Physiatric Practice Research Articles

Poster 124: Deep Venous Thrombosis Masquerading as Neurogenic Claudication: A Case Report

Setting: Outpatient physiatric practice. Patient: A 70-year-old male neurologist. Case Description: A 70-year-old male neurologist was referred to physiatry by an orthopedist, requesting nonsurgical management of neurogenic claudication. The patient complained of anterolateral left calf pain that was worse with ambulation. The orthopedist had obtained lumbar magnetic resonance imaging (MRI), which showed severe spinal stenosis at L3-4 and moderate spinal stenosis at L4-5. But physiatric physical exam revealed tenderness to palpation of the left proximal calf and the symptoms were not exacerbated by lumbosacral extension. Also, there were no motor, sensory, or reflex deficits. He was sent for lower-extremity Dopplers to rule out a deep venous thrombosis (DVT). The Dopplers revealed an acute left popliteal DVT. Assessment/Results: A left lower-extremity DVT was diagnosed as the cause of his presenting symptoms. He was treated with anticoagulation, with an excellent outcome. Discussion: As physiatrists become increasingly specialized, we must remember that life-threatening medical conditions may present similarly to common musculoskeletal and neurologic conditions. The case also excellently illustrates the importance of performing a careful history and physical exam, rather than relying primarily on diagnostic testing such as MRI. Specifically, in this case, an orthopedist and a neurologist had assumed, based on MRI findings, that the symptoms were due to spinal stenosis. Failure to properly diagnose the DVT could have led to an unnecessary spine surgery or, more acutely, could have led to life-threatening complications of an untreated DVT. Conclusions: Life-threatening medical conditions such as DVT can masquerade as common musculoskeletal and neurologic conditions seen in the outpatient physiatry setting. A careful history and physical exam is crucial prior to attributing symptoms to abnormalities found on MRI.

Efficacy and Safety of Hyaluronan Treatment in Combination Therapy With Home Exercise for Knee Osteoarthritis Pain

Stitik TP, Blacksin MF, Stiskal DM, Kim JH, Foye PM, Schoenherr L, Choi E-S, Chen B, Saunders HJ, Nadler SF. Efficacy and safety of hyaluronan treatment in combination therapy with home exercise for knee osteoarthritis pain. Objective To assess the efficacy and safety of intra-articular injections of sodium hyaluronate combined with a home exercise program (HEP) in the management of pain associated with osteoarthritis (OA) of the knee. Design Single-blinded, parallel-design, 1-year clinical study with sequential enrollment. Setting University-based outpatient physiatric practice. Participants Sixty patients (18 men, 42 women; age, ≥50y) with moderate-to-severe pain associated with OA of the knee. Interventions (1) Five weekly intra-articular hyaluronate injections (5-HYL); (2) 3 weekly intra-articular hyaluronate injections (3-HYL); or (3) a combination of an HEP with 3 weekly intra-articular hyaluronate injections (3-HYL+HEP). Main Outcome Measures The primary outcome measure was a 100-mm visual analog scale for pain after a 50-foot walk (15.24m). Secondary measures included the Western Ontario and McMaster Universities Osteoarthritis Index subscales. Results The 3-HYL+HEP group had significantly faster onset of pain relief compared with the 3-HYL ( P<.01) and 5-HYL groups ( P=.01). All groups showed a mean symptomatic improvement from baseline (reduction in baseline pain at 3mo was 59%, 49%, and 48% for the 3-HYL+HEP, 3-HYL, and 5-HYL groups, respectively) that was clinically and statistically significant. There were no between-group differences in the incidence or nature of adverse events. Conclusions The combined use of hyaluronate injections with HEP should be considered for management of moderate-to-severe pain in patients with knee OA.

Pharmacological management of neurobehavioural sequelae of traumatic brain injury: A survey of current physiatric practice

Objective: To describe pharmacological preference for the treatment of neurobehavioural sequela of traumatic brain injury (TBI).Design: Survey.Participants: TBI physiatrists were divided into specialists (completed a TBI fellowship or commit >70% of clinical practice time to TBI) and non-specialists.Outcome measures: Participants were asked to list the drugs most frequently prescribed for each of 15 neurobehavioural symptoms commonly encountered during TBI rehabilitation and enumerate neurobehavioural symptom for which they prescribed each listed drug or drug class.Results: There was no clear consensus on drug of choice for each target symptom. There were differences in drug choice patterns between specialists and non-specialists, especially for agitation.Conclusion: There is limited uniformity in drug selection for various TBI neurobehavioural sequela. Potential explanations include the availability of various medications with similar clinical effect, the variability of clinical presentation and severity of neurobehavioural symptoms and the lack of clinical practice guidelines.

PR_115: A Randomized Double-Blinded Crossover Trial of Acromioclavicular Joint Intra-Articular Sodium Hyaluronate for the Treatment of Chronic Shoulder Pain Due to Acromioclavicular Joint Osteoarthritis

Objective: To evaluate the effects of intra-articular sodium hyaluronate injections for chronic shoulder pain from acromioclavicular joint (ACJ) osteoarthritis (OA). Design: Randomized double-blinded crossover trial. Setting: University-based outpatient musculoskeletal physiatric practice. Participants: 19 subjects with chronic shoulder pain were enrolled as their pain was primarily due to ACJ OA, based on a positive response (>50% pain relief within 20min) after a diagnostic ACJ injection. Interventions: 3 weekly fluoroscopically guided intra-articular injections of sodium hyaluronate or saline, and monthly follow-up visits were conducted.

Office-Based Ultrasound-Guided Intra-Articular Hip Injection: Technique for Physiatric Practice

Smith J, Hurdle M-FB. Office-based ultrasound-guided intra-articular hip injection: technique for physiatric practice. Intra-articular hip injections are commonly used in the evaluation and treatment of hip disorders. Although these injections are typically performed with fluoroscopic guidance, ultrasound provides a viable alternative for ensuring accurate intra-articular needle placement. This report describes the technique for performing ultrasound-guided intra-articular hip injections in the context of an office-based physiatric practice. Ultrasound offers several advantages over fluoroscopy, including accessibility, compact size, lack of ionizing radiation exposure, and visualization of neurovascular and other soft-tissue structures. With appropriate training and experience, interested physiatrists can consider implementing ultrasound-guided injections into their clinical practices.

Primary Care Practitioners’ Understanding of Physiatric Practice: Effects on Intention to Refer

McKenna C, Farber NJ, Eschbach KS, Collier VU. Primary care practitioners’ understanding of physiatric practice: effects on intention to refer. Objectives To learn what family practice and internal medicine physicians understand about the scope of practice of physical medicine and rehabilitation (PM&R) and to study what effect that understanding and various demographic variables have on their intention to refer to physiatrists. Design Survey-based. Setting National survey. Participants One thousand internal medicine and family practice physicians were contacted, with 460 respondents. Interventions Not applicable. Main outcome measures Intention to refer patients to physiatrists using 13 case scenarios (10 appropriate referrals, 4 inappropriate referrals) and self-reported number of referrals per year associated with understanding of 7 skills of physiatrists analyzed by multiple logistic regression analyses. Results Although most respondents were likely to refer to physiatrists, a wide variation existed in the types of patients referred. Physicians with a greater understanding of the scope of physiatric practice were more likely to refer ( P=.003). Female physicians were more likely to refer than male physicians ( P=.003). Conclusions There appears to be an association between an understanding of physiatric practice and primary care practitioners’ willingness to refer to PM&R. Primary care physicians should be educated about the benefits of referring patients to physiatrists.

Rehabilitation of orthopedic and rheumatologic disorders. 4. Rheumatoid arthritis and calcium pyrophosphate deposition disease

Shih VC, Kamen LB, Kaplan RJ, Stitik TP, Bitar AA, Vo AN. Rehabilitation of orthopedic and rheumatologic disorders. 4. Rheumatoid arthritis and calcium pyrophosphate deposition disease. This self-directed learning module highlights a clinical vignette of 2 patients: (1) a woman with bilateral, distal, upper-limb pain assessed by differential diagnosis, laboratory work-up, and treatment of rheumatologic disorders frequently seen in the physiatric practice setting and (2) a 57-year-old man with an acute recurring monoarthritis of the knee and addresses clinical presentation, assessment, medical management, and rehabilitation approaches. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on 2 aspects: (1) the differential diagnosis of polyarthralgia, distal upper-limb pain, criteria for classification of rheumatoid arthritis, synovial fluid analysis, and comprehensive treatment of rheumatoid arthritis, both pharmacologic and nonpharmacologic and (2) the differential diagnosis, clinical diagnostic considerations, current pharmacotherapy, invasive procedure options, and orthotic and exercise interventions for a patient with calcium pyrophosphate dehydrate-induced monoarthritis of the knee. Overall article objectives (a) Clinical evaluation, diagnosis, management, and rehabilitation strategies in persons with initial presentations of inflammatory distal upper-limb pain and (b) clinical evaluation of an individual with crystal-induced monoarthritis and differentiation of the pathophysiology, assessment, and treatment of chondrocalcinosis.

3. New frontiers in pain management: Complementary techniques

Braverman DL, Ericksen JJ, Shah RV, Franklin DJ. Interventions in chronic pain management. 3. New frontiers in pain management: complementary techniques. Arch Phys Med Rehabil 2003;84 Suppl 1:S45-9. This self-directed learning module highlights complementary and alternative therapies that are often used by patients seen in the typical physiatric practice. This article contains information on acupuncture and its use to treat low back pain, recent therapeutic approaches to lateral epicondylitis, movement therapies appropriate for the osteoporotic patient, and spa therapies. Scientific literature and standards of clinical practice in these areas have been reviewed to put forth the most recent recommendations regarding these diagnoses and therapeutic interventions. Overall Article Objectives: (a) To familiarize the physiatrist with complementary techniques that are increasingly popular in the United States and (b) to identify when therapies, such as acupuncture, movement therapies, bodywork, and the like, may be integrated into a comprehensive treatment approach for common physiatric clinical scenarios.

Delineation of clinical privileges in rehabilitation medicine

Toerge JE, Soni SS, Bleiberg J. Delineation of clinical privileges in rehabilitation medicine. Arch Phys Med Rehabil 2001;82:700-1. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) in 1995 developed a list of 75 clinical privileges (in laundry-list format) that are typical of physiatric practice. This list has been used by some hospitals as a template for physiatric staff privileging. The National Association of Medical Staff Services has advocated a short list of core privileges, supplemented by a list of highly specialized procedures. To assess current practices in physiatric privileging, we surveyed 35 rehabilitation facilities. Results showed that 66% (20/30) of the respondents were not aware of the AAPM&R recommendations. Furthermore, we found an almost even split between facilities using core (16/30) versus laundry list (14/30) privileges. We also found evidence that the Joint Commission on Accreditation of Healthcare Organizations has recommended both types of approaches to different facilities in the recent past. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Cardiopulmonary rehabilitation and cancer rehabilitation. 2. Cardiac rehabilitation in disabled populations

Rashbaum IG, Walker WC, Glassman SJ. Cardiopulmonary rehabilitation and cancer rehabilitation. 2. Cardiac rehabilitation in disabled populations. Arch Phys Med Rehabil 2001;82 Suppl 1:S52-5. This self-directed learning module highlights the clinical characteristics, medical treatment, and rehabilitation interventions of several cardiac scenarios encountered in physiatric practice. It is part of the chapter on cardiac rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses myocardial infarction during amputation, stroke as a result of cardiac surgery, myocardial perfusion defects in spinal cord injury, and heart murmur in Down syndrome. It also covers current medical management and the benefits of comprehensive rehabilitation and interventions for specific impairments seen in these conditions. Overall Article Objective: To describe the clinical characteristics, medical treatment, and rehabilitation interventions of 4 cardiac scenarios encountered in physiatric practice.

Cardiopulmonary Rehabilitation and cancer rehabilitation. 2. Cardiac rehabilitation in disabled populations

This self-directed learning module highlights the clinical characteristics, medical treatment, and rehabilitation interventions of several cardiac scenarios encountered in physiatric practice. It is part of the chapter on cardiac rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses myocardial infarction during amputation, stroke as a result of cardiac surgery, myocardial perfusion defects in spinal cord injury, and heart murmur in Down syndrome. It also covers current medical management and the benefits of comprehensive rehabilitation and interventions for specific impairments seen in these conditions. Overall Article Objective: To describe the clinical characteristics, medical treatment, and rehabilitation interventions of 4 cardiac scenarios encountered in physiatric practice.

Neuromuscular rehabilitation and electrodiagnosis. 1. Central neurologic disorders

This self-directed learning module highlights the medical treatment and rehabilitation intervention of certain central neurologic disorders encountered in physiatric practice. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on multiple sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis. Information covered in these sections includes discussions of the current medical management and the benefits of comprehensive rehabilitation and interventions for specific impairments seen in these conditions.

Antihypertensives

Management of hypertension requires a thorough knowledge of currently available antihypertensive drugs. This article reviews the mode of action of the major classes of antihypertensives, indications for their use, and adverse effects. The main emphasis is placed on their use, in physiatric practice.

Use of alternative therapies by rehabilitation outpatients

Objective: To document the prevalence and patterns of use of alternative medical therapies as well as their perceived effectiveness by patients in a rehabilitation medicine outpatient practice. Design: Cross-sectional survey by written questionnaire. Setting: An urban rehabilitation medicine outpatient referral office. Patients: A random sample of 103 patients referred for rehabilitation outpatient care, while waiting for their appointment, were given a questionnaire addressing their use of alternative therapies. Main Outcome Measures: Use of alternative therapies and their perceived effectiveness. Results: One or more alternative medical therapies had been used by 29.1% of subjects in the past 12 months for their presenting problem. The most common therapies were massage, chiropractic, vitamin and mineral supplementation, and acupuncture. Musculoskeletal pain syndromes involving the spine and extremities were the most common problems for which patients sought both physiatric and alternative care. Of the patients who used alternative treatments 53% reported some degree of efficacy. Conclusions: A significant proportion of rehabilitation medicine patients use and frequently perceive a benefit from alternative therapies, particularly massage, chiropractic, vitamin and mineral supplementation, and acupuncture. Incorporating alternative therapies into physiatric practice is a desirable future direction for the specialty.

The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 3. Consolidating the position (1948–1953)

This article is a continuation of the story of the struggle to win recognition of physical medicine and rehabilitation as a medical specialty, as told in the pages of a daily diary kept by Frank H. Krusen, MD, from 1943 through 1967. The first two articles described Dr. Krusen's professional development before 1943, his efforts to establish a certifying Board for physiatrists, and the role of the Baruch Committee on Physical Medicine in Krusen's eventual successes. This article focuses on how Krusen and his physiatric colleagues campaigned to gain acceptance by organized medicine of the new specialty, to unite the fields of physical medicine and rehabilitation, and to identify and maintain the scope of physiatric practice despite challenges from other specialties.

The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 4. Triumph over adversity (1954–1969)

This article, the last of four based on the diary of Dr. Frank H. Krusen, picks up the story of physiatry's conflict with other medical specialty groups within the American Medical Association. The conflict was focused on PM&R's use of the term “rehabilitation,” but the underlying motive of groups opposing physical medicine was to limit the scope of physiatric practice. Dr. Krusen organized a well-documented and successful defense of the specialty and opened the door to the development of comprehensive care of persons with disabilities. Also related here are Dr. Krusen's legislative and public relations contributions to PM&R from 1963 until his retirement from Tufts-New England Medical Center in 1969. Dr. Krusen retired to Cape Cod and died there in 1973.

Development of an objective structured clinical examination (OSCE) for physical medicine and rehabilitation residents.

Clinical competency is poorly measured by knowledge-based written examinations. A five-station, four-interstation objective structured clinical examination (OSCE) has been developed in consultation with the National Board of Medical Examiners as a pilot study to standardize assessment methods that serve to evaluate the clinical competency of senior physical medicine and rehabilitation residents. Various stations demonstrating musculoskeletal and neurologic conditions commonly encountered in physiatric practice were included, incorporating the use of standardized patients into the OSCE format. This is a descriptive study of individual stations-evaluated history-taking, physical examination, and communication skills, whereas the interstations measured the residents' ability to write therapy and prosthetic/orthotic prescriptions, as well as interpret x-ray and electrodiagnostic data. The OSCE program development including case background, principal tasks, time allotment, evaluation objectives, performance criteria, therapeutic plan, standardized patients case descriptions, and assessment checklists as well as the training procedure is discussed. Additionally, cost analysis and scheduling issues are reviewed. This information should aid other training programs or consortiums in developing similar clinical evaluation tools.

Role of Strategic Planning in Physiatric Practice

Strategic planning in physiatric practice is the key to survival in the new health care environment. The basis of strategic planning is the establishment of sound vision that incorporates consideration of the changing environment and the practice’s strengths, weaknesses, and objectives. Key factors involved in strategic planning include participation of all physicians in the practice and consideration of all elements of environmental influences.

Integrating the Parts to form a Delivery System: Putting It All Together: Physiatric Practice in an Era of Managed Care

The health care environment is undergoing a rapid evolution from a "cottage industry" to a managed care industrial basis. To succeed in this managed care setting, physiatrists must be able to involve increasingly the use of outcomes methodologies. Rehabilitation and physiatry have essential contributions to make to this emerging cost-benefit system.

The Health Care Environment and Physiatric Practice

The future health care environment will demand that physiatrists serve more patients, achieve improved outcomes, and use fewer resources per case. These demands will result in altered patterns of service delivery and payment. For the foreseeable future, practices will deal with significant variation among the organizations controlling their payments. Physiatrists will succeed if they can show to payers that they contribute significantly to clinical outcomes and cost savings when managing high-cost cases.