American journal of physical medicine & rehabilitation / Association of Academic Physiatrists

Published by Lippincott, Williams & Wilkins
Online ISSN: 1537-7385
Print ISSN: 0894-9115
The purpose of this pilot study was to determine the effect of a 1.5-day multidisciplinary fibromyalgia treatment program on impact of illness, depression, and life fulfillment. A sample of 100 consecutive enrollees in a 1.5-day multidisciplinary group outpatient fibromyalgia treatment program between February 14, 2000, and May 9, 2000, in a tertiary medical center was used for this study. The Fibromyalgia Impact Questionnaire, the Life Fulfillment and Satisfaction Scales, and the Center for Epidemiologic Studies Depression Scale were administered to subjects immediately preceding the treatment program and by mail 1 mo after completing the program. The 78 subjects who returned their surveys 1 mo after treatment demonstrated significant improvement in the area of the impact of illness as measured by the Fibromyalgia Impact Questionnaire total score (51.3-44.7, P < 0.002). There was no significant improvement in depressive symptoms (P < 0.056) or the level of life fulfillment (P < 0.53). Subjects with depression improved on the Fibromyalgia Impact Questionnaire to the same degree as those without depression. The 22 nonresponders did not differ significantly from the responders in the variables of sex, age, pretreatment Fibromyalgia Impact Questionnaire score, marital status, educational level, family income, duration of symptoms, or history of depression. These results suggest that a 1.5-day multidisciplinary fibromyalgia treatment program does have a significant positive effect on the impact of illness among patients with fibromyalgia with or without concomitant depression and may be a cost-effective model for the treatment of these patients.
Venous thromboembolism continues to be a major cause of morbidity and mortality in patients with spinal injury (SI). Recently, we reported on the effectiveness and safety of a low molecular weight heparin (LMWH), tinzaparin, in preventing deep vein thrombosis in motor-complete SI patients. Recently, another LMWH, enoxaparin, was approved by the United States Food and Drug Administration for prevention of thromboembolism in hip and knee replacement surgery. Since its approval, we have used 30 mg of enoxaparin subcutaneously every 12 h as routine prophylaxis in all hospitalized SI patients. In this retrospective study, we present an analysis of safety and efficacy of the first six months experience, during which 105 patients received the drug. No patient developed clinical evidence of thromboembolism, and none of the 60 venous ultrasound examinations showed a deep vein thrombus. Eleven patients had evidence of hemorrhage, but the LMWH was considered to have contributed to the bleeding in only three. This additional experience with enoxaparin reinforces our previous conclusion that LMWHs are safe and effective thromboprophylactic agents in SI patients.
The aim of this study was to investigate the association between sex and functional outcome after acute inpatient rehabilitation in hip-fracture patients. We investigated 1094 of 1186 people admitted consecutively to our rehabilitation hospital because of a hip fracture. Functional outcome was assessed using Barthel Index scores. Barthel Index efficiency (improvement per day of stay length) and Barthel Index effectiveness (proportion of potential improvement achieved) were calculated. The median Barthel Index score at discharge from inpatient rehabilitation was 85 in the 970 women and 75 in the 124 men (interquartile range, 65-95 in women and 60-95 in men, P = 0.001). Both Barthel Index efficiency and effectiveness were significantly lower in men (P = 0.030 and P = 0.007, respectively). After adjustment for six confounders, we confirmed that men had lower Barthel Index scores (P = 0.030), Barthel Index efficiency (P = 0.024), and Barthel Index effectiveness (P = 0.040). The risk of achieving a low Barthel Index score (i.e., <85) at the end of acute inpatient rehabilitation was higher for men than for women (adjusted odds ratio, 2.055; 95% CI, 1.212-3.483; P = 0.007). In our large sample of hip-fracture patients, men had a significantly worse functional outcome than did women after acute inpatient rehabilitation.
Duchenne muscular dystrophy is caused by mutations in the gene encoding dystrophin, a 427 kd protein normally found at the cytoplasmic face of the sarcolemma. In normal muscle, dystrophin is associated with a multimolecular glycoprotein complex. Primary mutations in the genes encoding members of this glycoprotein complex are also associated with muscular dystrophy. The dystrophin-glycoprotein complex provides a physical linkage between the internal cytoskeleton of myofibers and the extracellular matrix, but the precise functions of the dystrophin-glycoprotein complex remain uncertain. In this review, five potential pathogenetic mechanisms implicated in the initiation of myofiber injury in dystrophin-glycoprotein complex deficiencies are discussed: (1) mechanical weakening of the sarcolemma, (2) inappropriate calcium influx, (3) aberrant cell signaling, (4) increased oxidative stress, and (5) recurrent muscle ischemia. Particular emphasis is placed on the multifunctional nature of the dystrophin-glycoprotein complex and the fact that the above mechanisms are in no way mutually exclusive and may interact with one another to a significant degree.
The two aims of this study are (1) to examine the concurrent and discriminant validity of a newly developed virtual ball catching test and (2) to explore the ball catching performance of typically developing children in a virtual environment. Three groups of children aged 60- to 140-mo-old (n = 368) participated in this study: (1) typically developing children (n = 272), (2) children with diagnoses of developmental coordination disorders (n = 33), and (3) children with premature birth history (n = 63). The concurrent validity of the virtual ball catching test was good, with Pearson's correlation coefficient = 0.67 between the virtual ball catching test and the Van Waelvelde's short ball catching test in successful catching rate. The discriminant validity of the virtual ball catching test was acceptable in differentiating the performance among typically developing children, children with developmental coordination disorders, and children with preterm history. The significant main effects in age, sex, speed, and location (Ps < 0.001) as well as significant interaction effects in age x location and age x speed were found when examining the virtual ball catching performance of typically developing children. The virtual ball catching test demonstrates acceptable psychometric properties in assessing the ball catching performance of children aged 5-11 yrs. We propose that testing children's motor performance in a virtual environment might be a useful and promising alternative for clinical assessment. Future research on its clinical application is needed.
A 10-yr retrospective review of 460,964 admissions to a 1,000-bed community teaching hospital identified 555 patients with a diagnosis of cervical spinal stenosis. Of this number, 118 were classified as "young." With an occurrence rate of 26 per 100,000, in this series there was not a significant difference in sex throughout the decade. During the first 5 yrs of this study, 186 patients with cervical spinal stenosis were identified, of whom 37 were <51 yrs of age. Of 369 patients in the remaining 5-yr period with cervical spinal stenosis, 81 were <51 yrs of age. The proportion of those <51 yrs old between the two 5-yr periods was not statistically different. Although spinal stenosis, both cervical and lumbar, has been regarded as a disorder of the elderly, 21% of those with cervical spinal stenosis and 10% with lumbar spinal stenosis can be anticipated to be <51 yrs of age.
The aim of this study was to examine the impact of pressure ulcers on inpatient rehabilitation facility (IRF) outcomes. This is a retrospective analysis of the IRF data in the United States from the Uniform Data System for Medical Rehabilitation between 2009 and 2011. The study sample included 2902 pairs of pressure ulcer and pressure ulcer-free patients upon IRF admission, matching on age at admission, sex, impairment groups, and comorbidity tier measures. The study outcomes were cognition and motor functional gains measured by the Functional Independence Measure instrument, IRF length of stay, and discharge to the community. The mean pressure ulcer prevalence upon IRF admission was 5.23%. After controlling for other covariates under study, the pressure ulcer group had a lower motor gain (20.12 vs. 21.58, P < 0.0001), had a longer length of stay (16.5 vs. 15.5, P < 0.0001), and were less likely to be discharged to the community after IRF stay (odds ratio, 0.72; 95% confidence interval, 0.62-0.84) than the patients without a pressure ulcer. The presence of a pressure ulcer among the patients seen in United States IRFs had no impact on cognition functional gain but was associated with a minor lower motor gain, a longer IRF length of stay, and lower odds of being discharged to the community.
Assess the effectiveness of intramuscular electrical stimulation in reducing hemiplegic shoulder pain at 12 mos posttreatment. A total of 61 chronic stroke survivors with shoulder pain and subluxation participated in this multiple-center, single-blinded, randomized clinical trial. Treatment subjects received intramuscular electrical stimulation to the supraspinatus, posterior deltoid, middle deltoid, and upper trapezius for 6 hrs/day for 6 wks. Control subjects were treated with a cuff-type sling for 6 wks. Brief Pain Inventory question 12, an 11-point numeric rating scale was administered in a blinded manner at baseline, end of treatment, and at 3, 6, and 12 mos posttreatment. Treatment success was defined as a minimum 2-point reduction in Brief Pain Inventory question 12 at all posttreatment assessments. Secondary measures included pain-related quality of life (Brief Pain Inventory question 23), subluxation, motor impairment, range of motion, spasticity, and activity limitation. The electrical stimulation group exhibited a significantly higher success rate than controls (63% vs. 21%, P = 0.001). Repeated-measure analysis of variance revealed significant treatment effects on posttreatment Brief Pain Inventory question 12 (F = 21.2, P < 0.001) and Brief Pain Inventory question 23 (F = 8.3, P < 0.001). Treatment effects on other secondary measures were not significant. Intramuscular electrical stimulation reduces hemiplegic shoulder pain, and the effect is maintained for > or =12 mos posttreatment.
The ulnar antidromic sensory conduction study to the fifth digit is commonly performed in clinical electrodiagnosis. Several authors have published normal ranges for this study, but these published reports have been limited by generally small sample sizes. The purpose of this article is to present a large database of normal ranges for this nerve study. After obtaining Institutional Review Board approval, 258 asymptomatic subjects were tested bilaterally with an ulnar antidromic sensory technique recording from the fifth digit. Stimulation was performed 7 cm and 14 cm proximal to the recording electrode. Onset latency, peak latency, onset-to-peak amplitude, peak-to-peak amplitude, area, duration, and rise time were recorded. Side-to-side and 14- to 7-cm comparisons were made. A repeated measures analysis of variance was performed to determine whether any of the subjects' demographic characteristics of age, race, gender, height, or body mass index (kg/m2) were associated with different results for the nerve conduction measures. Increasing age and body mass index were found to correlate with decreasing amplitude and area. No other correlations were noted between the results and the physical characteristics. Mean onset latency was 1.4 +/- 0.2 ms at 7-cm and 2.6 +/- 0.2 ms at 14-cm stimulation. Mean peak latency was 2.0 +/- 0.2 ms at 7-cm and 3.4 +/- 0.3 ms at 14-cm stimulation. Mean onset-to-peak amplitude was 32 +/- 20 microV at 7-cm and 33 +/- 17 microV at 14-cm stimulation. Mean negative-to-positive-peak amplitude was 55 +/- 36 microV at 7-cm and 50 +/- 32 microV at 14-cm stimulation. Mean side-to-side difference for onset latency was 0 +/- 0.2 ms. Additional data is presented in the study.
The purpose of this study was to derive a normative database for the median digital sensory conduction study using a large and varied subject population. Two hundred fifty-eight asymptomatic volunteers were tested with antidromic sensory technique at 14- and 7-cm distances to digits 2 and 3. Onset latency, peak latency, onset-to-peak amplitude, peak-to-peak amplitude, area, rise time, and duration were recorded. A repeated analysis of variance was performed, with the nerve conduction study measures as the dependent variables and age, race, gender, body mass index, and height as the independent variables. Factors that were significant at the P < or = 0.01 level were used to create separate normal ranges. Both increasing age and increasing body mass index correlated with decreasing amplitudes and area. No other correlations were noted between the results and the physical characteristics. For digit 3, the mean 14-cm onset latency was 2.7 +/- 0.3 ms and mean peak latency was 3.4 +/- 0.3 ms. The mean onset-to-peak amplitude was 41 +/- 20 microV for all subjects taken together. Mean rise time was 0.7 +/- 0.1 ms and mean duration was 2.1 +/- 0.4 ms. Mean side-to-side difference in onset and peak latencies was 0.0 +/- 0.2 ms. The upper limits of normal side-to-side differences in amplitudes and area were approximately 50%-60%.
To create a large database of normal values for the sural and saphenous nerve conduction studies and to compare the results for the two nerves. Using a 14-cm antidromic technique, data were collected for onset latency, peak latency, onset-to-peak amplitude, peak-to-peak amplitude, area, duration, side-to-side variability, and between-nerve variability. A total of 230 subjects were included in the study. For the sural nerve, the upper limits of normal, defined as the 97th percentile of observed values, for onset latency, peak latency, and duration were 3.6, 4.5, and 2.1 msec, respectively. The comparable values for the saphenous nerve were 3.8, 4.4, and 1.9 msec, respectively. The lower limits of normal (third percentile) for sural onset-to-peak amplitude and peak-to-peak amplitude were 4 and 4 microV. The comparable values for the saphenous study were 2 and 1 microV. The upper limit of normal difference in onset latency between the two nerves was: saphenous 0.7 msec longer than sural or sural 0.3 msec longer than saphenous. The corresponding values for peak latency were: 0.6 and 0.5 msec. Normal ranges are presented for a large database of subjects for the sural and saphenous nerve conduction studies.
We report the results of a Falls Consultation. Data concerning the first 150 patients are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home, and was reassessed by the same geriatrician 6 mo later. Of the 150 patients, 135 patients completed the initial evaluation. Most of them were frequent fallers. The population was very heterogeneous regarding the health status and the degree of disability. In most cases, falls were the result of several interacting factors. The most frequent recommendations from the staff were physical therapy, environmental changes, and medication changes. Over the following 6 mo, approximately one out of four patients had experienced new falls. However, the risk of falling was significantly reduced (5.3 +/- 7.3 falls in 6 mo before vs. 0.8 +/- 1.6 falls in 6 mo after the intervention). The Activities of Daily Living score was a predictor of recurrent falls, hospitalization, and institutionalization. Our results show that a multidisciplinary falls consultation can be efficient in reducing the risk of falls in nonselected elderly fallers but suggest that differential strategies are needed to manage adequately the more vigorous and the frail old person as well.
A 17-item questionnaire was designed to assess the relative importance of various factors to physical medicine and rehabilitation (PM&R) training directors when ranking PM&R resident applicants during the National Resident Match. The questionnaire was sent to all PM&R residency training directors. The recipients were asked to grade most selection factors based on a numerical scale: 1, unimportant; 2, some importance; 3, important; 4, very important; 5, critical. The specific factors addressed in the questionnaire were: academic criteria, letters of recommendation, individual applicant characteristics and aspects of the interview process. Twelve yes-or-no questions were also designed to determine the weight that residency training directors place on certain academic criteria. A response rate of 88% (66/75) was obtained. The most important academic criteria were grades in a PM&R clerkship in their facility (4.1 +/- 0.8), followed by grades in a PM&R clerkship in another facility (3.6 +/- 0.9). The most important letters of recommendation were from a PM&R faculty member in the respondent's department (4.0 +/- 0.8), followed by the dean's letter (3.7 +/- 1.0) and the PM&R chairman's letter (3.7 +/- 1.0). The three most important applicant characteristics evaluated during the interview were compatibility with the program (4.4 +/- 0.8), the ability to articulate thoughts (4.2 +/- 0.8) and the ability to work with the team (4.2 +/- 0.8). Most program directors used multiple criteria to complete their rank list, but the most important were based upon the interview (4.5 +/- 0.9), letters of recommendation (3.7 +/- 0.9), medical school transcript (3.6 +/- 0.8) and the dean's letter (3.6 +/- 1.1).(ABSTRACT TRUNCATED AT 250 WORDS)
Objective: The aim of this study was to analyze the effects of inclined treadmill training on the kinematic characteristics of gait in subjects with hemiparesis. Design: A blind, randomized, controlled study was conducted with 28 subjects divided into two groups: the control group, submitted to partial body weight-support treadmill gait training with no inclination, and the experimental group, which underwent partial body weight-support treadmill training at 10% of inclination. All volunteers were assessed for functional independence, motor function, balance, and gait before and after the 12 training sessions. Results: Both groups showed posttraining alterations in balance (P < 0.001), motor function (P < 0.001), and functional independence (P = 0.002). Intergroup differences in spatiotemporal differences were observed, where only the experimental group showed posttraining alterations in velocity (P = 0.02) and paretic step length (P = 0.03). Angular variables showed no significant differences in either group. Conclusions: In subjects with hemiparesis, the addition of inclination is a stimulus capable of enhancing the effects of partial body weight-support treadmill gait training.
The aim of this study was to determine the variables that improve spastic equinus foot caused by cerebral palsy when treated with botulinum toxin type A. We reviewed all patients treated for spastic equinus foot using botulinum toxin type A (Botox) in the triceps suralis during a 3 1/2-yr period and analyzed the results after the first injection. There were 117 patients (72 diplegic and 45 hemiplegic patients) and a total of 189 triceps suralis treated. Variables analyzed included age, total dose per session, total dose per kilogram for each session, total dose per triceps, triceps dose per kilogram, type of cerebral palsy, cognitive level, botulinum toxin dilution, and physiotherapy. Assessments of efficacy were done using a Global Assessment Scale rated independently by parents, therapists, and a neurologist; the Modified Ashworth Scale; and the Modified Physician Rating Koman scale. Improvement was observed in all scales (P < 0.001). The change of foot position during walking was the best parameter for measuring improvement. There was correlation between the grade of improvement and the dose per kilogram for each triceps suralis (P < 0.001). Patient age was inversely correlated with improvement (P = 0.043). Diplegic and hemiplegic patients improved similarly, but the hemiplegic patients required higher doses for each muscle (P < 0.001). The most effective dose for diplegic patients was 3-4 IU/kg for each triceps, compared with 4-6 IU/kg for hemiplegic patients. Different dilutions of Botox (100, 50, and 40 U/ml) resulted in similar outcomes. No better results were achieved when 2-3 sessions/wk of physiotherapy was added to a daily program of exercises at home to enhance foot dorsiflexion. The dose per kilogram of Botox injected into triceps suralis and the patient age influence the results. The most effective dose is different between diplegic and hemiplegic patients. The concentration of botulinum toxin type A does not play a significant role in the outcome.
LaBan MM, Grimm M: Handicapped parking: A privilege or a right?
This brief paper has reviewed a few of the basic concepts related to the understanding of leadership styles. The unavoidable nature of conflict in organizations has been described. One of the best ways a person can make conflict more manageable is to become increasingly aware of his or her own fundamental leadership style as well as that of others. Without such an effort, people run the risk of moving apart rather than toward a closer working relationship. Regardless of whether an organization is a rehabilitation team, a university faculty or any other group in society, improvements in organizational functioning cannot be made without an awareness of conditions that create conflict.
To estimate the United States prevalence of symptomatic hand osteoarthritis using American College of Rheumatology (ACR) physical examination criteria. The Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative cross-sectional health examination survey, performed upper-extremity physical examinations on a sample of United States adults age 60+ yrs. Data for demographics, pain history, analgesic use, and activity limitations were obtained by interview. Among United States adults, 58% had Heberden's nodes, 29.9% had Bouchard's nodes, and 18.2% had first carpal-metacarpal deformities. Women had significantly more first carpal-metacarpal deformities (24.3%) than men (10.3%). Symptomatic osteoarthritis prevalence at these sites was 5.4, 4.7, and 1.9%, respectively. Overall, symptomatic hand osteoarthritis prevalence by ACR criteria was 8% (95% CI 6.5-9.5%), or 2.9 million persons. Symptomatic hand osteoarthritis significantly increased with age and was decreased among non-Hispanic blacks, but there were no gender differences. Symptomatic hand osteoarthritis was associated with self-reported difficulty lifting 10 lbs (OR 2.31; 95% CI 1.23-4.33), dressing (OR 3.77; 95% CI 1.99-7.13), and eating (OR 3.44; 95% CI 1.76-6.73). Frequent monthly use was significantly increased for analgesics, especially acetaminophen, but not nonsteroidal antiinflammatory drugs. Symptomatic hand osteoarthritis affects 1 in 12 older United States adults. NHANES III data provide a population-based assessment of the impact and associated functional impairments of symptomatic hand osteoarthritis.
A survey was designed to explore the relationship among elective time (ET), residency research requirement (RR), mandatory research rotation (MR), and academic productivity for the 1993 graduating residency class. Sixty-seven of the 75 rehabilitation residency program directors listed in the 1993 Directory of Graduate Medical Education Programs responded (89% response rate). Data from 60 programs, representing 283 graduating residents, were analyzed (80% usable response rate). A resident was operationally defined as "active" if that individual submitted either articles (SART) for publication or abstracts (SABS) for oral/poster presentation during the training years; residents with accepted articles (AART) and/or abstracts (AABS) were defined as "productive." Odds ratios and chi 2 statistics were calculated for each study risk variable (ET, RR, MR) and the corresponding outcome variables (SART, SABS, AART, AABS). One hundred and fifty-nine residents (56%) submitted abstracts; 86 (30%) submitted articles; of these residents, 134 (47%) and 54 (19%) had their work accepted, respectively. Research was required by 26/60 (43%) programs. Research elective time was available in 41/60 (68%) programs; only 44/203 (22%) residents used this time for research. Residents who had research required had a 1.9 times greater likelihood of submitting both abstracts (P < 0.008) and articles (P < 0.014). No other study relationship was found to be significant. The study results suggest that implementing a research requirement in the residency training curriculum may lead to an increase in resident research activity.
To examine the use of physical therapy and occupational therapy among Medicare beneficiaries nationwide before and after the 1997 Balanced Budget Act, which introduced prospective payment for rehabilitation services. We analyzed responses from the longitudinal Medicare Current Beneficiary Survey, merged with Medicare claims, to track physical therapy and occupational therapy rates and intensity (units of service) from 1994 through 2001. This observational study focused on elderly and disabled Medicare beneficiaries within five conditions: stroke, acute myocardial infarction, chronic obstructive pulmonary disease, arthritis, and lower-limb mobility problems. We used cubic smoothing spline functions to describe trends in service intensity over time and generalized estimating equations to assess changes in service intensity. Controlling for demographic characteristics, adjusted mean level of physical therapy and occupational therapy intensity rose significantly between 1994 and 2001 for all five conditions. Service intensity leveled off in 1999 for occupational therapy and 2000 for physical therapy. With few exceptions, physical therapy and occupational therapy intensity was not significantly associated with patients' demographic characteristics. Medicare beneficiaries with conditions that can potentially benefit from physical therapy or occupational therapy or both continued to get these services at similar-and sometimes increasing-intensity during years after passage of the Balanced Budget Act.
To understand better how career choices are made by physiatrists, a 16-item, 7-page questionnaire was sent to all 1994 graduating physical medicine and rehabilitation (PM&R) resident physicians in the United States. Of the 343 senior residents, 202 completed the questionnaire for a response rate of 59%. The questionnaire focused on the following areas: timing of the decision to enter PM&R; and how the medical school curriculum, certain groups of people, and certain specific factors influenced their choices. There were 130 factors modeled after the American Association of Medical Colleges (AAMC) annual medical student questionnaire that the recipients were asked to grade on a numerical scale: 1 = unimportant to 5 = very important. Of the graduating residents, 60.1% (119/198) made the decision to enter PM&R in their 3rd or 4th yr of medical school, 13.1% (26/198) in the first 2 yr, and 11.1% (22/198) after starting another residency. The five factors ranked most important in the decision were (mean rank score): sufficient time/flexibility for family obligations (4.60); opportunity to make a difference in peoples lives (4.57); interest in helping people (4.55); types of patient problems encountered (4.50); and consistency with personality (4.49). We also obtained the AAMC's 1993 annual data on medical students choosing PM&R. Their top five factors were the same as those listed by the graduating residents, but in a slightly different rank order. Profiles have also been derived on those graduating PM&R residents who chose an academic career (n = 68) v nonacademic (n = 133) and fellowship (n = 34) v nonfellowship (n = 163).
This study was undertaken to determine the level of agreement between the most recent change in the American Spinal Injury Association International Standards (2000) and the previous (1996) classification. In a spinal cord injury rehabilitation hospital, data were collected on 94 subjects who had an initial neurologic examination according to the International Standards within 1 wk of injury and again at 1 yr. Comparisons were examined of the level of agreement between the 1996 and 2000 revisions in classification of the motor incomplete levels and ability to prognosticate outcome at 1 yr on the basis of the initial examination. Near perfect agreement between the 1996 and 2000 revised guidelines in the classification of motor incomplete injuries was found, with no statistically significant difference for prognosticating neurologic recovery at 1 yr on the basis of the initial examination. The 2000 revisions do not offer a significant difference in American Spinal Injury Association impairment classification or in predicting neurologic recovery at 1 yr.
Iwanenko W, Fiedler RC, Granger CV, Lee MK: Uniform Data System for Medical Rehabilitation: Report of first admissions to subacute rehabilitation for 1998. Am J Phys Med Rehabil 2001;80:56-61.
Despite increasing the need for physiatrists, there is more pressure on physiatry departments and training programs to reduce the number of resident training slots. Of 321 residents completing their training in June 1999 and surveyed by questionnaire, 161 (50%) responded to the survey. The factors accounting for a successful job search were analyzed. Surveys of graduating residents can provide accurate information on job opportunities and career choices; this information can be compared with previous physiatry manpower projections. Increasing difficulty in the job search process signals that the supply of residents may exceed the demand.
To investigate the relation of both peak leg power and usual gait speed in their association with varying domains of late-life disability. Participants (> or =60 yrs of age, n = 1753) were from the National Health and Nutrition Examination Survey, 1999-2002. Disability in activities of daily living, instrumental activities of daily living, leisure and social activities, lower limb mobility, and general physical activities was obtained by self-report. Peak muscle power was the product of isokinetic peak leg torque and peak force velocity. Functional limitations were evaluated via usual gait speed, which was obtained from a 20-foot timed walk. Low usual gait speed was associated with disability independent of basic demographics, cognitive performance, co-morbidities, health behaviors, and inflammatory markers. The odds ratios for disabilities in activities of daily living, instrumental activities of daily living, leisure and social activities, lower limb mobility, and general physical activities for each standard-deviation increase in walking speed were 0.72 (95% confidence interval [CI], 0.59-0.87), 0.63 (95% CI, 0.52-0.77), 0.57 (95% CI, 0.45-0.72), 0.56 (95% CI, 0.47-0.67), and 0.74 (95% CI, 0.64-0.85), respectively. The odds ratios for disabilities in activities of daily living, instrumental activities of daily living, leisure and social activities, lower limb mobility, and general physical activities for each standard-deviation increase in leg power were 0.70 (95% CI, 0.55-0.89), 0.67 (95% CI, 0.53-0.86), 0.62 (95% CI, 0.47-0.83), 0.58 (95% CI, 0.47-0.72), and 0.73 (95% CI, 0.61-0.87), respectively. Supplementary adjustment for walking speed mildly attenuated the relation of leg power to disability. Peak leg power and habitual gait speed were associated with varying domains of late-life disability. The association between peak leg power and disability seems to be partially mediated through usual gait speed.
This is the 10th annual report describing patients discharged from comprehensive medical rehabilitation programs in the United States that subscribe to the Uniform Data System for Medical Rehabilitation. The analysis included 298,973 complete records of first admission cases discharged alive from 676 facilities in 1999. The data show that patients receiving care in comprehensive rehabilitation programs show measurable functional improvement and that a high percentage of patients are discharged to community-based settings.
This is the third annual report describing patients discharged from subacute rehabilitation programs in the United States that subscribe to the Uniform Data System for Medical Rehabilitation (UDSmr). The analysis included 39,562 complete records of first admission cases discharged alive from 180 facilities in 1999. Sixty-five percent of the patients were women, and most patients (91%) were white. Sixty-two percent of the patients were 75 yr of age or older. Before the impairment onset, 55% lived with at least one other person. The average total FIM (motor and cognitive) score change for all patients was 21.1 points, and when stratified by rehabilitation impairment group, average scores ranged from 18.3 for patients with pulmonary conditions to 25.3 for patients with a joint replacement. The percentage of patients discharged to a community-based setting ranged from 67% for patients with stroke to 94% for patients with a joint replacement. These data show that patients receiving care in subacute rehabilitation programs show measurable functional improvement and that a high percentage of patients are discharged to community-based settings.
This study is a secondary analysis of results from the Multiple Sclerosis Collaborative Research Group multicenter trial. We investigated the effect of interferon beta-1a on disability in patients with relapsing-remitting multiple sclerosis (MS), using the FIM instrument to assess levels of decline in total, motor, and cognitive items. Of the 301 patients enrolled in the trial, 274 subjects with relapsing-remitting multiple sclerosis with baseline FIM and Kurtzke Expanded Disability Status Scale scores were studied in this secondary analysis. Mildly disabled patients were chosen, as indicated by a Kurtzke Expanded Disability Status Scale score of 1.0-3.5. Matched subjects were assigned to receive either interferon beta-1a or placebo. Kurtzke Expanded Disability Status Scale and FIM scores were measured serially every 6 mo. Failure was defined as a 4-point reduction in total FIM score sustained for 6 mo. Analysis was by Kaplan-Meier methodology. The Mann-Whitney test (log rank) compared mean change and Spearman's rank-correlation test determined correlation. A significant difference in treatment groups was seen, with a FIM score decline of > or = 4 points, with placebo subjects demonstrating greater loss of function than subjects treated with interferon beta-1a. There was no statistically significant difference in total, cognitive, or motor activities, with a decline of < or = 3 points. Disability, as measured by the FIM instrument, was slowed by treatment with interferon beta-1a compared with placebo. The treatment effect determined using the FIM instrument, with its motor and cognitive components, indicates an additional level of response to therapy for mild to moderate multiple sclerosis.
To determine whether neurophysiologic findings correlate to clinical respiratory signs or spirometric abnormalities in patients with hereditary motor and sensory neuropathy type 1 (Charcot-Marie-Tooth disease). A total of 11 patients with hereditary motor and sensory neuropathy type 1A, genetically identified, (age range, 10-58 yr) were included and studied by physical pulmonary examination, chest radiography, respiratory function tests, and bilateral transcutaneous phrenic nerve conduction. No patient complained of respiratory symptoms or revealed abnormal spirometric or maximal respiratory pressure data, despite a phrenic nerve conduction significantly slower (P < 0.0001; median conduction time, 18.6 msec; 95th percentile, 31.97 msec) than that recorded in the control group of healthy subjects (median, 6.05 msec; 95th percentile, 8.82 msec); the amplitudes of compound muscle action potentials were not statistically different from the controls. Our study confirms a dramatic phrenic nerve involvement in absence of clinical and laboratory evidence of diaphragmatic weakness; further studies and an adequate follow-up are necessary to discover whether the disease progress might encompass respiratory dysfunction at later stages.
Documentation of vascular uptake on spinal injection in the context of negative aspiration and negative passive filling of blood into the hub of the needle. A total of 1,295 consecutive outpatients receiving fluoroscopically guided, contrast-confirmed injection in a multispecialty practice over a 1-yr time frame were retrospectively reviewed with passive observation for inadvertent vascular uptake, passive filling, and required repositioning. Positive vascular uptake was seen in 2-13% of cases with variable degrees of aspiration, passive filling, and required needle repositionings to avoid vascular uptake. Negative aspiration and allotment for passive filling is inadequate to confirm the absence of vascular injection. Spinal injection will never be risk free. The safest method is fluoroscopically guided, contrast-confirmed injection, which should be considered the current standard of care.
The 200-m fast-walk test has been proposed as a high- intensity performance test in healthy, elderly subjects. Adaptation of low-risk coronary artery disease patients during this test were compared with those in a 6-min walk test and a maximal cardiopulmonary exercise test. Thirty patients with stable coronary artery disease (51.9 +/- 8.7 yrs), referred to the cardiac rehabilitation department, performed a cardiopulmonary exercise test, then a 200-m fast-walk test and a 6-min walk test in a random order, before and after the training period (6 wks, 3 days per week). Heart rate was monitored during each test. Peak workload of cardiopulmonary exercise test, distance walked on the 6-min walk test, and time to perform the 200-m fast-walk test were measured. A subsample of ten patients performed the exercise test with gas exchange measurements, with ventilatory threshold determination. All subjects completed walk tests without complaint or incidents. Compared with the cardiopulmonary exercise test, the cardiac relative intensity was higher during the 200-m fast-walk test than during the 6-min walk test, both before (89.6% vs. 78.1% of cardiopulmonary exercise test maximal heart rate; P < 0.05) and after (83.8% vs. 74.3%; P < 0.05) training. Among the subsample of ten patients, the 200-m fast-walk test heart rate was significantly higher than the ventilatory threshold heart rate, which did not differ from the 6-min walk test heart rate. The 200-m fast-walk test time significantly decreased after training (-9.1%, P < 0.01). In patients with coronary artery disease at low risk, the 200-m fast-walk test explores higher levels of cardiorespiratory capacity than the 6-min walk test. Thus, this could be a useful field test in complement to the cardiopulmonary exercise test to assess functional capacity improvement and update training targets regularly during the course of high-intensity rehabilitation programs in this population.
Top-cited authors
Alberto Esquenazi
  • Jefferson Health
Andrew Packel
  • Albert Einstein Healthcare Network
Mukul Talaty
  • Albert Einstein Healthcare Network
Levent Özçakar
  • Hacettepe University
John Robert Bach
  • Rutgers New Jersey Medical School