shelving Category: Physical Medicine & RehabilitationKey Features:➤➤Addresses core competencies for rehabilitation medicine physicians as required by the ACGME➤➤Covers all major physiatric practice areas with facts, concepts, goals, and objectives following the competency model➤➤Grounded in a holistic, patient-centered approach➤➤Presents sample case studies with discussion points read more..
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Physical Medicine and RehabilitationPatient-Centered CareMastering the CompetenciesEditorsAdrian Cristian, MD, MHCMVice-Chairman and Residency Program DirectorDepartment of Physical Medicine and RehabilitationKingsbrook Jewish Medical CenterBrooklyn, New YorkSorush Batmangelich, EdD, MHPEPresidentBATM Medical Education ConsultantsBuffalo Grove, IllinoisFounding Director of Medical EducationAmerican Academy of Physical Medicine and RehabilitationFounding Director of EducationAmerican Congress of read more..
Visit our website at www.demosmedical.comISBN: 9781936287833e-book ISBN: 9781617051333Acquisitions Editor: Beth BarryCompositor: Integra Software Services Pvt. Ltd.© 2015 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.Medicine is an read more..
It’s with great joy that I dedicate this book to my wife, Marilyn; my son, Ramsey; and my dear parents. In addition, I wish to acknowledge a handful of wonderful professors and teachers, who served as my mentors and role models, both in the United States and abroad, in medicine, medical education, and adult learning—your wisdom, encourage-ment, and generosity helped me to shape a rich, satisfying, and ever-expanding career. On behalf of all our authors, editors, contributors, I want to say read more..
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Part i: Basic PrinciPlEs 1. The Use of Milestones in Physical Medicine and Rehabilitation Residency Education 3Karen P. Barr Teresa L. Massagli 2. The Use of Narrative Medicine and Reflection for Practice-Based Learning and Improvement 9Alice FornariAdam B. Stein 3. Conscious, Compassionate Communication in Rehabilitation Medicine 16Susan Eisner 4. Application of Principles of Professional Education for Physicians 31Sorush Batmangelich 5. Ethical Considerations in the Practice of read more..
17. Parkinson Disease 200Mohammed Zaman Neil Patel Marc Ross Miksha Patel 18. Neuromuscular Diseases 211C. David Lin Grigory Sirkin Marwa A. Ahmed 19. Multiple Sclerosis 223Chauncy Eakins Debra Brathwaite*Adrian Cristian 20. Osteoarthritis 235Christine HinkeTravis R. von TobelBrandon Von Tobel 21. Rehabilitation Following Total Knee Arthroplasty and Total Hip Arthroplasty 248Basem Aziz Neil Patel Miksha Patel 22. Spasticity 257Navdeep Singh JassalDayna McCarthyJennifer SchoenfeldMatthew read more..
Debra Brathwaite, MD* Department of Rehabilitation MedicineKingsbrook Jewish Medical CenterBrooklyn, New YorkSorush Batmangelich, EdD, MHPEPresidentBATM Medical Education ConsultantsBuffalo Grove, IllinoisFounding Director of Medical EducationAmerican Academy of Physical Medicine and RehabilitationFounding Director of EducationAmerican Congress of Rehabilitation MedicinePast Assistant ProfessorDepartment of Physical Medicine and RehabilitationRush University Medical CenterChicago, IllinoisDavid read more..
x ■ ContributorsAlice Fornari, EdD, RDAssociate Professor of Science Education, Population Health and Family Medicine Associate Dean of Educational Skills DevelopmentHofstra North Shore-Long Island Jewish School of Medicine Hempstead, New YorkJennifer Gomez, MDDepartment of Physical Medicine and Rehabilitation Albert Einstein Medical CollegeMontefiore Medical Center New York, New YorkJonah Green, MDChairmanDepartment of Physical Medicine and RehabilitationWoodhull Medical and Mental Health read more..
Contributors ■ xiRachel Mallari, MS, OTR/LAdjunct FacultyDepartment of Occupational TherapyLaGuardia Community CollegeLong Island City, New YorkTeresa L. Massagli, MDProfessor of Rehabilitation Medicine and PediatricsUniversity of Washington Seattle, WashingtonDayna McCarthy, DODepartment of Physical Medicine and RehabilitationHofstra North Shore-Long Island Jewish School of MedicineGreat Neck, New YorkShane McNamee, MDAssociate Chief of StaffClinical InformaticsHunter Holmes McGuire read more..
xii ■ ContributorsAdam B. Stein, MDProfessor and ChairDepartment of Physical Medicine and RehabilitationHofstra North Shore-Long Island Jewish School of MedicineGreat Neck, New YorkMichelle Stern, MDAssociate ProfessorClinical Physical Medicine and RehabilitationAlbert Einstein Medical CollegeChairDepartment of Physical Medicine and RehabilitationJacobi Medical CenterBronx, New YorkRakhi Sutaria, MDDepartment of Physical Medicine and Rehabilitation Albert Einstein Medical CollegeMontefiore read more..
Although a number of excellent textbooks on physical medicine and rehabilitation are available, this comprehensive, self-directed textbook is the first to establish a standard in practice, education, and training with the introduction of a coordinated competency-based approach to shape the future of physiatric patient care.In Part I, foundations for the core competencies are provided with some basic principles for application toward competency-centric practice entwined with professional read more..
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Physical Medicine and RehabilitationPatient-Centered CareMastering the CompetenciesCristian_87833_PTR_fm_i-xiv_13-08-14.indd 158/18/14 11:44 AM read more..
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I: Basic Principles1Cristian_87833_PTR_01_1-8_13-08-14.indd 18/13/14 11:42 AM read more..
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COMPETENCY-BASED MEDICAL EDUCATIONThe Accreditation Council of Graduate Medical Education (ACGME) is a private nonprofit organization that sets the standards for and evaluates and accredits allopathic residency and fellowship programs in the United States. In 2002, the ACGME Outcome Project identified and endorsed six general competencies to assess resident competence: medical knowl-edge, patient care (PC), practice-based learning and improve-ment (PBLI), professionalism, interpersonal and read more..
4 ■ I: Basic Principlesallows a resident to become eligible for Board certification is specified by the American Board of PM&R, not by the ACGME.To be able to evaluate each resident using the milestones, programs will need an integrated mix of assessment tools. Table 1.1 summarizes the milestones, gives an example of some of the narratives in each milestone, and suggests what assessment tools may be helpful to determine an individual resident’s mile-stone attainment. For each milestone, read more..
1: The Use of Milestones in Physical Medicine and Rehabilitation Residency Education ■ 5MILESTONE (CORE COMPETENCIES IN BOLD)EXAMPLE OF PORTION OF A MILESTONEPOSSIBLE WAYS TO ASSESSMedical Knowledge (MK)“Predicts functional outcome and prognosis”Case discussionOral examinationsWritten testsSystems-Based Practice (SBP)SBP1: Systems thinking“Has learned to coordinate care across a variety of settings”Observation of patient case managementCase discussionSBP2: Team approach“Leads the read more..
6 ■ I: Basic Principlesthe care of patients (Level 3). These levels would best be assessed by residents learning about the QI process, and then participat-ing in a QI project. To reach Level 4, the graduation target, they would then be expected to identify opportunities for process improvement in everyday work.For PC milestones, the cornerstone of evaluation will be evaluation in the workplace. However, for certain skills, this could be supplemented by more standardized evaluation methods. read more..
1: The Use of Milestones in Physical Medicine and Rehabilitation Residency Education ■ 7THE CLINICAL COMPETENCY COMMITTEEEach PM&R residency program will need to ensure that its cur-riculum addresses the milestones so that individual resident progress can be documented. Residency programs will also need a system to determine if residents have successfully passed a rotation (i.e., what level of milestone attainment and other requirements constitute successful completion of a rotation). The read more..
8 ■ I: Basic Principles 6. Escaldi SV, Cuccurullo SJ, Terzella M, et al. Assessing competency in spasticity management: a method of development and assess-ment. Am J Phys Med Rehabil. 2012;91:243–253. 7. Van der Vleuten CPM, Schuwirth LWT. Assessing profes-sional competence: from methods to programmes. Med Educ. 2005;36:309–317. 8. Wilkinson JR, Crossley JG, Wragg A, et al. Implementing work-place based assessment across the medical specialties in the United Kingdom. Med Educ. read more..
2: The Use of Narrative Medicine and Reflection for Practice-Based Learning and ImprovementTHEORETICAL FRAMEWORK FOR LEARNING THROUGH REFLECTIVE PRACTICECarl Rogers (1) has distilled the writings of John Dewey on reflection to four criteria. These will frame the background of the work we describe to connect reflection as a skill contributing to competency-based resident education:1. “Reflection is a meaning-making process that moves learners from one experience into the next, each time with a read more..
10 ■ I: Basic Principlesunderstanding of this powerful small word. Reflection is intended to indicate a conscious and deliberate reinvestment of mental energy aimed at exploring and elaborating one’s understanding of a circumstance one has faced or is facing currently (5). This requires exploring “why” questions to add to this understand-ing. This reinvestment of mental energy supports achieving true expert status in one’s pursuit of personal and career goals but does not necessarily read more..
2: The Use of Narrative Medicine and Reflection for Practice-Based Learning and Improvement ■ 11It is common to use artwork depicting physicians participating in clinical encounters with patients. The goal is to select images the participants can interpret without specialized artistic knowl-edge; the analysis is a group process. There is a shared observation process that fosters critical, creative, and flexible thinking. The authors’ experience with residents is very positive and concludes read more..
12 ■ I: Basic Principlescan be electronic discussion boards set up to facilitate dialogue. Using technology, an electronic back-and-forth conversation can occur. Alternatively, protected time may be set aside during the program’s didactic sessions for this type of activity, where the residents voluntarily share their narratives with their peers. Mod-erated discussion then ensues, with an appointed moderator who has experience in facilitating such sessions.An example of a narrative written read more..
2: The Use of Narrative Medicine and Reflection for Practice-Based Learning and Improvement ■ 13TABLE 2.1 Steps in Establishing a Narrative Medicine Group 1. Define group membership and identify moderator. 2. Moderator provides didactic information regarding theoretical basis and rationale for use of narrative medicine for this group. Allow for moderated discussion. 3. Supplement didactic information with additional readings identifying benefits of narrative medicine. 4. Establish a read more..
14 ■ I: Basic Principlesgreat tension in the room whenever her mother spoke, but I could also see in the mother’s eyes that all she wanted is what is best for her daughter. However, the mother doesn’t understand that she is slowly tearing her daughter apart by setting such high expectations for therapy and recovery. Midway through the patient encounter, both parents were asked to leave the room. With her mother gone, our patient was able to share with us how she was suffering to the point read more..
2: The Use of Narrative Medicine and Reflection for Practice-Based Learning and Improvement ■ 15SELF-ExAMINATION QUESTIONS(Answers begin on p. 367)1. Name setting(s) where use of narrative has been useful in medical education.A. Patients with chronic illnessB. Medical student or resident small group learning to reflect on critical incidentsC. Promotion of interprofessional skills and teamworkD. All of the above2. A narrative promptA. Should be open-endedB. Should ask writers only to write read more..
163: Conscious, Compassionate Communication in Rehabilitation MedicineGOALTo demonstrate interpersonal and communication skills that result in effective information exchange and collaboration with patients, their families, and other health professionals.OBJECTIVES1. Exhibit effective communication with patients, families, other health professional team members, and the public across socioeconomic and cultural backgrounds.2. Demonstrate how to educate and counsel patients and family members.3. read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 17Communication Skills Are Not Taught Early EnoughUnfortunately, human beings are not born with communica-tion skills manuals. Nor do children typically learn the skills in school. Not until adulthood are people taught how to connect well with others—in chapters like this. Instead we fumble along through life and learn to communicate by default—for better or worse, from society, culture, and role models—parents, read more..
18 ■ I: Basic PrinciplesIssues That Arise During the Doctor–Patient VisitCertain factors, some uncontrollable, inhibit communication: too short appointment visits—a tough problem to address—cultural and language differences, unclear accents, and medical jargon. Pragmatic solutions for these issues include: ■Facilities should provide cultural sensitivity training to staff. ■For language barriers, patients should have personal or on-staff interpreters. ■Doctors with thick accents can read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 19feelings—with compulsive behaviors like drinking or overeat-ing, busyness, or intellectualizing emotions. This just buries the feelings, which have an uncanny way of surfacing sideways later—in illness, anger outbursts, and self-destruction.Understandable to a degree, medical schools promote sup-pressing emotions. Emotional attachment to patients is undesir-able, and emotions are inconvenient if a patient dies but read more..
20 ■ I: Basic Principlesself-esteem and feel better about themselves by making others feel happy with them. So clearly it is very important to become aware of and express one’s needs, or they may not get met.Communication StylesThere are basic communication styles that people use, each implying a certain level of underlying self-esteem. They tend to be more “automatic” than “chosen” ways of communicat-ing. While no one always uses only one style, most people can categorize themselves read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 21reflect a more lecture-type style when information is more likely to be given, or a more interactive approach where trainees are expected to provide much of the information.COMPONENTS OF COMMUNICATION—PART III: BODY LANGUAGE, LISTENING, AND SPEAKINGBody LanguageBody language can speak volumes without a word being said, and is an important aspect of communication. During communica-tion, how people act, how they express read more..
22 ■ I: Basic Principles(even if these weren’t exactly stated). Why do this sometimes awkward strategy? It makes the person really feel heard.The key features of active listening are as follows: ■Gathering and retaining the information correctly. ■Understanding the implications for the patient of what is being said. ■Responding to verbal and nonverbal signals and cues. ■Demonstrating that you are paying attention and trying to understand (12).This technique uses phrases along the read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 23Verbal Read-Back ProceduresAnother very effective feedback strategy is the “verbal read back” used to ensure accuracy of verbal orders, especially for medications. Giving medication orders verbally or over the phone increases the risk of patient medication errors. With read-back procedures, the person receiving an order writes it down, reads it back, and gets confirmation that it was understood correctly.“Verbal read more..
24 ■ I: Basic PrinciplesSpeakingCourtesyA very obvious but underused strategy is common courtesy. “Please,” “Thank you,” or “Excuse me” are often omitted, espe-cially in crises. Those who demand vs. request things, and don’t offer thanks elicit a desire to not cooperate. Try, “Please find me when the Medical Director calls,” “Thanks for handling that family so well,” and “Thanks for coming for your visit.” Remember, patients can go elsewhere.PraisePraise also greatly read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 25 State Needs/Wants: “I need/am asking you to. Can you do that? Does that work for you?” Consequences: Use if necessary: “If this doesn’t change, I’ll have to” or “The results will be” (16).Some prefer to memorize the key words in this model for a structure to follow, and it’s easy to remember: D When you… E I feel/felt … and the impact on me was… S I want/need… C If not, I’ll…The DESC model read more..
26 ■ I: Basic Principlesby Dr. Jones: Hi Angela. Got a minute? I’d like to discuss some-thing with you privately. Angela: Sure, what is it? D—Dr. Jones: Nurse Bonnie told me you wrote a prescrip-tion for penicillin for Mr. Morris. He’s allergic to this. Bonnie realized it before she gave it to him and no harm was done. Are you aware this happened? Angela: No. She hasn’t said anything to me today. E—Dr. Jones: When I heard this, I was quite concerned for both the patient and about read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 27 ■Elicit and ask about the patient’s perspective on his or her ill-ness, using open-ended questions (18):1. Ensure they’ve understood the patient’s symptoms/ problem by paraphrasing them back to the patient using reflective listening, and asking the patient if they’ve heard them accurately. ■Negotiate with their patients to reach common ground (18):1. Share their findings and propose/explain the management read more..
28 ■ I: Basic PrinciplesAs physicians become “conscious” of their emotions in these difficult situations, the emotions can be better managed. The common feelings that arise of fear, dread, anxiety, and so on, are normal, and physicians should reassure themselves of this. Telling a patient or family member about imminent death is never a pleasant task. Neither are typical conversations physiat-rists face when the outcome is likely to be poor, like talking to a patient with a spinal cord read more..
3: Conscious, Compassionate Communication in Rehabilitation Medicine ■ 29REMEMBER THIS: ■Underneath anger is fear. The more anger, the more fear. Try to get the person to get to the source of the fear and discomfort (23). And help the patient to feel his or her fear. A mother who is very angry that her seriously injured daughter’s physician hasn’t visited her yet today might be terrified her daughter will die. Say: “I hear how angry you are. You must be very fright-ened for your read more..
30 ■ I: Basic PrinciplesC. Paraphrasing back to the person the content of what he or she just heardD. Telling the person what he or she thinks the person should doE. Criticizing what the person has said5. Which of the following best characterizes “I” statements? They:A. Promote defensiveness in the listenerB. Create vulnerability and honesty in the speakerC. Are a self-absorbed, narcissistic form of speakingD. Keep the speaker focused outward and blaming othersE. Don’t create read more..
Sorush BatmangelichGOALSDemonstrate knowledge and application of principles to the practice of professional education in the physician teaching and learning enterprise.OBJECTIVES1. Discuss the principles and practice of adult education in the context of physician professional development.2. Describe Accreditation Council for Graduate Medical Edu-cation (ACGME)’s new accreditation system (NAS), mile-stones, competencies, clinical competency committee (CCC), clinical learning environment review read more..
32 ■ I: Basic PrinciplesThe new educational milestones are “developmentally based, specialty specific achievements that residents are expected to demonstrate at established intervals as they progress through training. Residency programs in the NAS will submit composite milestone data on their residents every six months synchronized with residents’ semiannual evaluations”(2).Milestones are shared understanding of expectations that map learning experiences to the six core competencies. read more..
4: Application of Principles of Professional Education for Physicians ■ 33systems based. CLER visits are scheduled every 18 months by a team of visitors, and these engage a different site each visit. CLER will focus on the six domains of (a) quality improvement, (b) patient safety, (c) supervision, (d) transitions of care, (e) duty hours/fatigue management, and (f) professionalism (6,7).Institutional procedures and outcomes will be reviewed. CLERs will observe and evaluate daily operations by read more..
34 ■ I: Basic Principles(born between 1946 and 1964), (c) Generation X (born between 1965 and 1984), and (d) Millennials or Generation Y (born between 1985 and 2005). Table 4.1 describes the top 10 multi-generational attributes (10).What Does It Mean to Teach?In the age of NAS, teaching and assessing the core competencies is a priority and should be seamlessly integrated with all teaching methods, didactics, journal clubs, mortality and morbidity con-ferences, seminars, hands-on procedural read more..
4: Application of Principles of Professional Education for Physicians ■ 35development of the physician beyond training well into the Main-tenance of Certification (MOC) and Maintenance of Licensure (MOL) phases.The ACGME is very sensitive to the balance between teaching/learning/education and service rendered by the resi-dent. Despite the importance given to teaching by ACGME and the RRCs, protected teaching time and creating incentives for teaching remain challenges. DaRosa (14) cited major read more..
36 ■ I: Basic Principles ■Learners treated according to their professional stage identi-ties, developmental readiness, roles/responsibilities, who they are, and their capabilities. ■Learners are clear about where they are going, how they will get there, and how they will know when they got there and have succeeded.Practice-based learning and improvement (PBLI), one of the six core competencies, is the cornerstone of adult learn-ing and self-directed learning. Lifelong learning (LLL) and read more..
4: Application of Principles of Professional Education for Physicians ■ 37actively does a task, discusses what is taking place, practices, and teaches others, referred to as “active learning.” As illustrated in the Learning Retention Pyramid (22), Figure 4.2, retention rate improves progressively as you more actively involve and engage the learner as when you move from passive to active learning. Figure 4.2 demonstrates that we remember only 10% of what we read, 20% of what we hear, 30% read more..
38 ■ I: Basic Principles2. Why are the authors trying to answer this question ( relevance)? (1–2 min)3. What is the study design (design)? (2 min)4. What are their methods (methods)? Include a brief description of the statistical approach (5 min).5. What did they find (findings)? (5 min)6. Critique of methods and conclusions (5–10 min)7. Is this applicable and relevant? Implications for further inves-tigation? Why? (5 min)To integrate and address ACGME competencies during journal club read more..
4: Application of Principles of Professional Education for Physicians ■ 395. Draw on learner experiences: The first rule for learning men-tioned earlier is “knowing your audience.” Part of this exercise to uncover what the learners want is to also capture their pre-vious knowledge and experiences as a resource for teaching.CLINICAL TEACHING, CASE PRESENTATIONS, AND FEEDBACK STRATEGIESFeedbackFeedback is vital, transformational, and enhances relationships. Feedback is important in the read more..
40 ■ I: Basic Principles 7. Feedback must be constructive and improvement oriented; it must clearly address specific behaviors a learner can control that are remediable. 8. Constructive feedback behavior fulfills 2 criteria: descrip-tive (specific) and nonjudgmental. Describe/articulate specifically what needs to be done to correct the problem. Phrase feedback in descriptive nonjudgmental language that is aimed at specific performance standards or recommen-dations, not generalizations. read more..
4: Application of Principles of Professional Education for Physicians ■ 41temptation for providing cues or prematurely providing the answers (avoid premature closure and pattern recognition), or providing cues for the diagnosis (not fully allowing the resi-dent to entertain alternative hypotheses) and management, so a bad example would be for the attending to say, “Sounds like brachial plexopathy…, don’t you think?” Step 2: Probing for rationale or supporting evidence by ask-ing, read more..
42 ■ I: Basic Principles2. Demonstrate Procedure: When you demonstrate the proce-dure, you are also modeling the skills. We are well into the age of simulations in medicine. Use of simulations is dra-matically on the rise in medical and surgical education, and is commonly used when demonstrating, teaching, and evalu-ating procedures. Simulations are defined as the disaggre-gation of clinical experience with the real patient in a safe environment that cannot harm the patient. Simulations allow read more..
4: Application of Principles of Professional Education for Physicians ■ 43attacking the person; (b) concerned about legal implications; however, GME-related lawsuits are rare and if you are follow-ing the established institutional standards and procedures, this should not be a concern; (c) you as faculty or supervisor might be implicitly or explicitly contributing to the problem and wish to avoid transparency in admitting or recognizing fault; remem-ber, professionalism is a required core read more..
44 ■ I: Basic PrinciplesQI project. Evaluators for these might be allied health pro-fessionals, program director, faculty attending, supervisors, patient/family member, self, peer resident, patient surveys, and others. Systems-Based Practice: project assessment such as QI proj-ect, global assessment, direct observation, structured case discussions, multisource 360, and RO&CA. Evaluators for these could be program director, allied health professional, faculty member, supervisor, self, peer read more..
4: Application of Principles of Professional Education for Physicians ■ 45requires based on his or her needs. This model is illustrated in Table 4.2.Peel (43) illustrated in Figure 4.7 a representation of super-imposed similarities of these four models of supervision, and correlated them with the ACGME Supervision Levels (direct, indirect, oversight), with the required amount of support across instruction and feedback. The lower right quadrant is a typical PGY 1 intern; the top right quadrant read more..
46 ■ I: Basic PrinciplesSAFETY: This is an education model to guide residents when to seek attending input. Seek attending input early: To prevent delays in appropri-ate care, involve your attending early. Attendings are legally responsible for patient care. Active clinical decisions: Contact your attending when an active clinical decision must be made such as transfer to sur-gery, ICU, or another service; invasive procedure; or adverse event. Feel uncertain about clinical decisions: To feel read more..
4: Application of Principles of Professional Education for Physicians ■ 47Mentors set high standards. Many professional medical organi-zations support mentorship programs for their members and col-leagues. Education on mentorship and coaching for faculty and resident development activities can be demonstrated and prac-ticed with exercises and case studies conducted around work-place experiences, followed by debriefings.One of the most rewarding aspects of mentoring is the per-sonal read more..
48 ■ I: Basic PrinciplesD. Kirkpatrick’s four-level model for evaluating case pre-sentation learning outcomesE. Moore’s conceptual model of faculty preceptor taking the lead in conducting case presentations6. Which of the following statements most accurately describes ACGME’s most desirable suggested best methods for evalu-ation of competencies?A. Professionalism: 360 multisource, patient survey, global rating, OSCEB. Systems-based practice: SP, 360 multisource, patient survey, global read more..
4: Application of Principles of Professional Education for Physicians ■ 49 22. http://www.virtuala.com.au/essays/learningpyramid.html. Accessed February 13, 2014. 23. https://www.cpp.com/products/mbti/index.aspx. Accessed February 13, 2014. 24. http://etec.ctlt.ubc.ca/510wiki/Kolb’s_Learning_Styles_Model_and_Experiential_Learning_Theory. Accessed February 13, 2014. 25. Bulstrode C, Hunt V. Assessment at the end of training—a necessity nuisance. Surgeon. February 2004;2(1):28–31. 26. read more..
50 ■ I: Basic PrinciplesACGME/ABMS CORECOMPETENCIES TOPICGUIDE Patient care/procedural skillsThe ability to providepatient care that iscompassionate,appropriate, andeffective for thetreatment of healthproblems and thepromotion of health Medical knowledgeThe knowledgeabout establishedand evolvingbiomedical, clinical,and cognatesciences and theapplication of thisknowledge topatient care Practice-based learning andimprovementThe ability toinvestigate andevaluate patient carepractices, read more..
Appendix 2ACGME Competencies: Suggested Best Methods for EvaluationEVALUATION METHODSCOMPETENCYREqUIRED SkILLRECORD REVIEWCHART STIM. RECALLCHEC kLISTGLOBAL RATINGSP OSCESIMULATIONS & MODELS360° GLOBAL RATINGPORTFOLIOSEXAM MCqEXAM ORALPROCEDURE OR CASE LOGSPATIENT SURVEYPatient CareCaring and respectful behaviors3121Interviewing1213Informed decision making1222Develop and carry out patient management plans212323Counsel and educate patients and families31121Performance of proceduresa) read more..
Medical knowledgeInvestigatory and analytic thinking1231Knowledge and application of basic sciences2311Practice-based learning and improvementAnalyze own practice for needed improvements22223312Use of evidence from scientific studies1132111Application of research and statistical methods23313Use of information technology22112Facilitate learning of others2313Interpersonal and communication skillsCreation of therapeutic relationship with patients31121Listening skills31121Appendix 2ACGME read more..
Professionalism Respectful, altruistic3121Ethically sound practice22132Sensitive to cultural, age, gender, disability issues2211322Systems-based practiceUnderstand interaction of their practices with the larger system213Knowledge of practice and delivery systems2321Practice cost-effective care312Advocate for patients within the health care system32121ACGME/ABMS Joint Initiative Attachment/Toolbox of Assessment Methods© Version 1.1 September 2000Ratings are 1, the most desirable; 2, the next read more..
54GOALSReflect a professional commitment to carrying out ethical responsibilities and an adherence to ethical principles in the practice of rehabilitation medicine.OBJECTIVES1. Demonstrate knowledge of the general principles of ethics and the steps in the methodology of making ethical decisions in the practice of rehabilitation medicine.2. Demonstrate knowledge of ethical issues in clinical research.Physiatrists, like other physicians, are taught throughout their training to place the interests read more..
5: Ethical Considerations in the Practice of Rehabilitation Medicine ■ 55Since the invention of Gutenberg’s printing press in the 15th century and the emergence of philosophers and scientists, especially during the period of the European Enlightenment, authors, particularly John Locke, David Hume, John Stuart Mill, and others, have expanded on rules found in the religious texts, often by exercising reason without claiming divine inspi-ration (4). Basically, their emphases, particularly read more..
56 ■ I: Basic Principlesto speed discovery and bring products to market, inadequate mentoring and supervision (by the principal investigator and the institution), and inadequate peer review by the institution and/or the scientific journals (being alert for “ repetitive publications, supernumerary authorship, lack of disclosure, among others”) when publication of a manuscript is sought (10,11).Readers of published work and society in general expect that researchers will truthfully report read more..
5: Ethical Considerations in the Practice of Rehabilitation Medicine ■ 57When making decisions about ethical issues, all parties should be involved in an identified decision-making process. One example of such a decision-making process was devel-oped by the Hastings Center and has been modified for use in this book (19).Steps in the Process for Making Ethical Decisions1. Professional commitment2. Systematic evaluation of the case3. Communication among all involved4. Consider ethical read more..
58 ■ I: Basic Principlesof the patient’s condition, the patient’s wishes, and the potential benefits and burdens of proposed treatments, as well as conse-quences of nonintervention, are cornerstones of effective com-munication. The wishes of a competent, well-informed patient take priority over other opinions. On occasion, patients may wish to withhold information from family members or members of the interdisciplinary team. Balancing a patient’s right to privacy with the family and read more..
5: Ethical Considerations in the Practice of Rehabilitation Medicine ■ 59 ■Failing to stop treatments when their burdens begin to exceed their benefits (e.g., continuing the provision of artificial nutri-tion when patients are actively dying or continuing IV fluids for dyspneic patients with congestive heart failure).Lack of knowledge and clinical misinformation can generate apparent ethical quandaries. For example, some physicians fail to prescribe adequate amounts of pain medication read more..
60 ■ I: Basic Principlescapacity to consent to or refuse medical care. A proper legal authority, usually a judge, determines competence. Decision-Making Capacity. A patient is presumed to have decision-making capacity unless proved otherwise. In medi-cal settings, it is the physician’s responsibility to determine decision-making capacity. Capacity may change depending on the patient’s condition and the complexity of the decision. To have capacity to make a specific decision, a patient read more..
5: Ethical Considerations in the Practice of Rehabilitation Medicine ■ 61the decision-making capacity of terminally ill patients tends to deteriorate rapidly, lengthy court proceedings rarely are practical or helpful for making clinical decisions. Ethics committees may serve as more practical intermediaries.A patient, family member, or surrogate can challenge a determination of decision-making capacity. When a challenge arises, the importance of continued open communication and reevaluation read more..
62 ■ I: Basic PrinciplesUpon learning from an “Internet search” that this is an incurable progressive disease, he felt extremely anxious. He explained his situation to his physiatrist and requested help com-mitting suicide. When the physiatrist refused, the patient reas-sured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medi-cine after pinning a note to his shirt to explain his actions and to refuse any medical read more..
5: Ethical Considerations in the Practice of Rehabilitation Medicine ■ 63ETHICAL ISSUEPRIMARY ETHICAL PRINCIPLES INVOLVEDEnd-of-life care and advance directivesPrinciple based: autonomy, beneficenceVirtue based: compassion and caring; fidelity to trust and promise; prudenceCaring based: empathy and compassionRespect for personhoodUse of opioid medications in the treatment of nonmalignant musculoskeletal pain—patient wishes vs. physician recommendations and concernsPrinciple based: autonomy, read more..
64 ■ I: Basic Principles Data: For poor nutritional status, options include percutane-ous gastrostomy (PEG) tube placement and diet counseling. For respiratory difficulty, options include initiating nonin-vasive positive pressure ventilation. For speech difficulty, options include recommending an augmentative communi-cation device by speech pathologist. A physical therapist can offer exercises, braces, and adaptive devices. This admission is also an opportunity to clarify the goals of care read more..
5: Ethical Considerations in the Practice of Rehabilitation Medicine ■ 656. Which of the following best describes the elements of the principle of double effect?A. Bad effect can be a means to a good effectB. Good effect does not need to be intendedC. Bad effect cannot be the means to good effectD. Symptoms don’t need to be severe to warrant taking risksE. The intent of treatment is to end lifeREFERENCES 1. Donovan WH. Ethics, health care and spinal cord injury: research, practice and read more..
66GOALSDemonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population applicable to rehabilitation medicine.OBJECTIVES1. Demonstrate compassion, integrity, and respect for others, as well as sensitivity and responsiveness to diverse patient popu-lations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.2. Role model respect for, read more..
6: Professionalism ■ 67skill set. They must learn how to form therapeutic physician–patient relationships via patient interviewing and physical examination. As they learn, they will show an increasing ability to commu-nicate with other members of their health care team, including nurses, care managers, respiratory therapists, physical therapists, pharmacists, and social workers. Focused care coordination contributes to developing the ACGME/ABMS core competen-cies of professionalism, patient read more..
68 ■ I: Basic Principles and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost- effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provi-sion of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the read more..
6: Professionalism ■ 69care to another provider, the current treating physiatrist has an obligation to transfer care to another physician in a safe manner.The Code addresses conflicts of interest that can impact patient care by stating: “Conflicts of interest must be resolved in the best interest of the patient” (7). Financial conflicts of interest have been described in the 6th edition of the American College of Physicians Ethics Manual. According to this manual, some examples of read more..
70 ■ I: Basic Principles2. Which of the following statements best describes the AAPM&R Code of Conduct?A. It addresses relationships between physiatrists and their patientsB. It addresses relationships between physiatrists and the state licensing boardsC. It addresses relationships between physiatrists and American Board of Physical Medicine and RehabilitationD. It addresses relationships between physiatrists and the American Medical AssociationE. It addresses relationships between read more..
7: Systems-Based Practice in Rehabilitation MedicineF. Use said skill set to improve the safety of rehabilitative services; andG. Work effectively as a team member and leader in maximizing patient safety and improving the quality of rehabilitative care.GRADUATE MEDICAL EDUCATION AND SYSTEMS-BASED PRACTICEMedical education focuses on obtaining medical knowledge about the diagnosis and treatment of diseases at the individual physician–patient level and tends to put less emphasis on the read more..
72 ■ I: Basic Principlessurgical team, and rehabilitation team specializing in spinal cord injury medicine). These microsystems can have multiple connec-tions with other microsystems in the same organization. Clinical staff can simultaneously be part of several microsystems within an organization, which only complicates matters further. The actions of individuals are not always predictable; however, given their connected and interdependent nature, actions of one can affect others within that read more..
7: Systems-Based Practice in Rehabilitation Medicine ■ 73Proficient systems thinking in health care requires that the phy-sician develop an understanding of how individual patient care relates to the health care system as a whole and how to improve the delivery of individual patient care by improving the health care system (3).THE PHYSIATRIST AS SYSTEMS CONSULTANT IN REHABILITATION HEALTH CARE DELIVERY SYSTEMSFollowing acute hospitalizations for illness or injury, individuals are often read more..
74 ■ I: Basic PrinciplesCoordination of care is especially important at transition points when attention to detail is paramount. The information passed from one treating team to another should be complete and include key information about the following: ■The patient’s hospital course and complications ■Past medical and surgical history ■Laboratory and imaging results ■Operative and procedure reports ■Medications ■Allergies ■Advance directives (e.g., do not resuscitate/do not read more..
7: Systems-Based Practice in Rehabilitation Medicine ■ 75improving care coordination among health care providers and hospitals and linking them through quality metrics, health care costs would also be reduced. Pay for performance metrics would also be used to incentivize high-quality care. As of 2011, PMR-specific performance metrics were limited (27).Patient-centered medical homes have been proposed as an integral aspect of ACOs. These are primary care practices in which care is coordinated read more..
76 ■ I: Basic Principles ■Patient’s perceived ability to return to the community setting ■Patient having clear functional goals that can be achieved in a realistic time frameOrganizational characteristics of IRF and SNF were described with some clear distinctions drawn between them. Some of these are given in Table 7.1.The task force characterized the patient admitted to the IRF as one having had a recent serious illness or exacerbation of a serious illness that decreased that read more..
7: Systems-Based Practice in Rehabilitation Medicine ■ 77challenges facing modern medical education and the importance of motivating physicians for continuous learning and improve-ment. They stated that there is a need for “fundamental change in medical education that will require new curricula, new pedago-gies and new forms of assessment.” The authors recommended that physicians should learn to work collaboratively with other health professionals such as medical assistants, nurses, read more..
78 ■ I: Basic PrinciplesThe effective physiatrist leader excels in the practice of both ground-up and top-down leadership. One realizes that he or she cannot effectively improve quality and safety just from sit-ting behind a desk in one’s office, but rather by walking around the institution, effectively listening to people, and empowering, mentoring, and inspiring others about the importance of safety and quality in rehabilitation medicine. The physiatrist leader is effective at breaking read more..
7: Systems-Based Practice in Rehabilitation Medicine ■ 79In the “Plan” phase, a plan is developed that will be carried out during the cycle. In the “Do” phase, the plan is carried out and data are collected and analyzed. In the “Study” phase, the effect of the change is compared against the goals and benchmarks and lessons learned are summarized. In the “Act” phase, the interven-tions and changes found to be successful are implemented. In this phase, the decision to carry out a read more..
80 ■ I: Basic PrinciplesC. Medicare pays the provided 50% of the fee schedule and the beneficiary pays a 50% copaymentD. Outpatient rehabilitation services are rarely necessary and therefore not covered by MedicareE. Medicare pays the provided 40% of the fee schedule and the beneficiary pays a 60% copayment6. Which of the following is true with respect to Medicare cover-age of costs for an admission to a skilled nursing facility (SNF)?A. Medicare pays the SNF on a predetermined annual rate for read more..
7: Systems-Based Practice in Rehabilitation Medicine ■ 81 23. Granger CV, Markello SJ, Graham JE, et al. The uniform data sys-tem for medical rehabilitation: report of patients with stroke dis-charged from comprehensive medical programs in 2000–2007. Am J Phys Med Rehabil. December 2009;88(12):961–972. 24. Ottenbacher K, Graham JE. The state of the science: access to postacute care rehabilitation services. Arch Phys Med Rehabil. 2007;88:1513–1521. 25. Chan L. The state of the science: read more..
OBJECTIVES1. Discuss characteristics of leadership based upon personal observations and experience.2. Describe qualities of effective leaders.Several years ago, I was asked to discuss the essentials of leader-ship in the field of Physical Medicine and Rehabilitation (PM&R) with a group of young academic physiatrists. In this regard, I was asked by the group’s leader to describe my own leadership style and how it has changed over time, name the qualities that I believe are important for a read more..
8: Essentials of Leadership in the Field of Physical Medicine and Rehabilitation ■ 83performance has been consistent and significant. People listen to you more carefully, which also means that you must be more careful in what you say and do. Your words may have a surpris-ing influence, for better or for worse!These observations of many of the leadership traits identified by my associates parallel the literature on leadership character-istics from distinguished thinkers and contributors such as read more..
84 ■ I: Basic PrinciplesPassion and CompassionMost leaders feel passionate about their work and are champions for inspiring others toward a desired mission. We know that one of the most evident qualities of an effective leader is the cha-risma and ability to inspire. Leaders must enjoy or even love what they are doing. They must passionately believe in the mission, be eager to get involved, and look at their work as an opportunity to do even more. In this regard, I passionately believe that read more..
8: Essentials of Leadership in the Field of Physical Medicine and Rehabilitation ■ 85 9. Be a good listener. Leaders are effective listeners. They don’t just hear, but they listen, read body language, and internal-ize messages that have a deeper meaning. Listen much more than you speak and be attentive. Be able to state exactly what the other party means and wants. Show people that you truly understand what they were saying. After you have done that, you can express your own view without read more..
86 ■ I: Basic PrinciplesFortunately, most people can learn to delegate and even build a team, although the success of the team may vary.Decisiveness and Ability to ImplementIt only helps to be decisive if you consistently make the right decisions. Decisions are preceded by gathering of lots of facts and by extensive discussions with your most trusted coworkers. Decisions should not be made impulsively and without knowing all the facts, risks, opportunities, and so on.However, when making read more..
87II: Core Clinical Competencies87Cristian_87833_PTR_09_087-098_13-08-14.indd 878/13/14 11:50 AM read more..
Cristian_87833_PTR_09_087-098_13-08-14.indd 888/13/14 11:50 AM read more..
89Patient CareGOaLSProvide patient care that is compassionate, appropriate, and effective for the treatment of the adult with an upper extremity amputation.OBJeCtiVeS1. Describe the key components of the assessment of the adult with an upper extremity (UE) amputation.2. Describe potential injuries associated with UE amputation.3. Formulate the key components of a rehabilitation treatment plan for the adult with UE amputation.The evaluation and assessment of the patient with an upper extremity read more..
90 ■ II: Core Clinical Competenciescandidates for externally powered prostheses such as a myo-electric or a hybrid prosthesis.2. Transhumeral—Ideally, the residual limb should be cylindrical in nature with retention of the tuberosity of the deltoid. The lon-ger the better for the lever arm, where retention of the affected humerus compared with the sound limb is 50% to 90%.Range of motion and presence of contractures of the resid-ual limb should be recorded. Skin integrity is also an read more..
9: Upper Extremity Limb Loss ■ 91tapping, and transcutaneous nerve stimulation. Virtual imaging techniques, mirror therapy, and acupuncture (4) have also been found to be quite helpful. Severe cases might necessitate nerve blocks: ganglion, epidural nerve blocks with steroids. Surgical intervention is deemed as a last resort as it is not as successful.It is important to be fit with the first prosthesis as soon as possible. The first UE prosthesis is intended to promote residual limb maturation read more..
92 ■ II: Core Clinical CompetenciesTerminal DeviceThe functional activities of the hand are intricate but can be sepa-rated into two groups: nonprehensile and prehensile. Voluntary opening terminal devices are normally held closed by a spring or a rubber band and open when the control cable is pulled. It takes the shape of a “c” configuration. Each rubber band produces approximately 0.45 kg (1 lb of prehensile force) between the hook fingers. A version of this type of terminal device is read more..
9: Upper Extremity Limb Loss ■ 93 ■Outside locking hinges—Elbow disarticulation/ transcondylar amputation ■Inside Locking Hinges—Transhumeral amputations, if 5 cm proximal to the elbow joint ■Flail—arm hinges—postbrachial plexus lesions ■Ratchet hinge—postbrachial plexus injury works like a beach chair positioning ■Friction units—lightweight, passive positioning ■Flexion assist—counterbalances the weight of the pros-thetic forearm ■Nudge control unit—originally read more..
94 ■ II: Core Clinical Competencies ■Biscapular abduction ■Glenohumeral depression, extension, and abduction ■Unnatural and difficult ■Unlocks or locks elbow ■Scapular adduction/chest expansion ■Unnatural ■Unlocks or locks elbow ■Allows TD functions ■Scapular elevation ■Requires another strap-waist belt ■Unlocks or locks elbowThe Krukenberg procedure is classically indicated for a person with bilateral transradial amputations who was also blinded in the same read more..
9: Upper Extremity Limb Loss ■ 95Alternatively, physiatrists can “reflect back” on the care they provided to a UE amputee and use that opportunity to assess their knowledge base about the various issues involved in the care of that patient.Once the gaps are identified, there are several resources and strategies that one can use to address them. One useful approach is “reading around your patient.” In this approach, one updates clinical and treatment skills as they apply to their read more..
96 ■ II: Core Clinical CompetenciesThe patient and his or her ongoing needs and wants are the center of the interdisciplinary care team’s efforts from step one of the process—the preoperative phase of the rehabilitation process.Patients need to be addressed on an individual basis. Their needs, hobbies and activities, and functional status all play a role in the specific prostheses prescribed. UE prosthetic needs are task specific; therefore, patients receive several to perform necessary read more..
9: Upper Extremity Limb Loss ■ 97in care along the health care continuum can predispose to injury. Information that is important to transmit between health care providers as it pertains to the UE amputee includes (a) reason for amputation, surgery performed, and complications follow-ing surgery; (b) weight-bearing precautions and range of motion restrictions; (c) comorbid medical conditions; and (d) current medications, their indication, dose, and adverse effects.CaSe StUDyA 25-year-old read more..
98 ■ II: Core Clinical Competencies 7. Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Guide to Allied Health Professionals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2010. 8. Commission on Accreditation of Rehabilitation Facilities, www.carf .org 6951 East Southpoint Road, Tucson, Arizona 85756. 2013 Medi-cal Rehabilitation Standards Manual. 9. National Limb Loss Information Center. Amputation statistics by cause. Limb read more..
Patient CareGOaLSProvide competent patient care that is compassionate, appropri-ate, and effective for the evaluation, treatment, education, and advocacy for lower extremity amputee (LEA) patients across the entire spectrum of care, from the acute injury until death, and the promotion of good health.OBJeCtiVeS1. Perform a comprehensive interdisciplinary assessment of the adult with a lower limb amputation.2. Describe the key components of a rehabilitation program for the lower limb amputee, read more..
100 ■ II: Core Clinical Competenciescare, progression of disease and disability, and the need for con-tinued patient-driven rehabilitation. Patients and their families should be educated on proper foot and skin care of the contra-lateral limb to minimize the risk of limb loss, strategies to mini-mize the risk of knee and hip flexion contractures, appropriate biomechanics, diabetic education if the patient is diabetic, medi-cation management, pain management techniques including read more..
10: Lower Extremity Amputation ■ 101years after their initial amputation. In elderly patients, only 50% survive longer than 3 years after their initial limb amputation. Greater than half of all diabetic amputees will face a second amputation within 5 years. Traumatic amputations account for 6% to 25% of all amputations. Malignancy-related causes are responsible for roughly 5% of all amputations, most commonly occurring in children and adolescents between 10 and 20 years of age. It is estimated read more..
102 ■ II: Core Clinical Competencieslimb pain management include desensitization techniques, medi-cations, and strategies for volume control and shaping of the residual limb. The preferred shape for the transfemoral residual limb is conical and for a transtibial residual limb it is cylindrical. Improved outcomes for a shorter transfemoral residual limb are noted with preservation of the greater trochanter and hip adduc-tors attachment. In a transtibial amputation, the tibial tuberosity with read more..
10: Lower Extremity Amputation ■ 103and desensitization techniques, ultrasound, wrapping, mirror therapy, short-wave diathermy, and transcutaneous electrical nerve stimulation (TENS). Medications that may have a positive effect on phantom pain include beta-blockers, neuromodulators such as gabapentin, tricyclic antidepressants, calcitonin, and topical anal-gesics. One topical analgesic that is being used more commonly in peripheral neuropathy is topical ketamine. The mechanism of action is read more..
104 ■ II: Core Clinical Competenciestraumatic brain injuries, pose particular safety concerns. As for patients who suffer traumatic brain injuries along with amputa-tion of one or multiple limbs, understanding and identifying key safety features in the rehabilitation process are integral to patient safety. These patients are prone to falls for having cognitive impairment that is compounded by an amputation, along with further issues such as spasticity, visual impairment, impulsivity, or read more..
10: Lower Extremity Amputation ■ 105to the underlying heterotopic ossification. An interdisciplinary team approach to manage these patients is of utmost importance to identify safety concerns as early as possible. Working within these teams, educating family members of patients with ampu-tations with concomitant cognitive deficits needs to be a focus to ensure safety and help prevent complications. Patient families need to be educated on issues such as skin monitoring, stump sock management, read more..
106 ■ II: Core Clinical Competencies(e) interpersonal and communication skills with his or her patient and the multidisciplinary team providing care for this patient. This self-assessment can be completed through reflection on one’s clinical practice, seeking feedback from colleagues as well as patients, and through self-assessment examinations.Once gaps have been identified during the self-assessment, there are several resources available to physiatrists to increase their skills and read more..
10: Lower Extremity Amputation ■ 107A shared understanding of the issues involved in the care of the LEA requires an understanding of the problem from several different perspectives—the physiatrist, the patient, her family, and at times the institution or setting where the patient is receiv-ing rehabilitative care. Once these have been defined, a “shared understanding” of the problem that combines the perspectives of all the stakeholders can be developed. Based on this shared read more..
108 ■ II: Core Clinical Competencieson the person’s self-image; ability to work, care for him- or herself and his or her provide self-care and care for the family; and engage in activities that were once meaningful prior to the amputation. It is very important to show respect, compassion, and empathy for the patient at this time in his or her life when he or she is most vulnerable and to provide the best possible care in an honest and respectful manner.It is important that all attempts be read more..
10: Lower Extremity Amputation ■ 109dependent on the patient’s medical stability and comorbidities, the patient’s current level of function, and the number of hours per day that the patient can participate in a rehabilitation pro-gram. Additional factors include level of support at home and health care insurance program. If the patient’s residual limb has not fully healed following the surgery, he or she may be sent home with visiting nursing and therapy services or to a skilled nursing read more..
110 ■ II: Core Clinical Competenciesoutcome measures, and evidence-based practices. What are the key points of a patient education program that emphasizes mini-mizing the risk of future limb loss? What are some key resources and references that the patient should know about?SYSTEMS-BASED PRACTICE: Are there any access-to-care issues? Are there any issues with affordability of medications or insurance coverage? Are there any patient safety concerns? Describe the advantages and disadvantages of read more..
10: Lower Extremity Amputation ■ 111 7. Amputee Resource Foundation of America, Inc. (n.d.). Amputee Resource Foundation of America, Inc. Retrieved from http://www .amputeeresource.org 8. Ehde DM, Czerniecki JM, Smith DG, et al. Chronic phantom sensa-tions, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000;81:1039–1044. 9. Latlief G, Kent R, Elnitsky C, et al. Patient safety in the rehabilita-tion of the adult with an read more..
112The goal of achieving competency in cardiopulmonary reha-bilitation is to be able to provide rehabilitation for two groups of patients. There are patients with primary cardiac and pulmo-nary disease who need cardiac/pulmonary rehabilitation and then there are patients with other disabilities who have a cardiac or pulmonary secondary disability. This includes patients with respiratory failure and patients who have need for ventilatory support. The incidence of dual-disability patients is now read more..
11: Cardiopulmonary Rehabilitation ■ 113hypercarbia, hypoxemia, ventricular arrhythmias, reentrant arrhythmias, high-degree atrioventricular (AV) block, or sick sinus syndrome. Postural syncope can be due to autonomic dysfunction, neurological disease, vagal stimuli, or psycho-logical stimuli.Edema. Peripheral edema may be an indication of CHF, and in pulmonary disease may indicate right heart failure and PH.Fatigue. Fatigue is common in cardiopulmonary disease, and there may be other causes read more..
114 ■ II: Core Clinical Competenciesboth cardiac and pulmonary patients is dyspnea, with chest pain more common in cardiac patients. Hypoxemia is the major physi-cal limitation, leading to activity limitation and participation restriction in pulmonary patients, while decreased cardiac output (CO) is the most common physical limitation, leading to activity limitation and participation restriction in patients with cardiac diseases. These limitations (fatigue, hypoxemia, dyspnea, chest pain, and read more..
11: Cardiopulmonary Rehabilitation ■ 115via nitric oxide pathways. It is the goal of most medical and surgical therapies for ischemia to restore or preserve myocar-dial perfusion, through vasodilation or bypass or endovascular procedures. Exercise is also a very effective therapy, as regular exercise can increase cardiac collateral circulation and improve arteriolar vasodilation (2).Appropriate fluid balance is also important in cardiac care, as adequate venous return can maintain appropriate read more..
116 ■ II: Core Clinical CompetenciesSTROKE VOLUME Stroke volume (SV) is the quantity of blood ejected with each left ventricular contraction. Normally, maxi-mal SV can be increased with exercise. SV increases the most during early exercise and is sensitive to postural changes, chang-ing little when one is supine but increasing in a curvilinear fash-ion until it reaches maximum at approximately 40% of VO2max. SV declines with advancing age, in cardiac conditions that result in decreased read more..
11: Cardiopulmonary Rehabilitation ■ 117TABLE 11.3 Effects of Physiological Conditions on the Interpretation of Pulmonary TestingABNORMALITYPHYSIOLOGIC ABNORMALITYGAS EXCHANGEObesityIncreased work with activity Rapid alveolar–arterial pA–PaO2 fall with exercisePeripheral vascular diseaseClaudication limits exerciseLow VO2maxLow anaerobic thresholdPulmonary vascular diseaseImpaired pulmonary blood flow Decreased O2 uptake at maximum workLow anaerobic thresholdRapid pulse at low read more..
118 ■ II: Core Clinical CompetenciesBy remembering the basic physiology described earlier, car-diopulmonary rehabilitation specialists can improve function, decrease symptoms, and have a positive effect on outcomes in their patients. The main benefits of cardiac conditioning are reduced cardiac risk and improved cardiac conditioning. The reduction of cardiac risk is established historically in numerous studies. As long ago as 1989, pooled data from 22 randomized studies of exer-cise in 4,554 read more..
11: Cardiopulmonary Rehabilitation ■ 119GOALSMETHODSFamily trainingTeaching regarding:COPDPulmonary toiletMedication useOxygen useFamily support groupCounseling as neededDyspnea Relief—Exercise TrainingExerciseMultifaceted program individualized to each patient’s needs StrengtheningEmphasis on gradual increase in strengthFocus on proximal muscle groupsAvoid injury to weakened musculotendinous structuresFocus more on high-repetition, low-intensity training ConditioningWork to gradually read more..
120 ■ II: Core Clinical CompetenciesCardiac rehabilitationCardiac rehabilitation programs come in 2 forms: primary pre-vention, which includes risk factor modification and education before a cardiac event; and secondary prevention, which is car-diac rehabilitation after the establishment of cardiac disease and includes exercise and risk factor modification.Primary prevention programs are not usually performed in a rehabilitation setting but are in primary care settings. Primary prevention read more..
11: Cardiopulmonary Rehabilitation ■ 121lipid abnormalities, and antiplatelet agents. These are all cost-effective approaches and can decrease mortality and morbid-ity on a population-based scale, in addition to the individual benefits (9–11).Secondary risk factor modification programs are an essen-tial part of cardiac rehabilitation programs for individuals after onset of cardiac disease. Secondary risk factor modification pro-grams include all of the features of primary prevention programs read more..
122 ■ II: Core Clinical Competenciesin increasing access to cardiopulmonary rehabilitation, creative programs have been developed, including at-home programs for low-risk patients, telemedicine programs, and community- and home-based programs. A key to success in home-based programs is assuring that patients are able to perform self-monitoring dur-ing their exercise program. Guidelines for self-monitoring are outlined in the standard references (15,16). Just as in the super-vised programs, all read more..
11: Cardiopulmonary Rehabilitation ■ 123Since CHF patients have higher risk than most cardiac rehabilitation patients, a graded ETT is essential before starting. Due to poor adaptation to exercise in CHF, long warm-up and cool-down periods are required with exercise at a limited workload. Dynamic exercise is preferable with a target HR at 10 bpm below any significant endpoint found with cardiopulmonary exercise testing. Isometric exercises need to be avoided since they increase diastolic read more..
124 ■ II: Core Clinical Competenciesexperienced debility prior to the institution of effective therapy or have concern about exercise many patients could benefit from pulmonary rehabilitation. It is important to maintain oxygen-ation during exercise, and patients with severe PH may need to have cardiac monitoring as arrhythmias and right heart failure are issues to be considered. High-flow supplemental oxygen and education in the use of their vasodilating agents are part of the program. read more..
11: Cardiopulmonary Rehabilitation ■ 125patient care practices based on constant self-evaluation and life-long learning.OBJeCtiVeS1. Describe learning opportunities for providers, patients, and caregivers with experience in cardiopulmonary rehabilitation.2. Use methods for ongoing competency training in cardiopul-monary rehabilitation for physiatrists, including formative evaluation feedback in daily practice, evaluating current prac-tice, and developing a systematic quality improvement and read more..
126 ■ II: Core Clinical CompetenciesOBJeCtiVeS1. Demonstrate skills used in effective communication and col-laboration with patients who have cardiac and pulmonary disorders, and their caregivers, across socioeconomic and cultural backgrounds.2. Delineate the importance of the role of the physiatrist as the interdisciplinary team leader and consultant pertinent to car-diac and pulmonary rehabilitation.3. Demonstrate proper documentation and effective communica-tion between health care read more..
11: Cardiopulmonary Rehabilitation ■ 127measures in the practice of rehabilitative medicine for patients with cardiac and pulmonary diseases.3. Examine risk–benefit analysis in the provision of reha-bilitation medicine to patients with cardiac and pulmonary diseases.4. Explain the role of the physiatrist as an advocate for qual-ity rehabilitative care and optimal patient care systems for patients with cardiac and pulmonary diseases.5. Identify system problems in the rehabilitation of read more..
128 ■ II: Core Clinical CompetenciesE. 75%2. Which of the following best describes myocardial oxygen consumption with exercise?A. Supine exercises have a higher myocardial oxygen con-sumption compared with erect exercises at low-intensity exercisesB. Supine exercises have a lower myocardial oxygen con-sumption compared with erect exercises at low-intensity exercisesC. Myocardial oxygen consumption decreases in cold weatherD. Myocardial oxygen consumption decreases after eatingE. Myocardial read more..
11: Cardiopulmonary Rehabilitation ■ 129coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Coun-cil on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Associa-tion of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111(3):369–376. 13. Williams MA, Fleg JL, Ades PA, et al.; read more..
Patient CareGOaLSProvide competent patient care that is compassionate, appropri-ate, and effective for the evaluation, treatment, education, and advocacy for patients diagnosed with cancer and associated problems all along the care continuum and survival trajectory.OBJeCtiVeS1. Describe the key components of the assessment of the patient with cancer.2. Formulate comprehensive interdisciplinary rehabilitation treatment plans for cancer patients that also include patient safety concerns.3. read more..
12: Cancer Rehabilitation ■ 131Specific cancers should lead physicians to pursue relevant avenues of investigation. For example:a. Head and neck cancer patients can have limitations in range of motion of the neck and shoulders, problems opening and closing the mouth, or speech and swallow-ing difficulties as a result of the cancer or its treatments.b. Breast cancer survivors may have complaints of swelling of the arm(s), restricted range of motion of the shoulder, and pain in the thorax read more..
132 ■ II: Core Clinical Competenciesalso beneficial to establish circumferential measurements in the affected extremity at the time of initial assessment and then sub-sequently chart the changes with appropriate treatments.As far as comorbid neurological pathologies are concerned, it is important to assess speech characteristics (e.g., dysarthria, fluency, comprehension, naming, and repetition) and swallow-ing function (e.g., ability to tolerate sips of water), and assess for vision or hearing read more..
12: Cancer Rehabilitation ■ 133risk factors, and utilize interventions that will minimize the risk for harm. Lastly, given the limited use of rehabilitation ser-vices by cancer patients in need, the physiatrist must work with the patient’s family, members of the oncology team, and health insurance companies to ensure that access to rehabilitation ser-vices is not restricted.MeDiCaL KnOwLeDGeGOaLDemonstrate knowledge of established evidence-based and evolving biomedical, clinical, read more..
134 ■ II: Core Clinical CompetenciesConsider that there are really three ways that the rehabilita-tion care may take place. The first way is that the oncology and rehabilitation departments are separate entities and don’t have much overlap or collaboration. This has historically been the case, and it has resulted in a significant gap in care. The second way is that the oncology health care team becomes part of the rehabilita-tion care continuum. This could work but is unlikely as oncologists read more..
12: Cancer Rehabilitation ■ 135exercise regardless of whether they have been screened for impair-ments and received appropriate rehabilitation interventions. Unfor-tunately, the “rehabilitation” of cancer survivors too often does not include any oversight by trained rehabilitation professionals. Estab-lishing appropriate screening protocols, identifying impairments, and referring patients to skilled rehabilitation professionals is criti-cal. However, even when all of this is in place, read more..
136 ■ II: Core Clinical Competenciescombination of Pentoxifylline and vitamin E with hyperbaric oxygen therapy improved RFS (18–22), but their benefits are still controversial. Preventive treatment including CXCR4 inhibition by drugs such as MSX-122 may alleviate potential radiation-induced lung injury, presenting future therapeutic opportunities for patients requiring chest irradiation.There are many physical impairments and functional prob-lems that may result from cancer and its read more..
12: Cancer Rehabilitation ■ 137Once gaps have been identified, there are several ways in which physiatrists can address them. Some examples include (a) specialty courses in cancer rehabilitation (29,30), (b) courses offered at the annual AAPMR meeting, (c) cancer rehabilitation fellowships (31,32), (d) AAPMR resources (e.g., Maintenance of Certificate [MOC] online review course  and Knowledge NOW ), and (e) textbooks (35). It is also recommended that physiatrists periodically review read more..
138 ■ II: Core Clinical CompetenciesOBJeCtiVeSExemplify the humanistic qualities as a provider of care for patients with cancer.1. Demonstrate ethical principles and responsiveness to patient needs superseding self and other interests.2. Demonstrate sensitivity to patient population diversity, includ-ing culture, gender, age, race, religion, disabilities, and sexual orientation.3. Respect patient’s beliefs and goals, privacy, confidentiality, and autonomy.Professionalism in the practice of read more..
12: Cancer Rehabilitation ■ 139coordinated and driven by the needs of the person served and his or her families/support system to improve quality of life. There is a strong emphasis on education of the person served that is “age and culturally appropriate and fosters self-management.” The cancer rehabilitation specialty program collects and analyzes outcomes data and shares that information with its stakehold-ers; it uses the data to improve the quality of the program. The program also read more..
140 ■ II: Core Clinical Competenciesdrive up costs for the patient’s care. To complicate matters fur-ther, the patient’s health insurance coverage may have limitations with respect to payment for tests and treatment.Another consideration for inpatient rehabilitation facilities is the need for the patient to be able to participate in 3 hours of therapy per day if the payer is Medicare. This can be challenging to achieve if the patient is away at tests, receiving chemotherapy, receiving read more..
12: Cancer Rehabilitation ■ 141SeLF-eXaMinatiOn QUeStiOnS(answers begin on p. 367)1. Which of the following medications has been associated with CIPN?A. DigitalisB. CisplatinC. CaporalD. SimvastatinE. Aspirin2. Which of the following is a significant and specific safety concern for the cancer patient undergoing a rehabilitation program?A. Weight-bearing precautions in a patient with metastatic disease to the lower extremitiesB. Blood pressure precautions in a patient with no history of read more..
142 ■ II: Core Clinical Competencies 9. Dimeo FC. Effects of exercise on cancer-related fatigue. Cancer. 2001; 15:92(suppl 6):1689–1693. 10. Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Interna-tional Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994;121(12):953–959. 11. Mock V, Atkinson A, Barsevick AM, et al. Cancer-related fatigue. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. read more..
12: Cancer Rehabilitation ■ 143 40. Dietz JH. Rehabilitation Oncology. New York, NY: John Wiley & Sons; 1981. 41. American Cancer Society. Cancer Facts and Figures 2012. Atlanta, GA: American Cancer Society; 2012. 42. Siegel R, Descants C, Virgo K, et al. Cancer treatment and survivor-ship statistics 2012. CA Cancer J Clin. 2012;62:220–241. 43. read more..
144PATIENT CAREGOALSProvide patient care that is compassionate, appropriate, and effective for the treatment of a patient with stroke and the promotion of health.OBJECTIVES1. Describe the key components of the assessment of the patient with stroke.2. Discuss the long-term outcomes of stroke.3. Assess the impairments, activity limitations, and participa-tion restrictions associated with stroke.4. Describe the psychosocial, vocational, and educational aspects of stroke.5. Describe potential read more..
13: Stroke ■ 145the ability to retain information. While under a physiatrist’s care, the patient’s decision-making capacity should be assessed. The key components of this are multifaceted—and it revolves around the patient’s understanding of his or her condition and treatment options. The patient should be able to ascertain how it affects him or her and be able to express choices made. In stroke patients, this may prove to be rather difficult, given possible cognitive deficits and/or read more..
146 ■ II: Core Clinical Competenciespoor sitting balance, visuospatial deficits, cognitive changes, incontinence, and low initial ADL scores. Approximately one-third of patients with acute stroke have clinical features of apha-sia. At 6 months or more after stroke, only 12% to 18% of patients have identifiable aphasia (13). Skilbeck and colleagues reported that patients with aphasia continue to show some late improve-ment in language function even more than 1 year after onset (14).Patients who read more..
13: Stroke ■ 147COMPLICATIONS OF STROKERISK FACTORSMONITORINGPREVENTIONQUALITY OF CAREAspiration pneumoniaSevere dysphagia and abnormal pharyngeal sensationAirway and oxygenation should be monitoredStructured swallowing assessmentInitiation of early mobilityEfficient pulmonary toiletingAssessment of dysphagia by speech pathologistDysphagia occurs in approximately 45% of all stroke patients admitted and is associated with higher risk of aspiration pneumoniaImmobility read more..
148 ■ II: Core Clinical CompetenciesImmobilityImmobility can lead to pressure ulcers, atelectasis, contractures, and DVT/pulmonary embolus (PE). To help reduce these risks, the patient should be mobilized as soon as medically appropriate. Patients should be evaluated for need for specialized beds and the nursing staff instructed on proper positioning of patients to reduce skin breakdown, limb edema, and contractures. Preven-tion of pressure ulcers depends on early identification of patients at read more..
13: Stroke ■ 149of stroke survivors still having problems on hospital discharge, and 15% remaining incontinent after 1 year (22). Increased age, increased stroke severity, the presence of diabetes, prostate hypertrophy in men, preexisting impairment in urinary function, and the occurrence of other disabling diseases increase the risk of urinary incontinence in stroke. Stroke survivors usually develop a hyperreflexic bladder. The development of a urinary tract infec-tion can occur with read more..
150 ■ II: Core Clinical Competenciestechniques (see Table 13.3). In his article about the effectiveness of the Bobath concept, Kollen describes it as the most popular treatment approach used, but limited data to support its superi-ority (33). Persons with motor deficiencies following stroke are unable to direct nervous impulses to muscles in the different com-binations used by persons with an intact central nervous system (CNS). The goal is to suppress abnormal muscle patterns before normal read more..
13: Stroke ■ 151ISCHEMIC STROKEAn ischemic stroke is caused by focal cerebral ischemia. There are several different mechanisms that can disrupt blood flow in the brain. The neurological deficits manifested after stroke will depend on the vascular distribution affected by the stroke. Eighty-five percent of strokes are ischemic in nature (36). Ischemic strokes can be further subdivided into thrombotic or embolic.The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system for read more..
152 ■ II: Core Clinical CompetenciesANATOMYAnterior CirculationMiddle Cerebral Artery ■Occlusion occurs at the stem of the MCA or at one of the two main divisions (superior or inferior) of the artery in the Sylvian sulcus.Superior division of the MCA: ■The superior division of MCA supplies the rolandic and pre-rolandic areas. ■Patients will present with sensory and motor deficits on the contralateral face and arm more than on leg. ■Head and eyes will deviate toward affected side. read more..
13: Stroke ■ 153VASCULAR SUPPLYSYNDROMELOCALIZATIONCLINICAL SYMPTOMSPosterior Cerebral Artery (cont.)Balint syndromeBilateral parietal–occipital lobesLoss of voluntary extarocular movemets (EOM)Optic ataxiaAsimultagnosiaClaude syndromeMidbrain-TegmentumIpsilateral-oculomotor nerve palsyContralateral—extremity ataxiaAnton-Babinski syndromeBilateral occipital lobesBilateral vision loss with unawareness of blindnessDejerine-Roussy syndrome (thalamic pain syndrome)ventral posterlateral nucleus read more..
154 ■ II: Core Clinical Competenciesbe asymptomatic in many patients, occlusion of the ICA can manifest as a variety of syndromes with a variable presentation depending on the severity of the infarction and the degree of collateral circulation.Distal ICA occlusion may affect part or all of the ipsilateral MCA territory as well. Patients will present with contralateral motor and/or sensory symptoms.Complete ICA occlusion will have a variable clinical presen-tation. In those with sufficient read more..
13: Stroke ■ 155HEMORRHAGIC STROKEHemorrhagic strokes are not as common as ischemic, but they have a higher rate of morbidity and mortality among the stroke population. Intracerebral hemorrhage (ICH) is bleeding directly in the brain parenchymal tissue, and subarachnoid hemorrhage (SAH) is due to a rupture of a vessel in the cerebrospinal fluid.The most preventable risk factor is hypertension for ICH (41). Other risk factors include smoking, heavy alcohol (ETOH) use, and drugs (cocaine, read more..
156 ■ II: Core Clinical Competenciesdiscuss interventional treatment options. Physiatrists should be familiar with the landmark Carotid Revascularization Endar-terectomy versus Stenting Trial (CREST), which compared the outcomes of carotid artery stenting with those of carotid endar-terectomy among patients with symptomatic or asymptomatic extracranial carotid stenosis (49). The 2010 CREST trial found no significant difference, after 4 years of follow-up, between surgery and carotid stenting read more..
13: Stroke ■ 157patient care practices based on constant self-evaluation and life-long learning.OBJECTIVES1. Describe learning opportunities for providers, patients, and caregivers with experience in stroke.2. Locate some resources including available websites for continuing medical education and continuing professional development.3. Describe some areas paramount to self-assessment and life-long learning, such as review of current guidelines, includ-ing evidence based, in treatment and read more..
158 ■ II: Core Clinical CompetenciesStroke is one of the foremost leading causes of disability, and the impact this has on patients and their families is immense. Stroke patients and their family members are faced with mak-ing many decisions regarding immediate medical care, as well as short-term and long-term follow-up. It is imperative to pro-vide appropriate education and counseling to help patients and their caregivers make informed decisions about their care and to assist them in read more..
13: Stroke ■ 159The rehabilitation specialist must be mindful of coverage based on insurance issues for rehabilitation services and durable medical equipment. Medicare does not cover wheelchairs for patients who can walk short distances on flat surfaces in the home, even though patients may not be able to negotiate at a com-munity level. It is important to be mindful of these restrictions that can impact your patient’s quality of life and reintegration to the community. The physiatrist must read more..
160 ■ II: Core Clinical CompetenciesOBJECTIVES1. Describe key components and available services in the reha-bilitation continuum of care and community rehabilitation facilities.2. Discuss how to work effectively in various systems of care.3. Describe optimal follow-up care.4. Identify important markers of quality of care.5. Discuss cost-effectiveness, utilization, and management of resources.6. Review proper medical record keeping and documentation as the patient moves along the continuum of read more..
13: Stroke ■ 161Collaboration concluded that patients receiving organized inpa-tient stroke unit care were more likely to survive, regain inde-pendence, and return home than those receiving a less organized service (15). Rehabilitation should start as early as possible, once medical stability is reached.Patient safety issues that need to be addressed in this patient population include adequate assessment of swallowing and risk for aspiration, risk of fall, decubitus ulcer prevention, read more..
162 ■ II: Core Clinical Competenciesupon discharge. When discharging a patient into the community, the physiatrist should, whenever possible, be in communication with the patient’s primary care doctor, particularly in regard to medication and follow-up appointments. Written instructions on post discharge care should always be provided and must clearly outline the necessary follow-up appointments and necessary restrictions in activity, diets, and level of supervision.Physiatrists need to be read more..
13: Stroke ■ 163 9. Perrier MJ, Korner-Bitensky N, Mayo NE. Patient factors associ-ated with return to driving poststroke: findings from a multicenter cohort study. Arch Phys Med Rehabil. 2010;91(6):868–873. 10. Fonarow GC. Relationship of National Institutes of Health stroke scale to 30-day mortality in Medicare beneficiaries with acute isch-emic stroke. J Am Heart Assoc. 2012;02(1):42–50. 11. Wade DF, Wood VA, Heller A, et al. Walking after stroke. Measure-ment and recovery over the read more..
164 ■ II: Core Clinical Competencies 49. Brott TG, Hobson RW, Howard G, et al. Stenting versus endar-terectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23. 50. VA/DoD clinical practice guideline for the management of stroke rehabilitation. Department of VA. http://www.healthquality.va.gov/stroke/stroke_full_221.pdf 51. Reeves MJ, et al. Development of stroke performance mea-sures: definitions, methods, and current measures. Stroke. 2010;41(7):1573–1578. 52. read more..
Ajit B. PaiIsaac DarkoWilliam RobbinsPATIENT CAREGOALSProvide patient care that is compassionate, appropriate, and effective for the treatment of moderate to severe traumatic brain injury (TBI) and the promotion of health.OBJECTIVES1. Identify appropriate components of a history and physical examination for a patient with TBI.2. Discuss impairments and complications after TBI.3. Describe a sample rehabilitation program for a patient with TBI.Appropriate care for the patient with TBI includes read more..
166 ■ II: Core Clinical Competenciesmembers about the person with TBI; it accounts for behavior and cognitive function.Cognitive impairments are very common. Arousal is one of the most basic cognitive functions; it is fundamental in per-forming other higher levels of function and is often impaired following injury (2). Attention is commonly affected in patients with more severe TBI. Impaired attention can result in reduced information processing, impaired memory, and poor perfor-mance of read more..
14: Moderate and Severe Traumatic Brain Injury ■ 167Constipation occurs often after TBI due to immobility. It is prevented with hydration and an aggressive bowel program with stimulants and softeners. Once a patient is on a stable bowel regi-men, then a slow wean of bowel medications can start.Heterotopic ossification (HO) occurs after TBI; it usually affects the hips, shoulders, and elbows. Preventative measures for HO include ROM exercises, nonsteroidal anti-inflammatory drug (NSAID) read more..
168 ■ II: Core Clinical CompetenciesOBJECTIVES1. Explain the anatomy, physiology, and pathophysiology of moderate to severe TBI.2. Discuss treatment options of complications of moderate to severe TBI.3. Discuss ethical issues involved in managing a person with moderate to severe TBI.ANATOMYThe brain is protected by the scalp, skull, and the dura, which is made up of three layers: the dura mater, which lines the skull; the arachnoid mater, a film that covers the entire brain and contains blood read more..
14: Moderate and Severe Traumatic Brain Injury ■ 169TREATMENTAlthough evidence for neuropharmacologic treatment is sparse, many providers choose to treat various conditions with medica-tion. Cognitive impairment can be treated with amantadine in patients with a disorder of consciousness. Giacino et al. found that it accelerates the pace of functional recovery during active treatment (9). Although the mechanism of action is unclear, amantadine appears to act as an N-methyl-D-aspartate read more..
170 ■ II: Core Clinical Competenciesstate. SSEP records transmission from the scalp after stimulation of peripheral or mixed nerves. EEG (electroencephalography) can detect injury severity and depth of coma; it is also used in evaluation of seizures. Continuous EEG can evaluate for subclin-ical seizures that are associated with a poorer outcome.ETHICAL ISSUESBioethics plays an important role in the recovery of persons with TBI. Table 14.4 describes six terms that play a role in ethi-cal issues read more..
14: Moderate and Severe Traumatic Brain Injury ■ 171persons with TBI can have vastly different outcomes, sometimes the outcome is death. It is important to incorporate the services of mental health and/or hospice providers when discussing end-of-life matters. A team approach will provide the family with an understanding of the process. If the person with TBI has an advanced directive dictating end-of-life care or his or her wishes, this will make the conversation and decision easier on family read more..
172 ■ II: Core Clinical CompetenciesIt is important to provide a structured environment for patients with TBI and to establish new routines to help them relearn old skills and develop new strategies. Caregivers should be encouraged to learn nursing routines and different therapeutic strategies so they can apply new caregiving skills (i.e., position-ing, transfers, feeding, bathing, toileting, and medication man-agement). Throughout this process, the medical team should guide and support the read more..
14: Moderate and Severe Traumatic Brain Injury ■ 173suicide. The patient will benefit from assistance with nutrition, wound care, ADLs, IADLs, and mobility. In addition, strategies for appropriate behavior with family and coworkers, side effects of medications, pain management, and possibility of long-term placement after acute rehabilitation stay are also topics to discuss.DOCUMENTATION AND EFFECTIVE COMMUNICATIONDocumentation helps with improving communication between health care read more..
174 ■ II: Core Clinical Competenciesthat the physiatrist promote the idea of appropriate patient care by embracing the patient and family’s needs, expectations, and beliefs. This includes accountability for balancing autonomy ver-sus beneficence in situations when a patient wants to exercise his or her individual rights, which are in direct conflict with the physician’s or team’s recommendations.SYSTEMS-BASED PRACTICEGOALAwareness and responsiveness to systems of care delivery, and the read more..
14: Moderate and Severe Traumatic Brain Injury ■ 175such high costs associated with moderate and severe TBI, it is of utmost importance to focus on primary prevention.The CDC, Defense Veterans Brain Injury Center (DVBIC), and the Brain Injury Association of America (BIAA) are a few of the organizations that provide educational material. Utilizing their resources allows a TBI provider to increase the awareness of his or her patients, their families, and the community at large (Table 14.8).CASE read more..
176 ■ II: Core Clinical Competencies5. What is the lifetime cost of a severely injured person with TBI?A. $100K to $600KB. $600K to $1.9MC. $2.0M to $3.4MD. $3.5M to $4.4ME. $4.5M to $5.4MREFERENCES 1. Wagner AK, Hammond FM, Sasser HC, et al. Use of injury severity variables in determining disability and community integration after traumatic brain injury. J Trauma. 2000;49:411–419. 2. Wagner AK, Arenth PM, Kwasnica C, et al. Traumatic Brain Injury. In Braddom RL, ed. Physical Medicine and read more..
Patient CareGOaLSProvide patient care that is compassionate, appropriate, and effective for the treatment of mild traumatic brain injury (MTBI) problems and the promotion of health.OBJeCtVeS1. Perform a pertinent history and physical of the MTBI adult patient.2. Identify key impairments, functional, and activity limitations for adults with MTBI.3. Identify the psychosocial and vocational implications of MTBI and strategies to address them.4. Describe injuries commonly associated with MTBI.5. read more..
178 ■ II: Core Clinical CompetenciesScreen for current medications that may worsen neurologic recovery or cause sedation, cognitive slowing, or increased risk for suicidal ideations.After each history taking, it is imperative that the physician validate the patient’s concerns and symptoms.Physical examination should include the following:A. Focused neurologic examination that includes the following:1. Mental status examination (MSE)2. Cranial nerve testing3. Sensation4. Extremity testing of read more..
15: Mild Traumatic Brain Injury ■ 179should be screened for comorbid mental health disorders. Head-ache is one of the most common symptoms associated with MTBI (3). Assessment and management of headaches in indi-viduals with MTBI should be comparable with those for other causes of headache (4). (See Table 15.1 for recommendations for specific symptoms.)In patients with persistent post-concussive symptoms, who are refractory to treatment, consideration should be given to other factors such as read more..
180 ■ II: Core Clinical Competencies1. Physical therapy for vestibular rehabilitation to address the dizziness and balance problems.2. Speech therapy for compensatory strategies and memory aids.3. Vision therapist for photosensitivity. Recommend sunglasses.4. Audiology for hearing impairments.5. Sleep management should include review and discussion of sleep hygiene. If sleep apnea is suspected, a referral for sleep study should be done first before prescribing sleep medications. In this case read more..
15: Mild Traumatic Brain Injury ■ 181SYMPTOMSKEY INFORMATION AND NONPHARMACOLOGY MANAGEMENTPHARMACOLOGICAL MANAGEMENTInsomnia/sleep dysfunction ■Goal is to establish a regular, unbroken, night-time sleep pattern and to improve perceptions of the quality of sleep ■Educate on sleep hygiene, establishing regular sleep routine, limiting caffeine and alcohol before bedtime ■Refer to sleep specialist to treat concurrent primary sleep disorder (e.g., sleep apnea, restless leg syndrome, or read more..
182 ■ II: Core Clinical Competenciesevidence of trauma above the clavicle, posttraumatic seizure, drug or alcohol intoxication, short-term memory impairment, coagulopathy, and focal neurological deficit.Noncontrast head CT should be considered (level B recom-mendation) in patients with head trauma but no LOC of PTA if one or more of the following is present: age >65 years, GCS <15, severe headache, vomiting, physical signs of basilar skull frac-ture, coagulopathy, focal neurological read more..
15: Mild Traumatic Brain Injury ■ 183days after the injury and most of those persisting beyond that resolve by 2 to 4 weeks. However, in a minority of patients, the symptoms persist beyond 6 months to a year. Postconcussion syndrome is a term frequently used to describe a constellation of symptoms (at least 2 nonfocal, neurologic symptoms) occurring at least 1 to 3 months after concussion. In a minority of persons, postconcussion symptoms persist late after injury (18).The etiology of these read more..
184 ■ II: Core Clinical CompetenciesEducation should also include avoidance of high-risk behav-ior that could increase the risk of additional head injuries, com-pensatory strategies for impaired memory and concentration; relaxation techniques; strategies for successful reintegration in work, school, and social activities; anger and stress manage-ment techniques; diet and exercise; limiting alcohol and caffeine intake; and avoidance of recreational drugs.KeY PraCtiCe-reLateD QUaLitY iMPrOVeMent read more..
15: Mild Traumatic Brain Injury ■ 185PHYSiatriSt aS teaM LeaDerThe physiatrist is in charge of coordinating and managing the patient’s medical care and therapeutic program and communi-cating regularly with the patient and his or her family regarding medical needs. The physiatrist directs the rehabilitation team in monitoring the patient’s recovery, making needed changes in treatment plans, and consulting with other physician specialists as necessary.PrOFeSSiOnaLiSMGOaLReflect a commitment read more..
186 ■ II: Core Clinical Competenciesspeech therapies may be referred to independent therapy clinics. Other patients may receive care in the school setting, while some patients may present to the psychiatric setting for behavioral issues.Outpatient multidisciplinary rehabilitation should include physiatry and may include the following disciplines: physical therapy, occupational therapy, vision therapy, optometry, speech and language pathology, neuropsychology, pain management, mental health, read more..
15: Mild Traumatic Brain Injury ■ 187 I. Medications J. Vision or hearing loss6. Advocacy role of physiatrist in ensuring quality of care for patients with MTBI.The physiatrist has an important role for the MTBI patient in the community and health care field. This role involves edu-cating the community and other health care providers about risk factors, etiology, pathophysiology, symptoms, and result-ing impairments in MTBI. An important part of this role is educating the public, families, read more..
188 ■ II: Core Clinical Competencies5. Which of the following is the best available treatment for MTBI and for preventing or reducing the development of per-sistent symptoms?A. Early education of patients and their familiesB. Cognitive rehabilitationC. Methylphenidate for brain recoveryD. Cognitive behavioral therapyE. Beta-blockers for brain recoveryreFerenCeS 1. VA/DoD clinical practice guideline on MTBI. http://www.healthquality.va.gov/management_of_concussion_mtbi.asp. Accessed December read more..
15: Mild Traumatic Brain Injury ■ 189 19. Alexander MP. Mild traumatic brain injury: pathophysiol-ogy, natural history, and clinical management. Neurology. 1995 45(7):1253–1260. 20. Goodman JC. Pathologic changes in mild head injury. Semin Neu-rol. 1994;14:19. 21. Povlishick JT, Katz DI. Update of neuropathology and neurologi-cal recovery after traumatic brain injury. J Head Trauma Rehabil. 2005;20:76. 16. Elder GA, et al. Blast-induced mild traumatic brain injury. Psychi-atr Clin N Am. read more..
19016: Spinal Cord InjuryPatient CareGOaLSProvide competent patient care that is compassionate, appropri-ate, and effective for the evaluation, treatment, education, and advocacy for persons with spinal cord injury and disease (SCI/D) across the entire spectrum of care, from the acute injury until death.OBJeCtiVeS1. Assess comprehensively persons with tetraplegia and paraple-gia in both the acute and chronic settings.A. Evaluate the adequacy of the workup for cause of SCI/D and subsequent read more..
16: Spinal Cord Injury ■ 191measurement of range of motion (ROM) of all major joints, espe-cially the shoulders, which often develop contractures in those with cervical injuries due to inadequate movement, and the hips, which can develop contractures due to heterotopic ossification (HO), a condition of the deposition of true bone at extraskeletal sites. Integumentary assessment is important as pressure ulcers are common over bony prominences in areas of altered sensation in persons who have read more..
192 ■ II: Core Clinical Competenciesbe managed by digital stimulation of the anus to trigger reflex colonic contractions for persons with an UMN-type bowel and digital removal of stool for persons with a LMN-type bowel (5).Symptomatic autonomic dysfunction in SCI/D is common in persons with high-level paraplegia and tetraplegia. Orthostatic hypotension and relative hypotension is nearly ubiquitous in those with higher level injuries. Orthostasis occurs as a result of loss of sympathetic tone read more..
16: Spinal Cord Injury ■ 193column ascends ipsilaterally and decussates at the medulla. The anterolateral spinothalamic tract, located peripherally in the lateral column, contains fibers that carry information for pain and temperature (laterally) and touch and pressure (anteri-orly). This tract decussates within three segments of their origin and ascends contralaterally to the thalamus. The corticospinal tract is located centrally and posteriorly in the lateral column and carries information read more..
194 ■ II: Core Clinical Competenciesdeficiency, safety concern, or regulatory necessity. Obvious choices include those which address accepted markers of qual-ity of care for SCI/D including unscheduled discharges from the inpatient setting and the incidence and prevalence of common complications such as falls, pressure ulcers, urinary tract infec-tions, urinary reflux, pneumonia, contractures of limbs, and pain.With regard to maintaining competancy in the care of those with SCI/D, one should read more..
16: Spinal Cord Injury ■ 195the difficulty for the family when a loved one is challenged with multiple life-altering functional impairments. Information pro-vided to patients and families must be straightforward, jargon free, and with vocabulary of an appropriate educational level for the target audience. Physicians should not avoid sensitive top-ics such as sexuality and reproduction. Physicians should avoid dominating the discussion both in terms of taking up the most time speaking and in read more..
196 ■ II: Core Clinical Competenciesabout the activities of other key team members (e.g., PTs and OTs) involved with the care of those with SCI/D can be facili-tated by frequently visiting and observing therapy sessions and participating in in-services with these other disciplines.PrOfeSSiOnaLiSMGOaLSReflect a commitment to carrying out professional responsibili-ties and an adherence to ethical principles in the approach to SCI/D.OBJeCtiVeS1. Describe and demonstrate People First Language.2. read more..
16: Spinal Cord Injury ■ 197Acknowledging the psychodynamics of the refusal can provide a basis for cognitive restructuring of the situation into a more productive one. For example, for a person who was previously independent in all activities and constantly making decisions and choices who now has a high-level SCI/D with profound body and activity limitations, the ability to make an important deci-sion may seem absent lying in bed attached to a ventilator in a controlled hospital setting but read more..
198 ■ II: Core Clinical Competenciesof the length of time a person with SCI/D spends in any one of the components of the rehabilitation continuum of care, if at all. The traditional components include acute hospital care, acute inpatient rehabilitation, subacute rehabilitation (rehabilitation in a nursing home or extended care setting), home care, and outpa-tient care. Nominally the cost of medical care is borne by medical insurers for those who have it, which include in the United States: read more..
16: Spinal Cord Injury ■ 199C. T6 AIS A status post fall from heightD. CCSE. CES4. A 76-year-old man with a history of cervical spondylosis presents to the emergency department complaining of weak-ness and decreased sensation more in the arms than in the legs after sustaining a fall. Which of the following syndromes below best describes the type of injury this gentleman most likely sustained?A. BSSB. CCSC. ACSD. PCSE. CMSF. CES5. What is the most common cause of death for persons with SCI?A. read more..
Patient CareGOaLSProvide competent patient care that is compassionate, appropri-ate, and effective for the evaluation, treatment, education, and advocacy for patients with Parkinson disease (PD) across the continuum of care and the promotion of health.OBJeCtiVeS1. Describe the key components of the assessment of the adult with PD.2. Define the impairments, activity limitations, and participa-tion restrictions for the adult with PD.3. Identify the psychosocial and vocational implications of the read more..
17: Parkinson Disease ■ 201bolus control, repetitive tongue motions, delayed triggering of the swallow reflex, and delayed laryngeal elevation. Dyspha-gia training including mechanically altered food consistency (chopped or pureed) with thickened liquids (honey/nectar thick), chin-down positioning, double swallow, oral-motor exercises, biofeedback, and verbal prompting can be helpful. Clinicians might also choose to administer antiparkinsonian medications before meals, so that the maximal read more..
202 ■ II: Core Clinical CompetenciesThe above-mentioned impairments can significantly limit ADLs in PD. Activities such as dressing, grooming, feeding, bathing, rising from a chair, and ambulation and executive func-tioning can be difficult to perform. These in turn can affect the individual’s role in the family and community. Activities such as work, leisure, and driving may be limited, making it difficult for the person to function in activities important to him or her. Social circles can read more..
17: Parkinson Disease ■ 203and muscular activity might enhance our knowledge of brady-kinesia and tremor. Finally, brainstem reticular nuclei seem to be involved in the generation of rigidity and axial symptomatol-ogy. These nuclei are awaiting further exploration to define their exact pathophysiological role in PD.Pathophysiology of gait: The underlying pathophysiology leading to fall in a person with PD is complex. The basal gan-glia play an important role in regulating muscle contraction, read more..
204 ■ II: Core Clinical Competenciesof PD. People with PD usually have mobility problems and are often at high risk for falls. Changes to the home environment to increase independence and safety are recommended. As a result, patients with PD will be able to cope better day to day and main-tain their independence.The role of physical therapy in the treatment of PD patients is widespread. Patients benefit from therapeutic exercises, range of motion (ROM), biofeedback, functional electrical read more..
17: Parkinson Disease ■ 205PraCtiCe-BaSed LearninG and iMPrOVeMentGOaLSDemonstrate competence in continuously investigating and eval-uating your PD patient care practices, appraising and assimilat-ing scientific evidence, and continuously improving your patient care practices based on constant self-evaluation and lifelong learning.OBJeCtiVeS1. Describe learning opportunities for providers, patients, and caregivers with experience in PD.2. Use methods for ongoing competency training in PD for read more..
206 ■ II: Core Clinical Competenciesfor treatment plan, side effects of medications, and strategies to minimize complications such as aspiration-related complica-tions, falls, contractures, and pressure ulcers.Patients should be equally educated about the latest infor-mation about the disease process. They should understand the difficulties they will face in their day-to-day activities, such as their personal hygiene, feeding, negotiating obstacles when ambulating in-house or outdoors, and read more..
17: Parkinson Disease ■ 2074. Describe markers of quality in the care of the patient with PD.5. Describe cost/risk–benefit analysis, utilization, and manage-ment of resources as they apply to PD.Participate in identifying and avoiding potential systems- and medical-related errors in the care of PD and strategies to minimize them.The continuum of rehabilitative care for the person with PD spans several components of the health care system such as med-ical wards in acute care hospitals, acute read more..
208 ■ II: Core Clinical CompetenciesC. SerotoninD. SomatostatinE. Substance P4. Which of the following pairs are considered the gold standard drug(s) for the treatment of PD and mechanism of action? (55)A. L-dopa; increasing the amount of dopamine availableB. The benzodiazepines; increasing the amount of dopamine availableC. L-dopa; increasing the amount of serotonin availableD. Prozac; increasing the amount of serotonin availableE. L-dopa; decreasing the amount of Substance P5. Which of the read more..
17: Parkinson Disease ■ 209 6. Ho AK, Iansek R, Marigliani C, et al. Speech impairment in a large sample of patients with Parkinson’s disease. Behav Neurol. 1998;11(3):131–137. 7. Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson’s disease. Mov Disord. October 2005;20(10):1255–1263. 8. Marsh L. Neuropsychiatric aspects of Parkinson’s disease. Psycho-somatics. 2000;41:15–23. 9. Awad RA. Neurogenic bowel dysfunction in patients with read more..
210 ■ II: Core Clinical Competencies 49. National Parkinson Foundation. http://www.parkinson.org/. Accessed January 29, 2014. 50. The American Parkinson Disease Association. http://www.apdaparkinson.org. Accessed January 29, 2014. 51. Parkinson Study Group. http://www.parkinson-study-group.org/. Accessed January 29, 2014. 52. Parkinson’s Action Network. http://www.parkinsonsaction.org/. Accessed January 29, 2014. 53. NINDS Parkinson’s Disease information page. National Institute of read more..
Patient CareGOaLSEvaluate and develop a rehabilitative plan of care for patients with neuromuscular diseases (NMDs) that is compassionate, appropriate, and effective for the treatment of neuromuscular problems and the promotion of health.OBJeCtiVeS1. Discuss common rehabilitation problems in patients with neuromuscular disorders.2. Perform a thorough neurological assessment in patients with neuromuscular disorders.3. Identify systemic complications and management of compli-cations in patients read more..
212 ■ II: Core Clinical Competenciesassessed as certain neuromuscular disorders, such as ALS and spinal muscular atrophies, can lead to respiratory compromise. Other organ systems should also be assessed as enlarged organs are seen in patients with neuropathies with POEMS (polyneu-ropathy, organomegaly, endocrinopathy, monoclonal gammopa-thy, and skin changes). Intellectual and cognitive function should also be assessed as it could be affected in patients with myotonic dystrophy.The muscle read more..
18: Neuromuscular Diseases ■ 213in the workplace to help patients with motor deficits. With improved computer technology, patients are even able to work from home and have alternate ways of communicating, from touchpads to head control units. Financial strains coupled with the cost of medical treatment may force many patients into gov-ernmental assistance programs.Aggressive rehabilitation and symptom management can help prolong life and improve quality of life for patients with neu-romuscular read more..
214 ■ II: Core Clinical CompetenciesOBJeCtiVeS1. Describe the epidemiology, anatomy, physiology, and patho-physiology of NMDs.2. Identify the types of NMDs (motor neuron disease, NMJ dis-order, neuropathies, myopathies).3. Describe the common NMDs.4. Discuss how to diagnose common NMDs.5. Formulate basic rehabilitation treatment plans for NMD.NMD describes any intrinsic disease to the nerves or mus-cles. The motor unit is considered the smallest functional unit of the neuromuscular system. The read more..
18: Neuromuscular Diseases ■ 215with predisposition to pressure palsy (HNPP) is similar to CMT1 except that there is a deletion of the peripheral myelin protein (PMP) gene rather than a duplication. Patients with HNPP will have recurrent mononeuropathies at sites prone to nerve com-pression such as in the elbow (cubital tunnel), wrist (carpal tun-nel), or knee (fibular head).Acute inflammatory demyelinating neuropathy (AIDP), also known as Guillain-Barré syndrome, causes an acute gen-eralized read more..
216 ■ II: Core Clinical Competencies(pseudohypertrophy) and tight heel cords result in toe walking. Respiratory function gradually declines and leads to death in most patients by the early 20s. Cardiac muscles may also be involved and echocardiograms can show dilation and/or hypo-kinesis of the ventricular walls. The central nervous system is also involved in DMD with affected children approximately 1 standard deviation below the normal mean.Becker muscular dystrophy (BMD) is a less severe read more..
18: Neuromuscular Diseases ■ 217devices such as built-up utensils, raised toilet seats, and long-handled reachers can help with self-care. As fatigue and muscle weakness become more problematic, use of a seated mobility system such as a motorized wheelchair or scooter may be nec-essary. Patients may also require noninvasive positive pressure ventilation to help maintain breathing as they tend to fatigue. Respiratory therapy is also important in clearing secretions. Speech therapy is important read more..
218 ■ II: Core Clinical CompetenciesPresentation of NMD symptoms varies widely, from mild cases of muscular dystrophy that have little effect on a patient’s functional capacity to uniformly lethal, rapidly progressive con-ditions, such as ALS. While no two patients with the same dis-ease are exactly alike, the knowledge that exists regarding the course of a condition can help patients and their families prepare for the obstacles that may lie ahead. Many of the family members of people read more..
18: Neuromuscular Diseases ■ 219OBJeCtiVeS1. Exemplify the humanistic qualities in patient-centered care.2. Demonstrate ethical principles and responsiveness to patient needs superseding self and other interests.3. Demonstrate sensitivity to patient population diversity, cul-tural competence, gender, age, race, religion, disabilities, and sexual orientation.4. Respect patient privacy, confidentiality, autonomy, and shared decision making.5. Recognize the socioeconomic factors and importance of read more..
220 ■ II: Core Clinical CompetenciesOBJeCtiVeS1. Identify the components, systems of care delivery, services, referral patterns, and resources in the rehabilitation contin-uum of care for patients with NMD.2. Coordinate and recruit necessary resources in the system to provide optimal care for the NMD patient, with atten-tion to safety, cost awareness, and risk–benefit analysis and management.3. Describe optimal follow-up, quality improvement mea-sures, and use of documentation in NMD read more..
18: Neuromuscular Diseases ■ 221NMD patients are complex and have multiple organ systems that are involved. As most NMDs are relatively rare, many doctors may not be familiar with the management of these patients. It is important for doctors to communicate with other consultants and caregivers as these patients are transferred from one point of care to another. Taking the time to go over the medical records and the discharge summaries is important in order to minimize the risk to these read more..
222 ■ II: Core Clinical CompetenciesC. Areflexia or hyporeflexia is present.D. CSF shows increased white blood cells and increased proteinsE. Treatment is with IVIG or plasmapheresis4. Which of the following is associated with weakness of the facial and jaw muscles resulting in a “hatchet face” appearance?A. Facioscapulohumeral dystrophy (FSH)B. Becker muscular dystrophyC. Duchenne muscular dystrophyD. Myotonic dystrophyE. Inclusion body myositis5. Myasthenia gravis is associated with all read more..
223Patient CareGOaLSProvide patient care that is compassionate, appropriate, and effective for the treatment of a patient with multiple sclerosis (MS) and the promotion of health.OBJeCtiVeS1. Describe the key components of the assessment of the patient with MS.2. Assess the impairments, activity limitations, and participa-tion restrictions associated with MS.3. Describe the psychosocial, vocational, and educational aspects of MS.4. Formulate the key components of a rehabilitation treatment plan read more..
224 ■ II: Core Clinical Competencies 1. General: Weakness, fatigue, heat intolerance. 2. Cognitive dysfunction: Memory loss, impaired atten-tion, difficulties in problem solving, slowed information processing. 3. HEENT: Facial weakness resembling Bell palsy not associ-ated with ipsilateral loss of taste sensation or retroauricular pain. Eyes: Decreased visual acuity, decreased color per-ception, periorbital pain aggravated by movement, blurry vision, and diplopia (4). 4. Cardiovascular: read more..
19: Multiple Sclerosis ■ 225pattern that can increase the risk for falls. Depression is a com-mon impairment that can be associated with sleep disturbances and poor concentration that can adversely affect IADLs and safety in the home. It is now recognized that impaired cognition can lead to impaired working memory, judgment, and processing speed. These can lead to difficulties in planning and organizing, cooking, balancing a checkbook, safely taking medications, and difficulties with reading. read more..
226 ■ II: Core Clinical CompetenciesOBJeCtiVeS1. Describe the epidemiology, anatomy, physiology, and patho-physiology of MS.2. Identify the pertinent laboratory and imaging studies impor-tant in MS.3. Review the treatment and management of MS.4. Examine the socioeconomic and ethical issues in MS.MS is the most common cause of nontraumatic disabil-ity affecting young people in the Northern Hemisphere. There are about 400,000 persons in the United States living with MS, and the prevalence range read more..
19: Multiple Sclerosis ■ 227potentials (SEPs) have been used to aid in the diagnosis of MS (25). Absence or prolonged latency of responses has been noted.4. Visual evoked potentials: Abnormalities are most consis-tently seen in MS and optic neuritis (1) and there is a high sen-sitivity along with MRI. A study by P. Asselman found that the latency of the VEPs was prolonged in one or both eyes in 84% of those with definite MS, in 83% of those with probable MS, and in 21% of those with possible read more..
228 ■ II: Core Clinical Competenciesfound that exercise training can help improve aerobic capacity, fatigue, health-related quality of life, strength, and mobility (28).Treatment for spasticity is also very important, especially if the patient has issues with positioning or complains of pain. Treatment should include positioning, stretching, splinting, icing, and oral medications such as baclofen, dantrolene, tizanidine, and injections such as botulinum toxin. Home exercises should also be read more..
19: Multiple Sclerosis ■ 229wishes, understand his or her belief system, identify any appli-cable laws or regulations that can provide guidance, and then seek common ground.PraCtiCe-BaSeD LearninG anD iMPrOVeMentGOaLSDemonstrate competence in continuously investigating and evaluating your own MS patient care practices, appraising and assimilating scientific evidence, and continuously improving your patient care practices based on constant self-evaluation and lifelong learning.OBJeCtiVeS1. read more..
230 ■ II: Core Clinical Competenciesaddress sexual dysfunction issues, which may be difficult for the couple to discuss; and make appropriate referral to the provid-ers for care. The physician should also help children and adoles-cents understand and cope with the parent’s disability. Anxiety problems, low self-esteem, fear of death, behavioral problems, or embarrassment should be identified and managed appropriately.In situations where the child may now become the primary caregiver, read more..
19: Multiple Sclerosis ■ 231Patient Counseling and Patient resources in MSEducating the patient and family about the disease process in MS is an important component of practice-based medicine and improvement. Educating the patient on recognizing various symptoms of MS, the onset of an exacerbation, and progression of disease empowers the patient to be his or her own advocate. In addition, this helps to develop an effective dialogue between the physician and patient leading to earlier read more..
232 ■ II: Core Clinical Competencieshealth plans in designing their benefits and coverage policies for MS and should be used in conjunction with clinical evidence (39).Whereas the use of disease-modifying therapies has been shown to reduce relapses and slow down the disease process, these come at a very high cost that prohibits some patients from receiving them. This is especially problematic for low-income patients, who may not have even received adequate education, particularly about read more..
19: Multiple Sclerosis ■ 233reFerenCeS 1. Lin VW, and Associates. Spinal Cord Medicine—Principles and Practice. 2nd ed. New York, NY: Demos Medical Publishing; 2010:486. 2. Trojano M, Paolicelli D. The differential diagnosis of multiple sclerosis: classification and clinical features of relapsing and pro-gressive neurological syndromes. Neurol Sci. November 2001;22 (suppl 2):S98–102. 3. Braddom RL, Chan L, Harrast MA, et al. Physical Medicine & Rehabilitation. 4th ed. Philadelphia, PA: read more..
234 ■ II: Core Clinical Competencies 30. Paltamaa J, Sjögren T, Peurala SH, et al. Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials. J Rehabil Med. october 2012;44(10):811–823. doi:10.2340/16501977–1047. 31. Beer S, Khan F, Kesselring J. Rehabilitation interventions in multiple sclerosis: an overview. J Neurol. September 2012;259(9):1994–2008. 32. Spooren AI, Timmermans AA, Seelen HA. Motor read more..
235Christine HinkeTravis R. von TobelBrandon Von Tobel Patient CareGOaLSEvaluate and develop a comprehensive rehabilitative plan of care for a patient with osteoarthritis that is compassionate, appropri-ate, and effective for the treatment and management of osteoar-thritic problems and the promotion of health.OBJeCtiVeS1. Perform a pertinent history and physical examination of the patient presenting with joint pain.2. Identify and assess key impairments, as well as functional and activity read more..
236 ■ II: Core Clinical Competenciesthe patient to the development of osteoarthritis. Table 20.1 shows examples of special testing for specific body parts.Impairment, as defined by the World Health Organization, is the loss or abnormality of a body structure or of a physiological or psychological function. Osteoarthritis can result in the follow-ing impairments: painful joint motion, restricted joint motion, absence of joint motion, joint soft-tissue swelling, joint effusion, joint deformity, read more..
20: Osteoarthritis ■ 237TABLE 20.1 Examples of Specialty Testing for the Joints of the Upper and Lower LimbNAME OF TESTEVALUATES FOR POSSIBLEShoulder (8)Neer impingement signRotator cuff tear, rotator cuff impingementHawkins impingement signRotator cuff tear, rotator cuff impingementCross body adductionAcromioclavicular joint osteoarthritisApprehension signAnterior shoulder instabilitySulcus signInferior shoulder laxityJerk testPosterior shoulder instabilityElbow (9)Valgus stress read more..
238 ■ II: Core Clinical Competenciesrisks of participation in medical research conducted for osteo-arthritis, as well as provide referral for expensive and high-level interventions whenever clinically indicated.MediCaL KnOwLedGeGOaLSDemonstrate knowledge of established evidence-based and evolving biomedical, clinical epidemiological, and sociobehav-ioral sciences pertaining to osteoarthritis, as well as the applica-tion of this knowledge to guide holistic patient care.OBJeCtiVeS1. Discuss the read more..
20: Osteoarthritis ■ 239reLeVant anatOMY and PatHOPHYSiOLOGYNormal joint function is dependent upon the smooth articulation of the involved bones to facilitate motion when force is applied to that joint. Articular cartilage is a thin, shock-absorbing interface that, combined with the effects of synovial fluid, provides an essentially frictionless surface on which joint motion can occur. The loads to articular cartilage are primarily imposed by muscle contraction and are further increased by read more..
240 ■ II: Core Clinical Competenciesweight-loss medications, exercise, dietary changes, and bariatric surgery. The choices again need to be individualized for each patient (22).Exercise in the treatment of osteoarthritis has several benefits. Exercise increases caloric expenditure and can assist in weight reduction. It also strengthens muscles supporting and acting on the involved joints, which helps to further reduce joint stresses. Many patients with osteoarthritis have pain with certain read more..
20: Osteoarthritis ■ 241clinician, and failure of, or intolerance to, one agent should not preclude trial of other agents (24). The clinician should consider the concomitant prescription of misoprostol, proton pump inhibi-tors, or H2 blockers to reduce toxicity to the GI tract (14).COX-2-selective NSAIDs preferentially inhibit COX-2 over COX-1 and have similar efficacy to nonselective NSAIDs for the reduction of osteoarthritis-related pain and improvements in function. These agents have read more..
242 ■ II: Core Clinical Competenciesthe role of the physiatrist as the educator of patients, families, residents, students, colleagues, and other health professionals.There are a variety of resources available to physiatrists, which provide evidence-based information regarding the treat-ment of osteoarthritis. The Agency for Healthcare Research and Quality (AHRQ) is one of the 12 agencies within the Department of Health and Human Services. It is dedicated to the improve-ment in the quality, read more..
20: Osteoarthritis ■ 243OBJeCtiVeS1. Demonstrate skills used in effective communication, counsel-ing, and collaboration with patients with osteoarthritis and their caregivers and families across socioeconomic and cul-tural backgrounds.2. Discuss how effective communication with patients results in better treatment options.3. Discuss appropriate documentation strategies in a patient’s medical records for osteoarthritis.4. Delineate the importance of the role of the physiatrist as the read more..
244 ■ II: Core Clinical Competenciesmake treatment decisions (23). Proper procedures for obtaining informed consent are appropriate for any invasive procedure and should include discussion of noninvasive options and the risks of refusal of the proposed procedure.Patients with the capacity to make decisions have the auton-omy to accept or refuse any and all treatments. Osteoarthritis is not a life-threatening disease, so treatment refusals are rarely grounds to breach patient confidentiality in read more..
20: Osteoarthritis ■ 245NSAIDs should be used with caution in patients with increased cardiovascular risk factors (24).The prescription of opioid analgesics has substantial risks as well. Patients need to be screened for risk factors of abuse and diversion prior to starting the medications and must be moni-tored closely for development of these risk factors. Caution is necessary in the use of opioids in the geriatric population as these patients have a higher tendency to develop sedation, read more..
246 ■ II: Core Clinical Competencies2. Which of the following imaging studies of the involved joint is indicated for the routine evaluation of patients suspected of having a diagnosis of osteoarthritis?A. Plain radiographs are often very helpful, especially in early osteoarthritisB. Musculoskeletal ultrasound of the medial meniscusC. MRI of the kneeD. CT of the kneeE. Osteoarthritis is a clinical diagnosis and imaging studies are often not necessary3. Medications used in the management of read more..
20: Osteoarthritis ■ 247Sports Medicine. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2010: electronic version. 19. Wilke WS, Carey J. Osteoarthritis. In: Carey WD, ed. Cleveland Clinic: Current Clinical Medicine. 2nd ed. Philadelphia, PA: Saun-ders Elsevier; 2009: electronic version. 20. Hunter DJ, Guermazi A. Imaging techniques in osteoarthritis. PM&R. 2012;4(5S):S68–S74. 21. McAlindon T. OA and obesity: more than mechanical. Chronic OA Management. 2011;1(2):1, 4–5. 22. Vincent HK, read more..
248Patient CareGOaLSA physician trained in Physical Medicine and Rehabilita-tion (PM&R) should be able to competently evaluate, care for, educate, and advocate for individuals preparing for total knee arthroplasty (TKA) and total hip arthroplasty (THA) and the rehabilitation that occurs before and after these procedures. Patients should understand all of the risks, benefits, and course of rehabilitation before undergoing TKA and THA.OBJeCtiVeS1. Identify the key elements of the history and read more..
21: Rehabilitation Following Total Knee Arthroplasty and Total Hip Arthroplasty ■ 249testing. The incision line should be inspected for signs of infec-tion or dehiscence. The skin should also be inspected for pres-sure ulcers at the heels, sacrum, and ischium. Presence of edema in the lower extremities should also be recorded. Palpation can provide evidence of painful structures as well as subcutaneous fluid collections or adhesions. In performing range of motion testing, it is important to read more..
250 ■ II: Core Clinical CompetenciesinJUrieS FOLLOWinG tOtaL JOint artHrOPLaStY in tHe LOWer eXtreMitieSIt is important to be aware of injuries that may occur after total joint arthroplasty. Complications and risks include but are not limited to venous thromboembolism in the lower extremities, dislocations, falls, fractures, infections, and pressure ulcers.Venous thromboembolismWhen a patient undergoes a hip or knee arthroplasty, he or she is at an increased risk for the development of venous read more..
21: Rehabilitation Following Total Knee Arthroplasty and Total Hip Arthroplasty ■ 251Physical examination can identify weakness in key muscle groups involved in knee flexion and foot dorsiflexion coupled with sensory loss depending on underlying location of injury. Nerve conduction studies and electromyography can help local-ize the site of nerve injury and determine severity. If the site is at the fibular neck, extra cushioning while sleeping and avoidance of crossing legs can help alleviate read more..
252 ■ II: Core Clinical CompetenciesThere is evidence that the use of continuous passive motion (CPM) following TKA can improve active and passive range of motion of the joint a few degrees more than without the use of CPM; however, the total number of degrees is too small to be clinically relevant according to the authors (26). The use of neuromuscular electrical stimulation has been described for the purpose of improving quadriceps strength before and after TKA; however, its effectiveness read more..
21: Rehabilitation Following Total Knee Arthroplasty and Total Hip Arthroplasty ■ 253the relationship with the patient can either improve or deter from the ultimate treatment-based efforts. When gathering informa-tion about the patient, it is always important to ascertain his or her understanding of the joint arthroplasty procedure, its possi-ble complications, and the rehabilitation process. The physiatrist should provide information at an appropriate level that takes into account the read more..
254 ■ II: Core Clinical Competencies5. Introduce quality improvement as a key factor in joint arthro-plasty rehabilitation programs, including identification of sys-tems errors.Following a total joint arthroplasty of the lower extremities, rehabilitation is typically performed in a variety of settings such as (a) acute inpatient rehabilitation facilities, (b) subacute rehabilita-tion facilities, (c) outpatient rehabilitation facilities, and (d) patient’s home. The decision on the most read more..
21: Rehabilitation Following Total Knee Arthroplasty and Total Hip Arthroplasty ■ 255walking over the past 10 years. He was a police officer, who had played college football, before retiring 5 years ago due to difficulty performing his work-related duties.Over the past 2 years, he has been suffering from chronic knee pain and has had difficulty performing activities of daily living. He suffers from decreased active range of motion in both knees, and bilateral pain in both knees, his right knee read more..
256 ■ II: Core Clinical Competencies 15. Mehrotra C, Remington PL, Naimi TS, et al. Trends in total knee replacement surgeries and implications for public health, 1990–2000. Public Health Rep. 2005;120(3):278–282. 16. Ravi B, Croxford R, Reichmann WM, et al. The changing demo-graphics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol. October 2012;26(5):637–647. doi:10.1016/j.berh.2012.07.014. 17. Centers for Disease read more..
Navdeep Singh JassalDayna McCarthyJennifer SchoenfeldMatthew ShatzerPatient CareGOaLSProvide competent patient care that is compassionate, appropri-ate, and effective for the evaluation, treatment, education, and advocacy for patients with spasticity-associated problems across the entire spectrum of care, and the promotion of health.OBJeCtiVeS1. Describe the key elements of the history and pertinent physi-cal examination of the patient with spasticity.2. Discuss the impairments, functional read more..
258 ■ II: Core Clinical Competenciescontrolled muscle stretch of the limbs. The Brunnstrom method advocates techniques to promote activity in weak agonists by facilitating contraction of either corresponding muscles in the unaffected limb or proximal muscles on the paretic side. No solid evidence exists for the use of modalities for spasticity; how-ever, there is a small body of evidence that electrical stimulation techniques, although used for movement loss related to muscle paresis, may read more..
22: Spasticity ■ 259FIGURE 22.1 (A): Nuclear bag and nuclear chain fibers of the muscle spindle. (B): Influences on the stretch reflex. (Redrawn from Braddom, RL. Physical Medicine & Rehabilitation, 4th ed., Chapter 30, Philadelphia, PA: Elsevier; 2011.)A)B)MUSCLE SPINDLEEFFERENTSStatic γmotor neuronDynamic γmotor neuronα motorneuronGroup Ia fiberGroup II fiberNuclear bag fiberMUSCLE SPINDLEAFFERENTSGroup Ia afferents ← Primary endingsGroup II afferents ← Secondary endingsStatic γ read more..
260 ■ II: Core Clinical CompetenciesTizanidine (Zanaflex) is a centrally acting alpha-2 adrener-gic agonist with the typical side-effect profile of sedation, hypo-tension, dry mouth, bradycardia, dizziness, flushing, and liver toxicity. For the latter, baseline liver function tests (LFTs) are indicated before starting this medication as well as consistent LFT monitoring. Studies have shown tizanidine to be as effec-tive as baclofen and diazepam in treating spasticity in SCI, MS, and TBI, as read more..
22: Spasticity ■ 261interpersonal and communication skills to effectively provide care and advocate for their patients with spasticity.There are several strategies that physiatrists can use to iden-tify gaps in their knowledge base about spasticity. Self-reflection on their clinical practice, self-assessment examinations, asking trusted colleagues to provide feedback to them on their practice, and asking patients under their care for their feedback on the care provided are just some read more..
262 ■ II: Core Clinical Competenciesclinical expertise in this area and the emphasis on teamwork that is part of his or her training.Preventive stretching, applying modalities, educating care-givers about ROM, identifying muscles for chemodenervation, and assisting with assessment during ITB trials are all integral aspects of care that these team members can offer. The person with spasticity clearly needs to be central to the process, ensur-ing that the main goal of treatment is appropriate read more..
22: Spasticity ■ 2633. Respect the importance of patient’s beliefs and goals, privacy, confidentiality, and autonomy as it applies to spasticity.4. Demonstrate sensitivity to culture, diversity, gender, age, race, religion, disabilities, and sexual orientation as it may apply to patients with spasticity.5. Exhibit responsibility and accountability of physiatry as it applies to spasticity.The physiatrist should treat patients affected by spasticity in a respectful, compassionate, ethical, and read more..
264 ■ II: Core Clinical CompetenciesSySteM-BaSed PraCtiCeGOaLSAwareness and responsiveness to systems of care delivery, and the ability to recruit and coordinate effectively resources in the system to provide optimal continuum of care as it relates to spasticity.OBJeCtiVeS1. Identify the key components in the spectrum of rehabilitation continuum of care settings for patients with spasticity.2. Coordinate and recruit necessary resources in the system to provide optimal and variety of care read more..
22: Spasticity ■ 265of spasticity and even fewer are experts on how to approach/man-age it. As previously stated, ideally physiatrists like to be able to start with patients from point A, the point where they are initially diagnosed, and be able to follow them through to point Z. Often-times, however, by the time they see a physiatrist, their spasticity has already begun to negatively impact their daily lives. Perhaps this is because physicians outside of physiatry are unaware that read more..
266 ■ II: Core Clinical Competencies4. When considering a treatment option for a patient with spas-ticity, what is the most important factor to guide treatment?A. CostB. Side effectsC. Patient preferenceD. Insurance coverageE. Physician preference5. A 15-year-old boy with spastic CP presents with worsening tone in his right elbow flexors. On examination the joint can-not be ranged due to the severity of his tone and is documented as a 4 on the MAS. Which term best defines this score?A. read more..
Patient CareGOaLSEvaluate and develop a rehabilitation plan of care for patient with upper extremity musculoskeletal injuries (UEMIs) that is com-passionate, appropriate, and effective for the treatment of neuro-muscular problems across the entire continuum of care and the promotion of health.OBJeCtiVeS1. Perform a comprehensive evaluation of a patient with UEMI.2. Formulate an optimal rehabilitation management plan for the patient with common acute, subacute, and chronic orthope-dic and read more..
268 ■ II: Core Clinical CompetenciesTABLE 23.2 Upper Extremity Range of MotionMovEMEnTDEgREEsshoulderFlexion0–180Abduction0–180Extension0–45/60Internal rotation at 90° abduction0–80/90External rotation at 90° abduction0–90Internal rotation (walk finger up the back)to T7ElbowFlexion0–145/150ForearmPronation/supination0–80/90WristFlexion0–80Extension0–70Radial deviation0–20Ulnar deviation0–30/35ThumbCMCAbduction0–70/80Flexion0–15/45Extension0–20OppositionTip of read more..
23: Musculoskeletal Disorders: Upper Extremity ■ 269The supraspinatus test or “empty can” test involves patient testing at 90° elevation in the scapular plane and full internal rotation (empty can) with the patient resisting downward pres-sure exerted by the examiner at the patient’s elbow or wrist. If weakness or pain occurs during the movement the supraspinatus tendon can be affected. In the drop arm test the examiner grasps the patient’s wrist and passively abducts the patient’s read more..
270 ■ II: Core Clinical CompetenciesOBJeCtiVeS1. Describe the epidemiology, etiology, anatomy, physiology, and pathophysiology of UEMI.2. Describe the role of imaging studies in the diagnosis of UEMI as well as their optimal timing and use.3. Propose management approaches for UEMI.Knowledge of anatomy and pathophysiology is the first step in developing a treatment plan for a patient with an upper extrem-ity musculoskeletal disorder. This section focuses on the anat-omy and pathophysiology of read more..
23: Musculoskeletal Disorders: Upper Extremity ■ 271Initial treatment of epicondylitis consists of relative rest, activity modification, thermal modalities, and anti-inflammatory medications. A forearm band (counterforce brace) worn distal to the flexor or extensor muscle group can dissipate forces over the forearm muscles and relieve stress from the tendon inser-tions. If the patient still has pain, a two-phase rehabilitation therapy program can be implemented. The first phase focuses on read more..
272 ■ II: Core Clinical Competencieslevel of success in his or her clinical practice regarding interven-tional vs. surgical vs. conservative treatments. Likely, the practi-tioner will need to facilitate a variety of treatment modalities to properly treat the patient’s pain and disabilities.A physiatrist should also undergo periodic reflection on out-comes in his or her clinical practice. For instance, patients should be instructed to fill out pain surveys on each office visit, which should read more..
23: Musculoskeletal Disorders: Upper Extremity ■ 273to take on the role of team leader and treat the patient in a multi-disciplinary team approach. He or she would be the one respon-sible for coordinating the patient’s treatment plan and monitoring the patient’s progress in the rehabilitation program. If there are any changes that need to be implemented—for example a change in weight-bearing status—it would be the physiatrist’s responsi-bility to convey this information to the rest read more..
274 ■ II: Core Clinical CompetenciesA physiatrist’s job caring for patients with upper extrem-ity musculoskeletal disorders from a diverse population can be rewarding and an eye-opening experience, while at the same time difficult due to obstacles that may arise from social, economic, and cultural differences. Ethical issues will also commonly arise during which time the physiatrist needs to maintain professional behavior without injecting his or her own personal judgment or beliefs that read more..
23: Musculoskeletal Disorders: Upper Extremity ■ 2754. Describe cost/risk–benefit analysis, including ordering tests and discharge planning, utilization, and management of resources as they apply to UEMI.Patients with UEMIs receive care in a variety of health care settings by a variety of health care providers. For example, occu-pational injuries involving the upper extremities can be treated in occupational medicine clinics or general physical medicine and rehabilitation clinics by read more..
276 ■ II: Core Clinical Competenciesright upper extremity is significant for some swelling over his lateral epicondyle. His muscle strength is 5/5 throughout the right upper extremity and he has full ROM. Cozen test is posi-tive. He has no sensory deficits and his reflexes are normal.CaSe Study diSCuSSiOn QueStiOnS1. What is your differential diagnosis for the patient’s condition?2. Discuss the anatomy involved and the mechanics of swinging a tennis racquet.3. Utilize available medical read more..
23: Musculoskeletal Disorders: Upper Extremity ■ 277 23. CDC. Prevalence and most common causes of disability among adults—United States, 2005. MMWR. 2009;58(16):421–426. 24. Loisel P, Buchbinder R, et al. Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence. J Occup Rehabil. December 2005;15(4):507–524. 25. Davidson KA. The most efficient health care systems in the world. The Huffington Post. August 29, 2013. 26. Bussieres AE, Peterson read more..
Patient CareGOaLSProvide patient care that is compassionate, appropriate, and effective for the treatment of lumbar spine disorders and the pro-motion of good health.OBJeCtiVeS1. Perform a pertinent history and physical of the patient with low back pain.2. Describe Waddell signs and its clinical use.3. Identify “red flags” and key impairments, activity limitations, and participation restrictions for patients with lumbar pain.4. Identify the psychosocial and vocational implications of low read more..
24: Lumbar Spine Disorders ■ 279iMPairMentS, aCtiVitY LiMitatiOnS, anD PartiCiPatiOn reStriCtiOnSThe lumbar spine is associated with a wide range of clinical disorders. Although lumbar spine pathology may be a result of rheumatologic, hematologic, endocrinologic, and even neoplastic disorders, most impairments of the lumbar spine are the results of mechanical disorders.Mechanical disorders refer to pain that results from overuse of a normal anatomic structure or pain that results from trauma read more..
280 ■ II: Core Clinical CompetenciesEven though most patients with low back pain usually recover within a few weeks, work absenteeism can be a problem encountered by the physician. The biggest risk factors for delayed return to work and chronic disability are psychosocial variables, such as depression, level of education, excessive pain level, fear avoidance, job dissatisfaction, legal representation, somatization disorder, unemployment, and workers’ compensation (5).Recommendations for read more..
24: Lumbar Spine Disorders ■ 281distraction, etc.). The third component involves the application and maintenance of learned coping skills (13).treatMentTreatment of musculoskeletal disorders in the lumbar spine involves patient education, activity modification, lumbar sup-port, therapy, medications, and injections.Patient education topics include reassurance, methods of symptom control, and recognition of the red flags. Activity mod-ification may include limiting prolonged sitting, heavy read more..
282 ■ II: Core Clinical CompetenciesElectrodiagnostic studies may play a pivotal role in the diag-nosis of lumbar spine pathology. Nerve conduction studies and electromyography (EMG) assist in the physiologic (as opposed to anatomic in MRI) localization of a pathologic lesion. It is also useful in determining the type and severity of the neural injury, chronicity, as well as the prognosis for neural recovery. A nerve conduction study may be useful in ruling on peripheral nerve pathology, which read more..
24: Lumbar Spine Disorders ■ 283developed clinical practice guidelines for the diagnosis and treat-ment of specific lumbar spine diseases, such as lumbar stenosis and degenerative spondylolisthesis. Additional resources are also available from the AAPMR’s online resources such as “Knowl-edge NOW” and Academe, PubMed searches, and the Cochrane Database. Physiatrists can also obtain education in pain medicine and interventional spine procedures through fellowship training.interPerSOnaL anD read more..
284 ■ II: Core Clinical Competenciesincludes use of therapeutic touch, especially in musculoskeletal medicine. Patients are frequently disrobed for the low back pain physical examination; sensitivity toward respecting patient pri-vacy is applicable.A prior study by Sanders et al. attempted to determine the cross-cultural differences in patients with low back pain (21). The study found that Mexican and New Zealander low back pain patients had significantly fewer physical findings than read more..
24: Lumbar Spine Disorders ■ 285The optimal follow-up care is individualized for each patient, depending on the diagnosis and treatment. An individual with a serious diagnosis (e.g., lumbar spine malignancy) will require more frequent follow-up compared to an individual with a “benign” diagnosis (e.g., myofascial pain syndrome). Patients who have been treated with modalities that may have serious complications (opiates, injections, etc.) will also require more frequent follow-up.MarKerS OF read more..
286 ■ II: Core Clinical Competencies2. The percentage of patients who recover from “acute” low back pain isA. 10% to 30%B. 30% to 50%C. 50% to 70%D. 70% to 90%E. 90% to 100%3. A 45-year-old man presents with low back pain radiating down the right lower limb for 2 weeks. He has tried bed rest, as well as over-the-counter NSAIDs, with no benefit. He presents to your office for a consultation. On examination, you obtain a positive straight leg raise. There are no other red flags present. Of read more..
24: Lumbar Spine Disorders ■ 287 16. Boos N, Semmer N, Elfering A, et al. Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imag-ing: predictors of low back pain-related medical consultation and work incapacity. Spine (Phila Pa 1976). 2000;25(12):1484–1492. 17. Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181–189. 18. read more..
Patient CareGOaLSEvaluate and develop a rehabilitative plan of care that is com-passionate, effective, and targeted at the individual patient with rheumatoid arthritis (RA).OBJeCtiVeS1. Perform a detailed history and physical examination of a patient with RA.2. Identify the key components of a rehabilitation program as they relate to the rheumatoid patient with RA.3. Identify the psychosocial and vocational implications for the patient with RA and strategies to address them.4. Formulate a read more..
25: Rheumatoid Arthritis ■ 289lateral bands to migrate downward, causing PIP flexion and DIP hyperextension. The swan-neck deformity is a hyperextension at the PIP joint, with MCP and DIP joint flexion. It can occur from multiple combinations of joint disruptions, which usually involve PIP volar support loss (e.g., volar plate rupture) and eventual con-tracture of the hand intrinsic muscles. In the upper extremity, elbow synovitis can lead to loss of extension and sometimes a compressive ulnar read more..
290 ■ II: Core Clinical CompetenciesModalities can also assist in physical and occupational ther-apy programs. Cold therapy is ideal for acute flares, especially in joints with effusions. Deep heat is indicated for patients with chronic inflammation and contractures (Box 25.4).HOW SHOULD tHe reHaBiLitatiOn PrOGraM Be MODiFieD DUrinG a FLare?In a word, rest! Reevaluate and reduce all resistive exercises, especially those that stress the small joints of the hands and feet. In this case, read more..
25: Rheumatoid Arthritis ■ 291in women (13). This incidence has remained stable over many years. New criteria for diagnosing early RA were published in 2010, and follow-up studies estimating incidence rates using the new criteria have yielded similar results (14). The etiology of RA remains unknown, but is considered to be multifactorial, resulting from an interaction between a genetic predisposition and environmental exposure, the exact contributions of which are still being elucidated. The read more..
292 ■ II: Core Clinical Competencieswhereas a “high positive” (greater than three times the ULN) contributes three points. Either erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels above the ULN contrib-ute 1 point to the “elevated acute phase” section of the criteria.Other laboratory tests that do not directly contribute to the diagnosis are often ordered for the purposes of ruling out other diseases or in preparation for starting pharmacologic therapy. For read more..
25: Rheumatoid Arthritis ■ 293In early RA, suggestions for therapy depend on disease activity (scored as low, moderate, or high) and on presence or absence of “features of a poor prognosis.” For early RA, low disease activ-ity, and no poor prognostic factors, the recommendation is to start with DMARD monotherapy (which is most often metho-trexate). In early RA, as disease activity and prognostic factors worsen, the ACR recommends adding an additional DMARD. Anti-TNF agents for early RA are read more..
294 ■ II: Core Clinical CompetenciesFLareSA flare is described as “a worsening of disease activity of suf-ficient intensity and duration to consider a change in therapy,” (34) but there is no current consensus for objectively diagnosing a flare period. Physiologically, flare represents an activation of inflammatory mediators in the synovium. The EULAR recom-mends that rapid remission is the primary goal of treatment in every patient, and strict monitoring should dictate the adjustment of read more..
25: Rheumatoid Arthritis ■ 295TABLE 25.2 Summary of Available Cochrane Reviews Related to Treatments for Rheumatoid ArthritisTREATMENT/NO OF STUDIESSUMMARyDynamic exercise/8 ■Land-based dynamic exercise moderately improved aerobic capacity and strength, and was safe both in the short and long term (8) ■Aquatic-based exercise did not provide any additional benefit versus land-based exercise ■In a different meta-analysis of 14 randomized controlled trials (RCTs), aerobic exercises (at read more..
296 ■ II: Core Clinical Competenciesan effective PDSA addressed the original 68-joint count sur-vey, the original time-intensive intake for rheumatologists, and whether fewer joints could be assessed, while still providing adequate information for clinical decision making (54).Plan: Use an available pool of RA patients to analyze the stan-dard 68-joint count compared to other counts of 42, 36, or 28 joints and how this related to other measures of clinical status, such as patient read more..
25: Rheumatoid Arthritis ■ 297think that their doctor truly understood their condition (58). This article highlights the differences in perception between physi-cian and patient with statements such as “You don’t look swollen enough”; “it shouldn’t hurt that bad”; “your ‘inflammation mark-ers’ look good, so what’s the problem?”Many patients will have guilt of causation (i.e., a feeling that some lifestyle choice led to the disease), and it is important to stress that they read more..
298 ■ II: Core Clinical CompetenciesOBJeCtiVeS1. Exemplify the humanistic qualities in patient-centered care.2. Demonstrate ethical principles, responsibilities, and respon-siveness to patient needs superseding self and other interests.3. Demonstrate sensitivity to patient population diversity, cul-tural competence, gender, age, race, religion, disabilities, and sexual orientation.4. Respect patient privacy, confidentiality, autonomy, and shared decision making.5. Recognize the socioeconomic read more..
25: Rheumatoid Arthritis ■ 299managed in a home environment, which has the advantages of patient independence, family support, and familiar and comfort-able environment. In the community setting, the patient with RA has access to multispecialty care, and these visits typically focus on nonemergent pain or functional limitations.The inpatient setting is usually reserved for significant changes in the patient’s medical status that require close moni-toring and coordinated medical care; for read more..
300 ■ II: Core Clinical Competencies“usual care” (72). In both groups, patients could receive individual physical therapy. Over the 2-year period, there was a cost reduc-tion of 62% in the high-intensity exercise group compared to the “usual care group”; however, this was not able to offset the overall cost of implementing the RAPIT program (cost of two physical therapists teaching 94 classes/year at 75 minutes/class).Another area of potential cost savings lies in the prescrip-tion of read more..
25: Rheumatoid Arthritis ■ 3015. Which of the following is an IL-1 inhibitor?A. Etanercept (Enbrel®)B. Anakinra (Kineret®)C. Infliximab (Remicade®)D. Adalimumab (Humira®)E. Gabapentin (Neurontin®)reFerenCeS 1. Tehlirian CV, Bathon JM. Chapter 6: rheumatoid arthritis— Figure 6B-2. In: Klippel JH, ed. Primer on the Rheumatic Diseases. 13th ed. New York: Springer; 2008. 2. Ono S, et al. Reconstruction of the rheumatoid hand. Clin Plast Surg. 2011;38:713–727. 3. Chung KC, Pushman AG. read more..
302 ■ II: Core Clinical Competencies 39. http://www.curearthritis.org/rheumatoid-arthritis/ 40. http://rheum4us.org/ 41. http://www.ra.com/ 42. Seultjens EEMJ, Dekker JJ, Bouter LM, et al. Occupational therapy for rheumatoid arthritis. Cochrane Database Syst Rev. 2004;(1). Art. No.: CD003114. 43. Verhagen AP, Bierma-Zeinstra SMA, Boers M, et al. Balneotherapy for rheumatoid arthritis. Cochrane Database Syst Rev. 2004;(1). Art. No.: CD000518 44. Welch V, Brosseau L, Casimiro L, et al. read more..
Lauren R. EichenbaumGeet PaulStephen NicklDavid BresslerPatient CareGOaLSProvide competent patient care that is team based, patient cen-tered, compassionate, appropriate, and effective for the evalua-tion, treatment, education, and advocacy of fibromyalgia (FM) patients across the continuum of care and the promotion of health.OBJeCtiVeS1. Describe the key components of fibromyalgia and the assess-ment of FM, including history and physical examination.2. Define the impairments, activity read more..
304 ■ II: Core Clinical CompetenciesWHat are tHe PriMarY SOMatiC anD COGnitiVe SYMPtOMS aSSOCiateD WitH FMS?SOMATICCOGNITIVEIBS - Irritable Bowel SyndromeChronic fatiguePalpitationsMemory impairment (“fibrofog”)Subjective sensory deficitsDepressionHeadacheWHat are tHe KeY PSYCHOSOCiaL aSPeCtS aSSOCiateD WitH FiBrOMYaLGia SYnDrOMe?According to Winfield, the population suffering from FM is likely to have had traumatic experiences in their childhood or other emotional stressors throughout read more..
26: Fibromyalgia ■ 305been shown to produce significant improvement (9). Aerobic training improves fatigue and depression, and participants were found to tolerate increased levels of pressure over their tender points (10). Aerobic training has also been shown to reduce muscle and cognitive fatigue, and to decrease symptoms of depression (11). A sample physical therapy (PT) prescription is presented in Table 26.4.alternative treatmentThere are many alternative treatments such as yoga, read more..
306 ■ II: Core Clinical Competenciessensitization” (20). An electrical correlate, which reflects cen-tral sensitization can be objectively demonstrated by using the nociceptive flexion reflex (NFR). The test is performed as fol-lows: the sural nerve that is purely sensory is slowly (start at 1 mA) stimulated over the lateral malleolus until a spinal flexion reflex contraction is recorded at the ipsilateral biceps femoris muscle tendon. The current threshold required to produce the initial read more..
26: Fibromyalgia ■ 307tramadolTramadol is a weak opioid with mild SSRI properties. Both APS and EULAR gave it a high level of recommendation. Bennett et al. in 2003 in a double-blind RCT demonstrated that tramadol combined with acetaminophen was effective in reduc-ing pain in patients with FM (33).nOnPHarMaCOLOGiCaL treatMent OF FiBrOMYaLGiaexercise ProgramEvidence supports the efficacy of AE for patients with FM. In a Cochrane review from 2008 (34), the authors concluded that moderate read more..
308 ■ II: Core Clinical Competenciessymptoms are multifaceted. Management of patient’s symptoms requires a holistic team approach, including physicians, physi-cal and occupational therapists, and a psychologist. Each visit should include an accurate assessment and modification of the treatment plan based on the patient’s self-reported pain, sleep, fatigue, and overall well-being. Two well-known validated scales used to assess pain intensity are the Visual Analog Scale (VAS) and Verbal read more..
26: Fibromyalgia ■ 309teams. The physiatrist develops a treatment plan for the patient. This plan should establish treatment goals that are (a) specific, (b) realistic, (c) measurable, and (d) have a targeted date of com-pletion. Adhering to this plan establishes a format for follow-up visits where progress and/or impediments can be reviewed and new treatment goals established.Patient education plays an important role in the manage-ment of FM. A study done in 2002 showed that providing a read more..
310 ■ II: Core Clinical Competencieswith education can significantly improve quality of life and self-efficacy (41,42).Documentation is an important communication tool between clinicians involved in the care of the patient with FMS. The documentation should provide key elements of the patient’s medical history and physical examination that are consistent with the diagnosis of FMS as well as pharmacological and non-pharmacological treatments rendered and their level of effective-ness. Side read more..
26: Fibromyalgia ■ 311Minimizing the risk of harm begins with an early accurate diagnosis of FMS in order to reduce the risk of injury associated with unnecessary or invasive diagnostic tests. Once the diagnosis is made, it is important to minimize the risk of side effects or adverse events associated with medications commonly used to treat FMS. Under ideal circumstances, the FMS patient is prop-erly managed by caregivers who are competent and experienced in providing comprehensive care for read more..
312 ■ II: Core Clinical CompetenciesB. Pain for a minimum of 3 months, including the four mus-culoskeletal body regions, excluding the head but includ-ing the axial skeletonC. Pain for a minimum of 6 months, including the four mus-culoskeletal body regions, excluding the head but includ-ing the axial skeletonD. Pain for a minimum of 3 months in all four quadrants of the body, including the axial skeleton both above and below the waistlineE. Pain for a minimum of 9 months in three read more..
26: Fibromyalgia ■ 313 23. Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from pathophysiology to therapy. Nat Rev Rheumatol. July 19, 2011;7(9):518–527. 24. Burckhardt CS, Goldenberg D, Crofford L, et al. Guideline for the Management of Fibromyalgia Syndrome. Pain in Adults and Chil-dren. APS Clinical Practice Guideline Series No. 4. Glenview, IL: American Pain Society; 2005. 25. Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of read more..
314 ■Aggravating factors ■Alleviating factors ■Neck trauma associated with neck pain ■Ask if this is the first time that the pain has occurred or if this is an exacerbation of an ongoing neck pain ■Functional impact of the neck pain on activities such as driv-ing, work, reading, sexual activity ■Diagnostic tests and treatments prior to current visit to physiatristIn reviewing the past medical history, it is important to ask about unplanned weight loss, fever, chills, and night sweats read more..
27: Cervical Radiculopathy ■ 315can limit activities such as driving, overhead movements, and lifting, which can in turn restrict ability to work and engage in avocational activities. Neck pain at night can impair sleep, lead-ing to daytime drowsiness.Psychosocial implications due to cervical radiculopathy can include anxiety and depression due to the limitations in social activities and hobbies with friends and family. Work restrictions can lead to loss of/decreased productivity, reduction in read more..
316 ■ II: Core Clinical Competenciesthe inflammatory response and the release of thromboxane and prostaglandins. Muscle relaxants, antineuropathic agents, and antidepressants can be used as adjuvants for pain control. Opiates can be used as a modality; however, they carry the risk of opiate-induced morbidity and mortality. Initially, the patient should be advised to avoid any actions that aggravate the symptoms. Physical therapy should be initiated soon after the pain symptoms begin to read more..
27: Cervical Radiculopathy ■ 317evaluation, validation, education, and advocacy of percutane-ous techniques used in the diagnosis and treatment of spine disorders” (7).Additionally, the physiatrists must sharpen not only their intellectual skills, but also their communication skills with patients, their families, and other professional colleagues. Effective communication is of the utmost importance. A holistic approach is often required to treat the many different causes of cervical read more..
318 ■ II: Core Clinical Competenciesrecognize the emotional impact of the cervical neck pain and review and summarize, often using the patient’s own words, to describe his or her challenges. The physician must be the leader but should demonstrate leading through suggestion.To be an effective communicator requires active listening skills on the part of the interventional pain specialist. Ask open-ended questions initially, followed by more focused questions. Reflect back what the patient read more..
27: Cervical Radiculopathy ■ 319OBJeCtiVe1. Demonstrate importance of integrity, respect, compassion, ethics, and courtesy in the care of patients with cervical radiculopathy.2. Exhibit the importance of patient-centered care, informed consent, and maintaining patient confidentiality in cervical radiculopathy.3. Discuss the importance of patient’s beliefs and goals, privacy, and autonomy as it applies to cervical radiculopathy.4. Demonstrate sensitivity to culture, diversity, gender, age, read more..
320 ■ II: Core Clinical Competenciesphysical and occupational therapy at the bedside or in the facility’s rehabilitation gym. Pain management and physiat-rist consultations services should be available. If the patient’s symptoms are severe and have failed to respond to conserva-tive treatment, cervical epidural steroid injection can be per-formed as an inpatient procedure. The decision on which of these options is selected is often dependent on the patient’s medical stability and read more..
27: Cervical Radiculopathy ■ 3215. Which of the following interventional procedures carries the highest risk of cerebrovascular accident (CVA)?A. Interlaminar epidural steroid injectionB. Transforaminal epidural steroid injectionC. Facet blocksD. Medical branch blocksE. Trigger point injectionsreFerenCeS 1. Shabat S, Leitner Y, David R, Folman Y. The correlation between Spurling test and imaging studies in detecting cervical radiculopa-thy. J Neuroimag. October 2012;22(4):375–378. 2. Merskey read more..
322KEY ELEMENTS OF HISTORYCurrent Condition ■Injuries or illnesses since last checkup ■Active acute or chronic illness ■Recent viral illness—mononucleosis ■Medications, allergies, and supplements ■Adequate caloric intake ■Stress ■Menstrual abnormalities (as applicable) ■Sleep ■Pain ■Paresthesias ■WeaknessPast Medical/Surgical History ■Hospitalizations ■Surgeries ■Loss of consciousness/syncopal episodes (particularly dur-ing exercise) ■Cardiac conditions (prompt read more..
28: Sports Medicine: Preparticipation Evaluation ■ 323Marfanoid features are particularly important to catch due to the cardiac implications of the syndrome. It is also important to be aware of normal variants seen in certain sports: for exam-ple, baseball pitchers routinely have increased external rotation in their throwing arm compared to the contralateral side. This should not be mistaken for instability or acute ligamentous injury, and need not be documented or worked up further. Pain is a read more..
324 ■ II: Core Clinical Competenciespractices, and making improvements based on progressive self-evaluation and lifelong learning.OBJECTIVES1. Describe learning opportunities for providers, patients, and caregivers as applicable to PPEs of athletes.2. Locate resources including available websites and profes-sional organizations for continuing medical education and professional development in sports medicine.Physiatrists performing PPEs should have a working knowl-edge of musculoskeletal read more..
28: Sports Medicine: Preparticipation Evaluation ■ 325 ■Personal or family history of any sudden death, cardiac abnor-malities, or lightheadedness when exercising ■History of concussion ■Medications, prior medical conditions, and details of limited clearance ■Loss of any paired organs (eyes, kidneys, testicles, ovaries), which may disqualify an athlete from competing in many contact sports ■History of seizuresWith regard to athletes with disability, it is important to document any read more..
326 ■ II: Core Clinical CompetenciesSYSTEMS-BASED PRACTICEGOALSAwareness and responsiveness to systems of athletic care deliv-ery, and the ability to recruit and coordinate effectively resources in the system to provide optimal continuum of care as it relates to sports medicine and the athlete.OBJECTIVES1. Identify the key components in the spectrum of athlete con-tinuum of care settings.2. Discuss some limitations of the PPE.3. Coordinate and recruit necessary resources in the system to read more..
28: Sports Medicine: Preparticipation Evaluation ■ 327SELF-EXAMINATION QUESTIONS(Answers begin on p. 367)1. The designation of “conditional clearance” for sports partici-pation indicates which of the following?A. The athlete is cleared for participation as long as a referred clinician also agreesB. The athlete can participate as long as a waiver is signedC. The athlete can only participate under certain weather conditionsD. The athlete can participate if his or her parents agreeE. The read more..
328 ■ II: Core Clinical Competencies 5. Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a pre-participation screening program. JAMA. 2006;296:1593–601. 6. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for car-diovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Coun-cil on read more..
Patient CareGOaLSProvide patient care that is compassionate, appropriate, and effective for the treatment of the adult with an entrapment neuropathy.OBJeCtiVeS1. Describe the key components of the assessment of the adult with an entrapment neuropathy.2. Discuss the long-term implications of entrapment neuro - pathies.3. Assess the impairments, activity limitations, and participa-tion restrictions associated with entrapment neuropathies.4. Describe potential injuries associated with entrapment read more..
330 ■ II: Core Clinical CompetenciesPatients with CTS or ulnar neuropathy in their dominant hand may complain of bothersome paresthesias which impair certain work activities requiring fine motor skills (e.g., typing, driving, and electrical work). Ulnar neuropathy, in particular, may be associated with decreased grip strength as the ulnar part of the hand provides a powerful grip. These patients may require written work restrictions from the physician if symp-toms are thought to endanger the read more..
29: Entrapment Neuropathies ■ 331Optimal timing of surgical decompression in CTS or CuTS has not been established in the medical literature. Ideally, patients should be referred for decompression after an adequate trial of nonoperative therapy has been attempted, but prior to the devel-opment of thenar muscle atrophy or intrinsic muscle weakness. It is certainly reasonable to stop or defer nonoperative therapies in those patients presenting with moderate-to-severe findings on EDX studies or read more..
332 ■ II: Core Clinical CompetenciesDorsal ulnarcutaneoussensoryPalmarcutaneoussensoryHypothenarmotorDigitalsensoryPisiform boneHook of the hamateDeep palmarmotor branchFIGURE 29.3 Anatomy of the Ulnar Nerve at the WristSource: Adapted from Cuccurullo SJ. Physical Medicine & Rehabilitation Board Review, 2nd ed. Demos Medical Publishing; 2010.AnteriorCutaneousDistributionLateralLCNCSuperficialperonealLCNCSuperficialperonealLateralcutaneous n.of calf(LCNC)FibulaDeepperoneal n.Peroneus longus read more..
29: Entrapment Neuropathies ■ 333extensor digitorum brevis (EDB) muscle should be performed. If the EDB muscle is atrophied or a response is difficult to obtain, then recording from the tibialis anterior muscle may be used instead. An accessory peroneal nerve should be suspected if, during routine peroneal NCS to the EDB, the CMAP amplitudes obtained at the fibular head and popliteal fossa are greater than the CMAP amplitude obtained at the ankle. A response obtained by stimulating posterior read more..
334 ■ II: Core Clinical CompetenciesFIGURE 29.7 An example of “positive-site” between i4 and i3 corresponding to the relatively smaller cross-section area (CSA) at i2. The peak latencies (arrowhead) at i4 and i3 are 1.9 ms and 2.9 ms, respectively, and the difference between them is 1.0 ms, i.e. >0.4 ms. The CSA measured at i2 (arrow) is smaller than those measured at nearby levels. Markers of the 8-point: i4, i3, i2, i1, w, o1, o2, and o3.Interestingly, longer duration of CTS read more..
29: Entrapment Neuropathies ■ 335of confounding neurological conditions (e.g., cervical/lumbar radiculopathy, brachial/lumbosacral plexopathy) from the dif-ferential diagnosis. A careful EDX examination that excludes the presence of a radiculopathy or plexopathy and confirms the presence of a peripheral entrapment neuropathy refutes a more proximal etiology of a patient’s painful symptoms. This may help avoid unnecessary spinal surgery and prevent further mor-bidity, as seen when patients read more..
336 ■ II: Core Clinical Competenciesburn injuries where superimposed peripheral entrapment neurop-athies are more common. This system of care, with the physiatrist serving as team leader, is employed primarily in acute rehabilita-tion settings once the patient is medically stabilized, to expedite functional recovery and promote community reintegration.For example, an orthopedic trauma patient whose injuries include a proximal tibia–fibula fracture is admitted to the reha-bilitation unit of read more..
29: Entrapment Neuropathies ■ 337referenCeS 1. Katz JN, Stirrat CR. A self-administered hand diagram for the diag-nosis of carpal tunnel syndrome. J Hand Surg. 1990;15A:360–363. 2. Werner RA, Chiodo A, Spiegelberg T, et al. Use of hand diagrams for screening for ulnar neuropathy: comparison with electrodiag-nostic studies. Muscle Nerve. 2012;46:891–894. 3. Katz JN, Stirrat CR, Larson MG, et al. A self-administered hand symptom diagram for the diagnosis and epidemiologic study of car-pal read more..
338 ■ II: Core Clinical Competenciesand Rehabilitation. Practice parameter for electrodiagnostic eval-uation of carpal tunnel syndrome: summary statement. Muscle Nerve. 2002;25:918–922. 38. American Academy of Neurology, American Association of Elec-trodiagnostic Medicine, American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic stud-ies in ulnar neuropathy at the elbow: summary statement. Muscle Nerve. 1999;22:408–411. 39. Robinson LR, Micklesen read more..
Rajashree SrinivasanPatient CareGOaLSEvaluate and develop a comprehensive rehabilitative plan of care for the pediatric patient with traumatic brain injury (TBI) that is compassionate, appropriate, and effective for the treatment and management of TBI problems and the promotion of health.OBJeCtiVeS1. Describe the key elements of the history and pertinent physi-cal examination of the child with TBI.2. Describe the key impairments, functional and activity limita-tions, and participation read more..
340 ■ II: Core Clinical Competenciesrestrictions in an existing limb after amputation (depending on the level). Depending on the ability of the patient, he or she might sit up on the edge of the bed, or in a chair—if able to do so with adequate head and trunk control—providing assistance when necessary. Use of standing frames, tilt tables, wheelchairs for positioning and mobility, and development of skills is of para-mount importance. Spasticity may interfere with these, requiring read more..
30: Pediatric Traumatic Brain Injury ■ 341dysfunctions like syndrome of inappropriate antidiuretic hor-mone secretion (SIADH), Diabetes Insipidus (DI), and cerebral salt wasting and address them as they arise.Speech impediments may be seen in the form of dysarthria, word-finding problems, grammatical errors, or understanding social cues. This can complicate communication further, deep-ening the patient’s gorge of social isolation.Neuropharmacologic agents are frequently used in the acute read more..
342 ■ II: Core Clinical Competenciestherapies on a daily basis 5 to 6 times a week, particularly dur-ing the acute phase of recovery. Once the recovery plateaus off, or slow progress is seen, then outpatient therapies are set up. It is important for the outpatient therapists to have access to documen-tation to the inpatient progress as this provides a basis for future care. For instance, if the patient had performed certain activities during the inpatient stay that he or she is unable to read more..
30: Pediatric Traumatic Brain Injury ■ 343Nonaccidental TBI is characterized by a triad of subdural hemorrhage, retinal hemorrhage, and encephalopathy with an incompatible history of mechanism of injury. The history of mechanism of injury does not match the actual injury.The Glasgow Outcome Scale is a functional outcome scale rating patients into death through vegetative state to recovery (Table 30.4).Given how common TBI is in the pediatric population, it is important to be able to pay read more..
344 ■ II: Core Clinical CompetenciesTABLE 30.5 Benefits and Limitations of Procedures in Brain InjuryTESTBENEFITSLIMITATIONSMRI of head and neck;Magnetic resonance angiographyEffective in obtaining information about structural damage to the brain, including evidence of diffuse axonal injury, hydrocephalus, encephalomalaciaLesser exposure to radiationAssociated information regarding cervical ligamentous injury can be obtainedInformation about vascular structures obtainableAs obtaining an MRI read more..
30: Pediatric Traumatic Brain Injury ■ 345rehabilitation of brain injury focuses not only on the medical and rehabilitation aspect, but also on the integration into schools and the community.It was initially erroneously thought that children recovered better from brain injury when compared to adults. This has been disproved with ongoing research showing that children have more of a functional impact due to brain injury. They do not have the same repertoire of information and experience read more..
346 ■ II: Core Clinical Competenciesmedical and rehabilitative care of these patients. Self-reflection on their clinical practice, self-assessment examinations, and ask-ing trusted colleagues to provide feedback to them on their prac-tice are some examples. Seeking feedback from the families and caregivers of these children is another.To offer best care, it is important to be able to provide the latest information regarding the care of the child with TBI. Hence it is valuable to be aware of read more..
30: Pediatric Traumatic Brain Injury ■ 347TABLE 30.6 Rehabilitation Checklist for FamiliesTechnology training:Tracheostomy careNasogastric (NG) or gastrostomy (G) tube careVentilator careFamilies should be trained in the care of tracheostomies, their replacements, identification of mucous plugs, and ensuring adequate supplies at home. Ideally two caregivers should be trained. (This is per the American Thoracic Society recommendations, 2012.)Gastrostomy tube or NG tube care should be suitable read more..
348 ■ II: Core Clinical CompetenciesTalking to families in a nonthreatening manner and maintaining a compassionate attitude are supportive in the care.PrOFeSSiOnaLiSMGOaLSReflect a commitment to carrying out professional responsibili-ties and an adherence to ethical principles in pediatric TBI.OBJeCtiVeS1. Demonstrate humanistic qualities of integrity, respect, com-passion, ethics, and courtesy in the care of the child and ado-lescent with a brain injury.2. Exemplify patient-centered care, read more..
30: Pediatric Traumatic Brain Injury ■ 349in communicating with the other specialists and helping coordi-nate care. The family may have difficulty in comprehending that their loved one is not as before. Hence, expectations may still be that the patient will function at the same level as prior to the injury. This can cause a lot of angst and anger with the situation. Families have to be provided with information about the injury, interventions to manage the same, and the benefits versus risks read more..
350 ■ II: Core Clinical Competenciesstable but needs intensive therapies, this can be achieved with services in a day rehabilitation setting. Day rehabilitation set-tings provide consistent daily therapies, simulating an entire school or work day. Therapies provided usually include physical therapy, occupational therapy, speech therapy, and neuropsycho-logical services. School services also are incorporated during the day, as the patient works on increasing endurance. Outpatient therapies, on read more..
30: Pediatric Traumatic Brain Injury ■ 351minimize these risks. At the time of transfers, written docu-mentation of a list of medications, setting up of therapies, weight-bearing restrictions, type of feeds being given (via either a nasogastric tube or a gastrostomy tube), and docu-mentation of home health companies and durable medical companies can be helpful in providing a checklist for the families. Having the nurse call from an acute care setting to the rehabilitation unit can be helpful read more..
352 ■ II: Core Clinical CompetenciesSeLF-eXaMinatiOn QUeStiOnS(answers begin on p. 367)1. Which of the following medications is used in the treatment of spasticity in pediatric brain injury?A. AmoxicillinB. PropranololC. Carbolic acid 5%D. AmytryptilineE. Sertraline2. Signs of autonomic dysfunction after TBI includeA. ApneaB. HypotensionC. Decreased respirationsD. Sweating and posturingE. Hypothermia3. Which of the following assessment tools is most recom-mended to monitor patients in coma?A. read more..
Patient CareGOaLSProvide patient care that is compassionate, appropriate, and effective for the treatment of a child with juvenile idiopathic arthritis (JIA) and the promotion of good health.OBJeCtiVeS1. Describe the key components of the assessment of the child with JIA.2. Discuss the long-term outcomes of JIA.3. Assess the impairments, activity limitations, and participa-tion restrictions associated with JIA.4. Describe the psychosocial, vocational, and educational aspects of JIA.5. Describe read more..
354 ■ II: Core Clinical Competenciesantagonist canakinumab, and IL-6 inhibitor tocilizumab; and (e) history of intraarticular steroid injections.Current and Past Functional HistoryPhysiatrists should obtain a thorough current and past functional history. Some pertinent questions include the following: (a) How long does it take the child to get out of bed? (b) Is the pain worse after sitting or lying a while? (c) Compared to prior visits, what is the child’s activity level? (d) Is the child read more..
31: Juvenile Idiopathic Arthritis ■ 355in reaching and maintaining milestones. Weight-bearing exer-cise is not ideal for patients with large joint disease, and alterna-tive exercise therapies that can be tried include yoga and tai chi. The goal is not only to increase activity in the present but to also make healthy habits for a lifetime (6).PSYCHOSOCiaL, VOCatiOnaL, anD eDUCatiOnaL aSPeCtS OF JiaMost kids with JIA can expect to lead normal lives (7). However, at some point in the course of read more..
356 ■ II: Core Clinical Competenciesavascular necrosis of the femoral neck should be followed by early rehabilitation with adequate pain control. Provision of assistive devices like a long-handled sponge and long-handled hairbrushes can make independence in day-to-day activities more manageable. Occupational therapists can help with school modifications like frequent rest breaks, having two sets of text-books (one at home and one at school), reduced amount of writ-ing, extra time to move read more..
31: Juvenile Idiopathic Arthritis ■ 357extremities during the first 6 months of disease. It is also possible for only one joint to be involved, which is most often the knee (1). Approximately 50% of patients with oligoarthritis JIA proceed to develop extended disease, and within a few years are afflicted with polyarticular JIA. Oligoarthritis JIA is the most common subtype associated with chronic uveitis (1,9–11). Other differen-tial diagnoses should be considered if the patient displays a read more..
358 ■ II: Core Clinical CompetenciesIn the past, in order to evaluate the degree of joint inflam-mation and erosion, plain radiography was frequently employed. However, joint erosion is not made apparent on plain radiographs until there is substantial damage to the joint. There are joint scor-ing systems in place for adults suffering from chronic arthritis that are able to monitor joint destruction. These include the sim-ple erosion narrowing score (SENS) and Sharp/van der Heijde score (16). read more..
31: Juvenile Idiopathic Arthritis ■ 359One of the most common initial medications used in JIA treatment is NSAIDs (e.g., Naproxen, diclofenac, and ibupro-fen). Prescribers should be careful in prescribing Naproxen in fair-skinned children, as they are at risk for developing pseudo-porphyria cutanea tarda, a photodermatitis that may cause skin scarring. If patients require long-term NSAID use, then kidney and liver function tests must be followed carefully (20).JIA patients, specifically read more..
360 ■ II: Core Clinical CompetenciesCommon therapies used include copper bracelets, diet modifications, natural health products, and chiropractic. Popu-lar types of interventions include prayer, massage therapy, and meditation/relaxation.Pain is the common symptom for which CAM is chosen. Health care providers should be able to help the patient and family make a correct choice with regard to CAM and about its potential benefits and harm. An open dialogue should be main-tained with the read more..
31: Juvenile Idiopathic Arthritis ■ 361OBJeCtiVeS1. Describe key components of self-assessment and lifelong learning for the physiatrist with respect to continuing medical education (CME) and continuing professional development (CPD) as related to JIA.2. Teach patients, families, residents, students, and other health professionals regarding JIA.3. Identify benchmarks/best practices, and describe key practice-related systematic quality improvement (QI) markers and prac-tice performance read more..
362 ■ II: Core Clinical Competenciesplan including any precautions (e.g., weight-bearing restrictions). The documentation should be dated, timed, and written in leg-ible handwriting with an easily recognizable signature for the provider if electronic medical records are not available.It is important to also document patient and family educa-tion. The patient’s key family members should be educated about (a) weight-bearing status; (b) recommended medical, surgical, and rehabilitative read more..
31: Juvenile Idiopathic Arthritis ■ 363The rehabilitation of a child with JIA can be achieved in an inpatient rehabilitation setting, subacute setting, outpatient ther-apy setting, or home health setting. Once the child has been stabi-lized from an acute inpatient medical setting, the appropriateness of determining the rehabilitation process sets in. In the acute medical setting, the rheumatologist and the hospitalist are more of the key members of the team. Once the child is transferred to read more..
364 ■ II: Core Clinical CompetenciesDescribe the key elements of the rehabilitation treatment plan for this child if she is diagnosed with JIA.MEDICAL KNOWLEDGE. What are the different types of JIA? Describe the epidemiology and the important laboratory param-eters in JIA.PRACTICE-BASED LEARNING AND IMPROVEMENT. What are the important areas to educate patients and families about JIA?INTERPERSONAL AND COMMUNICATION SKILLS. Describe the importance of communicating with families. Identify the read more..
31: Juvenile Idiopathic Arthritis ■ 365 24. http://www.rheumatology.org/ACR/practice/-Re- Accessed on 6-19-14 25. Duffy CM. Measurement of health status, functional status, and quality of life in children with JRA: clinical science for the pedia-trician. Rheum Dis Clin North Am. 2007;33:389–402. 26. Martin RW. Communicating the risk of side effects to rheumatic patients. Rheum Dis Clin North Am. 2012;38:653–662. 27. Crossing the Quality Chasm; 2001. 28. read more..
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Chapter 2: the Use of Narrative MediCiNe aNd refleCtioN for praCtiCe-Based learNiNg aNd iMproveMeNt1. Correct answer: D. All levels of learners (students, residents, fellows, and professionals) can benefit from deliberately focusing on their clinical experiences and using narrative as a tool to both begin the reflective process and to enhance it as they process their own learning during a clinical encounter.2. Correct answer: A. To promote “reflection on action,” which Donald Schon promotes read more..
368 ■ Answerswith future practice? Will reflective learning or reflective skill building be an explicit focus of the exercise? Is one of the goals to identify learning or practice needs and strategies to address them?— From Aronson, L. Twelve tips for teaching reflection at all levels of medical education. Med Teach 2011; 33: 200–205.The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights read more..
Answers ■ 369cycle is a process for conducting quality and continuous prac-tice improvement. Kern’s six-step approach is one of the best tools to use when developing a curriculum. Kirkpatrick is well known for articulating four levels of evaluation (perceived reaction change, learning change, translation to behavior change, and results or learning outcomes). Moore, Cervero, and Fox contributed to a conceptual model for continuing medical education (CME).6. Correct answer: E. All the methods read more..
370 ■ Answersdeveloped a Code of Conduct for the practice of rehabilita-tion medicine. This code is meant to “serve as a guideline for professional and personal behavior and to promote the highest quality of physiatric care.” The code is meant to outline ethi-cal practice for physiatrists. The code addresses relationships between physiatrists and their patients and families, members of the rehabilitation team, other physicians, and the commu-nity and government. It also addresses research read more..
Answers ■ 3714. Correct answer: D. The most important person on any health care team is the patient. Patient-centric models are now being adopted across the health care industry as evidenced in Patient Aligned Care Teams (PACTs) in the VA.5. Correct answer: B. Hand transplants are a major undertak-ing and are not the answer for everyone. They are considered when there are multiple amputations, particularly in military-related injuries. The screening for hand transplants is complex and needs to read more..
372 ■ AnswersPatient education about this is important to reassure a patient that the altered responses are normal post transplant and to allow them to incorporate longer warm-up and cool-down periods for exercise.Chapter 12: CaNCer rehaBilitatioN1. Correct answer: B. Cisplatin is a platinum-based compound that is used to treat metastatic testicular and ovarian cancers and advanced bladder cancer. It has been linked with dose-related and cumulative nephrotoxicity, ototoxicity, read more..
Answers ■ 3732. Correct answer: C. This patient has chronic daily posttrau-matic migraine headache that is interfering with his function. At this point, he requires not only an abortive but also a pro-phylactic treatment because his headaches are daily.3. Correct answer: D. Obstructive sleep apnea is often seen after a traumatic brain injury. Headache upon awakening from sleep and unrefreshed sleep are some of the symptoms that may raise suspicion of sleep apnea. In addition to treatment of read more..
374 ■ Answersappearance. Many patients are not aware of their myotonia but it usually can be seen on examination when there is delayed relaxation of the fingers after forceful hand grip. Percussion of muscle groups gives rise to a delayed relaxation. Associ-ated manifestations include cataracts, mild mental retarda-tion, infertility, and cardiac arrhythmias/cardiomyopathy.5. Correct answer: D. Acetylcholine receptor at the postsynap-tic neuromuscular junction causes destruction of the read more..
Answers ■ 3752. Correct answer: C. The common life span of the majority of joint replacements is approximately 10 to 20 years in 90% of patients.3. Correct answer: C. Antibiotics serve to both protect and treat bacterial infections associated with surgery. Antibiotics do not directly affect the other complications of bone frac-tures, joint dislocations, contractures, and joint pain.4. Correct answer: E. All of these diseases can cause joint pain in adults, including the hip joint.5. Correct read more..
376 ■ Answerstheir full range and an ROM of 5° to 115° would be found on examination.4. Correct answer: C. Corticosteroid injections for tendon-itis can have both short- and long-term complications. Short-term complications include shrinkage (atrophy) and lightening of the color (depigmentation) of the skin at the injection site, introduction of bacterial infection into the body, local bleeding from broken blood vessels in the skin or muscle, and aggravation of inflammation in the area read more..
Answers ■ 3775. Correct answer: B. Anakinra (Kineret®) is the only IL-1 inhibitor. Etanercept (Enbrel®), Infliximab (Remicade®), and Adalimumab (Humira®) are TNF-alpha blockers. Gabapentin (Neurontin®) is a GABA analog used to treat neuropathic pain and epilepsy.Chapter 26: fiBroMyalgia1. Correct answer: D. Chronic widespread pain is character-ized as pain for a minimum of 3 months’ duration in all four quadrants of the body, including the axial skeleton. The pain must be present on read more..
378 ■ AnswersChapter 29: eNtrapMeNt NeUropathies1. Correct answer: B. Anterior or anterolateral approaches to total hip replacements are a rare but likely underreported cause of femoral neuropathies. The femoral nerve enters the thigh lateral to the femoral vessels approximately 1 to 4 cm distal to the inguinal ligament, where it is vulnerable to compression, traction, and stretch injuries. Injuries to the tensor fascia lata muscle and lateral femoral cutaneous nerve may, in fact, be more read more..
Answers ■ 379Chapter 31: jUveNile iNflaMMatory arthritis1. Correct answer: D. Asymmetric limb use, blurred vision suggesting uveitis, fine motor skill problem, and joint swell-ing are all seen with JIA. Isolated musculoskeletal pain is nonspecific and does not signify JIA, as it can be seen with viral infections, fatigue, and generalized malaise.2. Correct answer: A. CHAQ correlates with the patient’s/parent’s perception of pain, well-being, level of disease, and functional status. It read more..
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IndexAAN. See American Academy of NeurologyAAPMR. See American Academy of Physical Medicine and Rehabilitation“ABC” approach, cervical radiculopathy, 316abductor pollicis longus (APL), 269ACA syndrome. See anterior cerebral artery syndromeAccreditation Council for Graduate Medical Education (ACGME), 3, 16, 317competency of professionalism, 9competency protocols, 71NAS and educational milestones, 32–33program requirements, 7residency programs, 3supervision levels, 44–46ace wrapping, read more..
382 ■ Indexrheumatoid arthritis (RA), 300spasticity, 266spinal cord injury (SCI), 198–199stroke, 162total hip arthroplasty (THA), 254–255total knee arthroplasty (TKA), 254–255traumatic brain injury (TBI), 175, 351–352upper extremity limb loss, 97upper extremity musculoskeletal injuries (UEMIs), 275–276cauda equina syndrome (CES), 193CBT. See cognitive behavioral therapyCCC. See clinical competency committeeCCS. See central cord syndromeCDT. See complex decongestive therapyCenter for read more..
Index ■ 383de Quervain tenosynovitis, 269DESC Communication Model, 24–25detail complexity, 72diazepam (Valium), 260didactic lecture presentations, 38–39diffusion of the lung for carbon monoxide (DLCO), 116disruptive behavior, 69distraction tests, 280DNR/DNI. See do not resuscitate/do not intubatedoctor-patient visit, issues during, 18do not resuscitate/do not intubate (DNR/DNI), 204double swallow technique, 207dynamic complexity, 72dysfunctional listening behavior, 23dysfunctional speaking read more..
384 ■ Indexformal physical therapy, 280formative evaluation, 43Foundation for Education in Research in Neurological Emergencies (FERNE), 171four-box model, 57functional capacity evaluation (FCE), 280GARS. See Groningen Activity Restriction ScaleGCS. See Glasgow Coma ScoreGlasgow Coma Score (GCS), 155glucocorticoids, 293government relationships, community and, 69graduate medical education, 71–73Groningen Activity Restriction Scale (GARS), 106hand disordersmedical knowledge, 271patient care, read more..
Index ■ 385interpersonal and communication skills (ICS), 84–85qualities, 83–84vision and foresight, 84learningcontinuum over life span, 36principles and practice, adult, 36retention pyramid, 37rules for, 39styles, 37levels of needs, 19–20levels of questioning, 41listening, 22–23behaviors, 23LMN. See lower motor neuronLMWH. See low-molecularweight heparinlower extremity amputee (LEA), 91case study, 110interpersonal and communication skills (ICS), 106–108K-level rating with read more..
386 ■ Indexmotor neuron disease, 214MS. See multiple sclerosisMSAA. See Multiple Sclerosis Association of AmericaMTBI. See mild traumatic brain injurymultigenerational workforce, 34attributes, 35multiple sclerosis (MS)case study, 232cost-benefit considerations in, 232diagnostic testing in, 226–227ethical issues in care of, 228impairments, activity limitations, and participation restrictions in, 224–225interpersonal and communication skills (ICS), 229–230medical knowledge, read more..
Index ■ 387cervical radiculopathy, 314–315coordination, 74entrapment neuropathies, 229–331fibromyalgia, 303–305lumbar spine disorders, 278–280multiple sclerosis (MS), 223–225neuromuscular diseases (NMDs), 211–213osteoarthritis, 235–238Parkinson disease, 200–202preparticipation evaluation (PPE), 322–323rheumatoid arthritis (RA), 288–290spasticity, 257–258stroke, 144–151total hip arthroplasty (THA), 248–251total knee arthroplasty (TKA), 248–251traumatic brain injury read more..
388 ■ Indextotal hip arthroplasty (THA), 253total knee arthroplasty (TKA), 253traumatic brain injury (TBI), 348–349moderate and severe, 173–174upper extremity limb loss, 95–96upper extremity musculoskeletal injuries (UEMIs), 273–274proprioceptive technique, 150prospective payment system (PPS), 73prospective surveillance model (PSM), 134PSM. See prospective surveillance modelpsychomotor skills, 41–42pulmonary anatomy, cardiopulmonary rehabilitation, 115–116pulmonary physiology, read more..
Index ■ 389medical knowledge, 270patient care, 267–269sign-out/transition of care, 161simple erosion narrowing score (SENS), 358simulation tests, 280situation monitoring, 273skilled nursing facilities (SNFs), 73–74IRF versus, 76skills checklist, 38–39SNAPPS, 40–42six-steps, 40social justice, 56socioeconomic issues in cancer rehabilitation, 136somatosensory evoked potential (SSEP), 170spasticity, 149, 340case study, 266defined, 260, 341interpersonal and communication skills (ICS), read more..
390 ■ Indextotal hip arthroplasty (THA)case study, 254–255interpersonal and communication skills (ICS), 252–253medical knowledge, 251–252patient care, 248–251practice-based learning and improvement (PBLI), 252professionalism, 253systems-based practice (SBP), 253–254total joint arthroplasty in lower extremities, injuries following, 250–251total knee arthroplasty (TKA)case study, 254–255interpersonal and communication skills (ICS), 252–253medical knowledge, 251–252patient care, read more..
Index ■ 391systems-based practice (SBP), 274–275upper motor neuron disorders (UMNDs), 258urinary incontinence, 149VA/DoD clinical guidelines, 106venous thromboembolism (VTE), 250prophylaxis, 168ventilatory failure, assessment of, 125ventilatory support, indications for, 125verbal read-back procedures, 23vertebrobasilar system, 155Veterans Affairs Amputee System of Care, 110Visual Teaching Strategies (VTS), 10vital capacity (VC), 116VTE prophylaxis. See venous thromboembolism prophylaxisVTS. read more..
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