Physical Medicine Specialists Research Articles

Reflecting the World Report on Disability

There is a range of statistics in Sweden regarding people with functional limitations available from different authorities presenting diverging information. Although healthcare and social welfare legislations aim for equal access and treatment, surveys about unmet needs show that opportunities for rehabilitation are unequal among diagnoses and around the country and insufficient in the long-term. There is also a law granting certain supports and services to those people who are considered to be in need of having someone to speak for them. Disability-related services are tax financed with a symbolic fee. Rehabilitation is performed by not only physical and rehabilitation medicine specialists. Rehabilitation research is mainly within healthcare science but also in social science. Disability services need better coordination, and an agency has recently been founded with this responsibility. More politicians should engage in disability-related issues, and more people with disability should get into politics.

The Effect of Teaching Practical Physical Modalities on the Ordering Skills of Residents in Physical Medicine and Rehabilitation

Introduction: Physical modalities are performed by physiotherapists based on physiatrists’ orders, so the residents pay less attention to the need and importance of learning the practical modalities. The aim of this study was to determine the effect of teaching the practical aspects of modalities to residents of Physical Medicine and Rehabilitation in order to improve their skills and attitudes toward ordering and doing physical modalities. Methods: In an interventional, before after study, all residents of physical medicine and rehabilitation, took the medical history of the patients willingly participatedand performed physical examinationand ordered physical modalities. They were also assessed by performing the modalities on the patient. Following the primary assessment, an experienced physiotherapist taught the residents how to do physical modalities. After the practical education, residents were assessed by ordering the modalities and performing them on simulated patients. Their satisfaction of the educational program was evaluated after the intervention. Results: The mean scores of using modalities before and after the education were 23.08± 5.50 and 52±10.18 respectively (p=0.0001). The mean scores of ordering the modalities before and after the education were 1 and 1.66 (p=0.038). The mean score of satisfaction was 91.66±8.74 out of 100. Conclusion: Since physical medicine and rehabilitation residents and specialists who order physical modalities for patients do not perform it on their own patients, teaching the practical physical modalities can improve their skills. The satisfaction rate of residents with the course was very high.

Clinicians' Attitudes and Beliefs About Opioids Survey (CAOS): Instrument Development and Results of a National Physician Survey

Beliefs surrounding the use of opioids for chronic noncancer pain have vacillated over time. Concerns regarding long-term efficacy and adverse effects of opioids, along with increases in opioid prescribing, have contributed to many political, regulatory, and clinical responses. The present study was designed to 1) develop a reliable and valid measure (Clinicians' Attitudes about Opioids Scale [CAOS]) to assess current and evolving beliefs regarding opioids and opioid use in patients with chronic pain; and 2) survey these beliefs in a nationally representative sample of providers from multiple medical specialties throughout the United States. We developed the questionnaire in 3 phases: 1) focus groups and content development; 2) pilot testing and subsequent revisions; and 3) formal survey (N = 1,535) and assessment of stability (N = 251). The resulting 38-item measure assessed 5 domains: 1) Impediments and Concerns; 2) Perceived Effectiveness; 3) Schedule II versus III Opioids; 4) Medical Education; and 5) Tamper Resistant Formulations. No significant differences were identified among geographical regions; however, several differences were observed among medical specialties. Orthopedists were most troubled by impediments/concerns from long-term opioid use and had the least confidence in opioid efficacy, whereas Pain Medicine specialists and Physical Medicine and Rehabilitation specialists were the most confident in efficacy. PerspectiveThis article presents the psychometric properties of a new measure of clinicians' beliefs surrounding opioid use for chronic pain. Using this measure, beliefs and behaviors of physicians across medical specialties and geographic regions using a nationally representative sample are presented, updating findings from a similar survey conducted 20 years ago.

The role of physical and rehabilitation medicine specialist in lymphoedema

The role of physical and rehabilitation medicine specialist in lymphoedema

How Well the ICF Concepts of Functioning, Capacity and Performance are known Amongst the Finnish Specialists in Physical and Rehabilitation Medicine?

Purpose: To investigate how well Finnish specialists in physical and rehabilitation medicine (PRM) are familiar with ICF-based concepts of functioning, capacity, and performance. Methods: In February 2013, the 5-minute survey was conducted amongst participants at the annual meeting of the Finnish Society of PRM. The 54 participants (response rate 81%) were asked to define the difference between concepts of functioning and capacity/performance. They were also asked to give some examples of medical tests related to these concepts. Two independent researchers evaluated the responses basing on appropriate definitions presented by ICF and researchers own experience. Results: Of respondents, 83% were able to define the concept of functioning accordingly to the ICF framework as a complex relationship between health condition and contextual factors. Instead, only 24% were capable to describe concept of capacity/performance as an ability to execute single tasks in a standard or current environment. Of respondents, 40% emphasized the physical dimension of performance. Over 80% of respondents suggested at least one test for assessment of the level of performance, but only 57% introduced an example of tests for measuring limitation of functioning. Conclusions: The ICF-based concepts of functioning and performance were not widely used amongst Finnish physicians specialized in PRM even if the responses to survey reflected the biopsychosocial way of understanding the functioning.

A Multidisciplinary Rehabilitation Approach for Writer's Cramp: A Case Study

Abstract A 61 year-old male was referred from neurology to PMR department RML hospital, New Delhi, with difficulty in writing for 2 years prior to consultation. Initially difficulty in writing which is accompanied with pain after prolonged writing. Also he noticed tremor and stiffness while writing. Disability progressed and he was unable to write even a few words legibly and cannot hold object (spoon) which leads to anxiety and dependency. When the patient was examined at PMR OPD, EMG/NCV study was advised, which showed normal sensory and motor nerve functions. The present treatment involved the use of a multidisciplinary therapeutic approach with Physical Medicine and Rehabilitation Specialist, Clinical psychologist and Occupational Therapist which gave us satisfactory results within 6- 8 months. The findings in this case is very encouraging and studies with large sample sizes can be considered for further conclusive evidence on the treatment of writer's cramp.

Evaluation of cooperation between general practitioners and physical medicine and rehabilitation specialists

Evaluation of cooperation between general practitioners and physical medicine and rehabilitation specialists

Study of the counseling role of the Physical Medicine and Rehabilitation (PMR) specialist with patients initiating claims for damages on personal injury, analysis of 20 cases

Study of the counseling role of the Physical Medicine and Rehabilitation (PMR) specialist with patients initiating claims for damages on personal injury, analysis of 20 cases

Myofascial Low Back Pain

Low back pain is a common condition that is encountered by both primary care physicians as well as various specialists, which include: orthopedic surgeons, physical medicine and rehabilitation specialists, neurologists, rheumatologists, and pain management specialists. Associated muscular pain is very common and often a reactive response from nociception from other structures. Myofascial pain may arise, which is characterized by the presence of myofascial trigger points (MTrPs) that are located in fascia, tendons, and/or muscle. This article reviews the current evidence regarding the pathophysiology, assessment, and recommended treatment options for myofascial low back pain.

Department of acute geriatric and remobilisation under the direction of a specialist in physical medicine and rehabilitation

Department of acute geriatric and remobilisation under the direction of a specialist in physical medicine and rehabilitation

Consistency between physical medicine and rehabilitation specialists and a radiologist in interpretation of lumbosacral radiographs

To investigate intra- and inter-observer reliability among physical medicine and rehabilitation specialists and a radiologist in interpretation of plain lumbar spine X-ray films in patients with low back pain. Three assessors (A: a resident of PM&R, B: an experienced PM&R specialist, C: an experienced radiologist) read the standard lumbosacral plain radiographs of 79 patients with 2-3 month time interval. Each assessor recorded the presence or absence of abnormalities on the radiograph according to a standardized assessment form. For assessors B and C, all kappa values were > 0.40. Transitional vertebrae abnormalities reached to the highest agreement ratio. The intrarater agreement showed higher kappas than the interrater agreement. The radiologists had the highest intrarater agreement, closely followed by the experienced PM&R specialist. Agreement among three assessors was substantial in sacralisation, lumbarisation and facet joint pathologies. We usually obtained a good intrarater agreement, especially for the experienced PM&R specialist and the radiologist indicating that experience increases diagnostic consistency. Besides the systematic differences in radiographic interpretation between the assessors, institutional specific conditions (esp. patient profile and regularities) may cause the phycians to pay more attention to a specific group of pathologies.

Interobserver reliability of the Turkish version of the expanded and revised gross motor function classification system

Purpose: Cerebral palsy (CP) is the most common disability in childhood. The gross motor function classification system (GMFCS) has become an important tool to assess motor function in CP patient. In 2007, the expanded and revised (E&R) version of GMFCS which includes age band for youth 12–18 years of age was developed. The aim of this study was to evaluate reliability of Turkish version of expanded and revised GMCS. Methods: We assessed interobserver reliability between two physical medicine and rehabilitation specialists in 136 children with CP and test-retest reliability within a subgroup of 48 patients. Percent agreement, intraclass correlation coefficient (ICC) and μ statistics were used to evaluate reliability. Result: The ICC between two physicians was 0.97 and the total agreement was 89%. This result indicates excellent agreement. The overall weighted μ was 0.86. High test-retest reliability was found (ICC: 0.94 95% confidence interval) and the total agreement was 75% for test-retest reliability. Conclusion: The Turkish version of the E&R GMFCS is shown to be reliable and valid for assessment of Turkish CP children.Implications for RehabilitationCerebral palsy (CP) is the major developmental disability affecting function in children.Assessment of functional status of children with CP is important for planning treatment.The gross motor function classification system (GMFCS) can be considered to be a diagnostic tool for predicting motor development in children with CP based on self-initiated movement, emphasising on sitting, transfers and mobility. The expanded GMFCS includes an age band for youth 12–18 years of age.

Rehabilitación desde la perspectiva de atención primaria

The specialty of physical medicine and rehabilitation is largely unknown by primary care physicians, who are generally unfamiliar with the services’ portfolio of this specialty, leading to scarce interaction between the two levels of care. In addition, referral criteria vary widely, depending on the autonomous region, province and even health district. These obstacles reflect the need to improve coordination between health administration and health professionals, as well as to provide specific training courses taught by specialists in physical medicine and rehabilitation.

GEER, the Multidisciplinary Spanish Society for Spine Specialists

In 1981, a group of orthopedic surgeons and physical medicine and rehabilitation specialists founded the first multidisciplinary spine society in Spain, under the name of GIEDER (Grupo Iberico de Estudio de las Deformidades del Raquis or Iberian Group for the Study of Spinal Deformities). Eleven years later, this multidisciplinary group of physicians dedicated entirely to the assessment and care of patients with spinal disorders adopted a new name: GEER (Grupo de Estudio de Enfermedades del Raquis or Spinal Disorders Study Group). Since then, GEER has grown exponentially, during a time when health care delivery has changed rapidly and unpredictably, and spine care has been under the microscope [1]. Besides Europe, GEER has established close links with Latin America, and in the early 1990s founded with several South American Spine Societies SILACo (Sociedad Ibero Latino Americana de Columna or Iberian and Latin American Spine Society), the largest worldwide Spanish-speaking Spine Society. Nurtured by many outstanding leaders, GEER adopted very rapidly a proactive attitude that enabled it to enter adulthood as a highly respected professional society. Based on its awareness of the relevance of outcomes research in the new millennium, GEER sponsored several task forces in 2000 to standardize patient outcome assessment by developing validated Spanish outcome measures. As a result of this effort, the GEER Deformity Task Force published one of the first transcultural adaptations of the SRS-22 outcome measure [2] and participated actively in refining the final version [3, 4] before it became the global scoliosis outcome measure. Simultaneously, the GEER Back Pain Task Force provided the first available data [5, 6] on the psychometric characteristics of the Deyo Core Set Outcome Measure, further modified to become the COMI [7], the main outcome measure of the International EuroSpine Tango Registry. In addition, GEER has continuously improved its research and educational offer (http://www.geeraquis.org) and linked its website patient area to the Spanish version of the EuroSpine Patient Line. In May 2010, Patient Line was the most frequently visited area of the EuroSpine website, and Spanish documents were the ones most often accessed [8]. Since 2009, GEER has awarded grants to young trainees to complete the EuroSpine Education Program [9]. A few months ago the first graduates of these modular courses received their certificate, establishing a landmark in the effort to offer independent educational programs on the way to a Spine Specialist recognition in Europe. It is expected that the first module of the EuroSpine Diploma courses in Spanish will be delivered by GEER during 2011. In 2005, GEER became an affiliated society of the European Spine Journal, and since then, the abstracts of its annual meeting have been regularly published. This special GEER supplement of the European Spine Journal follows other National European supplements [10], in keeping with the trend initiated by the Journal, the EuroSpine Foundation, and EuroSpine to increase mutual collaboration among the various European National Spine Societies. The papers included in this supplement are blindly peer-reviewed and selected by the GEER Scientific Committee from the abstracts submitted to the 2010 GEER Annual Meeting. We wish you fruitful reading.

Book Review: AMA Guides to the Evaluation of Work Ability and Return to Work, Second Edition

American Medical Association, 2011Reviewed by David A. Fetter, MD, FAAOS, FAADEP, CEDIRDiplomate American Board of Orthopaedic SurgeryFellow American Academy of Orthopaedic SurgeonsFellow American Academy of Disability Evaluating PhysiciansCertification in Impairment and Disability Rating - American Academy of Disability Evaluating PhysicianThe second edition of “Return to Work,” in one word, is a masterpiece. The authors are to be congratulated for their scientific approach to a topic that at times has nonscientific contributing factors to consider.The preface to the second edition acknowledges the increasing importance of evidence-based medicine concepts to support physician opinion reports. Today's health care medical provider is asked on an increasingly frequent basis to issue a report, including an opinion for work return, by insurance adjustors, attorneys, and other third parties, sometimes with little knowledge of complex medical issues. The primary care physician, occupational medicine, physical medicine, orthopedic, neurological surgeons, and other specialists are frequently involved in opining with “reasonable medical probability” and with civil penalties imposed for basing an opinion on “junk science” or only “personal anecdotal experience” if the opinion is contrary to evidence-based medicine concepts. For adjustors, administrative and civil law judges, and others involved in the daily decisions including workers' compensation and personal injury claims, it is imperative that the medical physician's opinion withstand Daubert and other legal challenges. It is important that physicians take as much time as required to continually update their knowledge to support their verbal or written opinions with evidence-based medicine concepts (EBM) as referred to throughout the second edition of Return to Work.The table of contents in the second edition includes new topics, specifically Chapter 24, “International Perspectives on Return to Work.” As the focus of health care shifts to diagnosis-based–evidence-based medicine treatment and duration of treatment, not only in the United States, but throughout the world, the authors note the importance of the physician-coded International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses. Although the introduction in the second edition for assistance in disability duration is mainly focused on the USA, the reference to other evidence-based medicine (EBM) guidelines including the Official Disability Guidelines (ODG) as well as the MDGuidelines applies worldwide.The Chapter 6 authors have updated the current concepts in regard to risk, function, and tolerance. The physician needs to read and re-read this chapter and know the difference as it applies to work capability prior to opining on ability to return to work. Although there are circumstances when an individual is unable to work even with modifications or is unable to return to a prior occupation/employment, the vast majority of common diagnoses (including cervicalgia, lumbago, and strains/sprains) for which billions of health care funds are expended and enormous lost time from work occurs, are topics addressed in detail. When an employee misses any time from work from a work-reported or other claim, the provider will want to document why an injured individual cannot return to work.A few words the reader can “take home” from Chapter 1 are summarized in a consensus statement by the American Academy of Orthopaedic Surgeons and a policy statement of the American Medical Association: early, safe return to work is in the best interest of our patients.In closing, I recommend this book to all medical providers, as well as adjustors, attorneys, administrative and civil law judges, and all who are involved in the evaluation, treatment, and disability determination of injured, or reported injured, individuals who are able to perform work. This book is a must.Please refer to the AMA's e-book library that allows easy access to read on a computer, phone, or notepad while traveling. The softbound book is available as an e-book in a PDF format.

From codes to language: is the ICF a classification system or a dictionary?

Monitoring disability across the world: is the ICFthe answer?In a recent international seminar held in Rome [1], anexperts’ meeting explored the suitability of the Interna-tional Classification of Functioning, Disability, and Health(ICF, [2]) as a tool to implement the Convention on theRights of Persons with Disabilities [3] passed by the UnitedNations General Assembly in 2005, and now being aninstrument of international law valid in many States acrossthe world. The reader of this issue of BMC Public Healthhas the unique opportunity to get an overview of success-ful applications of ICF, but also of emerging concerns anddifficulties. The ICF was introduced in 2001. Its historydates back to its progenitor, the International Classifica-tion of Impairments, Disabilities, and Handicaps, pub-lished in 1980 [4]. The ICDH conceptual framework wasquite revolutionary: the “consequences of the disease” atorgan, person, and person-community levels were givenan official conceptualization (impairments, disabilities, andhandicaps, respectively), and were coded according to ataxonomy independent of the old established taxonomy ofdiseases issued by the World Health Organization (Inter-national Classification of Diseases, ICD). “Symptoms” like“difficulty walking” became a condition worth coding (andthus, studying and treating)“per se”. “Phenomena” wereupgraded to “reality” rather than being underestimated as“appearance” [5]. Rehabilitation became an autonomousform of medical care at any stage of the disease or the dis-ablement process, and thus a respected Specialty: it wasno more bound to a palliation coming after“true” carebecame ineffective. The new ICF model emphasizedthe value of the individual from a societal perspective:“disability” was up-coded (actually, sidelined) to a generic“umbrella term”, under which a positive gradient towards“enablement” was placed. Activity replaced disability, andparticipation replaced handicap. Whatever a disabled per-son can achieve “in the context of health experience” isnow better than nothing, rather than being less than anideal standard. The bidirectional flow from organ impair-ment to person’s performance, to his/her social participa-tion actually became a 3D space expanding along twomore axes, through the interactions with individualdiseases and individual living environments, respectively(see ref. [6], Fig.1). “Limitations” and “restrictions” wereseveredfromthe“intrinsic” person’s status and wereascribed to the community context. Personal bad luck wasobscured, and responsibilities of policy makers werespotlighted.Yet, something went wrong with this otherwise suc-cessful project: the philosophic and ethical constructgained an enthusiastic consensus, while the codingstructure of the model is still awaiting for wide accep-tance and routine application across the health careworld [7].Specialists in Physical Medicine and Rehabilitation(I am one of them) might be considered biased towardsa medically oriented view of disability. On the otherhand, bio-medicine considers us, the physiatrists, toomuch biased towards a social view of diseases [8,9]. Thisentitles me to express some opinions and commentswhile claiming for a decent neutrality.International experiences: successes and concernsThe successes emerging from the set of articles are wellrepresented by the paper by Kostanjsek, a WHO officer[6]. There have been plenty of applications of the ICFmodel and coding system in fields like legislation, healthcare planning, disability surveys and policy monitoring.

Surgery with disc prosthesis may produce better outcomes than multidisciplinary rehabilitation for patients with chronic low back pain

Hellum C et al (2011) Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ 342: d2786 doi:10.1136/bmj.d2786. [Prepared by Margreth Grotle and Kåre Birger Hagen, CAP Editors.] What are the effects of surgery with disc prosthesis compared to multidisciplinary rehabilitation for patients with chronic low back pain? A single blind randomised controlled multicentre trial. Five university hospitals in Norway. Men and women 25-55 years with low back pain as the main symptom for at least one year, physiotherapy or chiropractic treatment for at least six months without sufficient effect, a score of at least 30 on the Oswestry disability index, and degenerative intervertebral disc changes at L4/L5 or L5/S1, or both. Patients with nerve root involvement were excluded. Randomisation of 179 participants allocated 86 patients to surgical treatment and 87 to rehabilitation. Rehabilitation consisted of a cognitive approach and supervised physical exercise directed by physiotherapists and specialists in physical medicine and rehabilitation. Intervention was standardised and organised as outpatient treatment in groups; it lasted for about 60 hours over 3-5 weeks. Follow-up consultations were conducted at 6 weeks, 3 and 6 months, and 1 year after the intervention. Surgical intervention consisted of replacement of the degenerative intervertebral lumbar disc with an artificial lumbar disc. Surgeons were required to have inserted at least six disc prostheses before performing surgery in the study. Patients were not referred for postoperative physiotherapy, but at 6 weeks follow-up they could be referred for physiotherapy if required, emphasising general mobilisation and non-specific exercises. The primary outcome was the Oswestry Disability Index (ODI, 0-100 scale) at 2 years. Secondary outcomes included low back pain (0-100 VAS), SF-36, and EQ-5D scores. The drop-out rate at 2 years was 15% in the surgical arm and 24% in the rehabilitation arm. At 2 years follow up, the between group differences (95% CI) in favour of the surgical treatment were -8.4 (-13.2 to -3.6) for ODI, -12.2 (-21.3 to -3.1) for pain, and 5.8 (2.5 to 9.1) for SF-36 physical health summary. No differences were found in SF-36 mental health summary or EQ-5D. Surgery with disc prosthesis produced significantly greater improvement in variables measuring physical disability and pain, but the difference in ODI between groups did not exceed the pre-specified minimally important difference of 10 points, so it is unclear whether the observed changes were clinically meaningful.

“The Rehabilitation of the Hand”: C. B. WYNN PARRY, M.B.E., M.A. Diploma of Physical Medicine, Specialist in Physical Medicine, R.A.F.

“The Rehabilitation of the Hand”: C. B. WYNN PARRY, M.B.E., M.A. Diploma of Physical Medicine, Specialist in Physical Medicine, R.A.F.

Fatigue in Multiple Sclerosis: Mechanisms, Evaluation, and Treatment

Among patients with multiple sclerosis (MS), fatigue is the most commonly reported symptom, and one of the most debilitating. Despite its high prevalence and significant impact, fatigue is still poorly understood and often under-emphasized because of its complexity and subjective nature. In recent years, an abundance of literature from specialists in sleep medicine, neurology, psychiatry, psychology, physical medicine and rehabilitation, and radiology have shed light on the potential causes, impact, and treatment of MS-related fatigue. Though such a diversity of contributions clearly has advantages, few recent articles have attempted to synthesize this literature, and existing overviews have focused primarily on potential causes of fatigue rather than clinical evaluation or treatment. The aims of this review are to examine, in particular for sleep specialists, the most commonly proposed primary and secondary mechanisms of fatigue in MS, tools for assessment of fatigue in this setting, and available treatment approaches to a most common and challenging problem.

European union of medical specialists (UEMS) section of Physical & Rehabilitation Medicine: A Position Paper on Physical and Rehabilitation Medicine in Acute Settings

Physical and rehabilitation medicine (PRM) specialists have an important role in the clinical care of patients during the acute phase of a disabling health condition. This phase is defined as once definitive care or resuscitation has taken place and a patient's need to stay in hospital as an inpatient is primarily for PRM services for rehabilitation. This paper describes 4 options for the delivery of services for people, who continue to require to be inpatients and who will benefit from PRM interventions. These are described, along with their clear benefits during the acute phase of a health condition. The first 2 models are the most effective in making best use of the acute facilities and PRM services. The benefits of dedicated PRM beds appear to outweigh those of the other options and may be cheaper, although no cost-effectiveness studies comparing the first 2 options have yet been undertaken. Prospective trials are required to show this benefit, and a number of examples need to be set up to pilot this in order to provide realistic cost-effectiveness data.