Physical Medicine & Rehabilitation

Caring for Patients with Physical Disabilities: Assessment of an Innovative Spinal Cord Injury Session that Addresses an Educational Gap Despite the fact that one-fifth of Americans live with disability, caring for these patients is not routinely part of the undergraduate medical student curriculum. An innovative session addressing care of patients with spinal cord injury (SCI) was developed for medical students and led by physiatrists, faculty experts in communications and individuals with SCI. A mixed-method design was utilized in evaluating students' knowledge, skills and attitudes following this curriculum. Quantitative evaluation was performed with a written essay question and checklist items from an objective structured clinical examination (OSCE) station. The session was given to 296 students from 2016 to 2018. On the OSCE, 94% asked about sexual function, 85% asked about activities of daily living (ADL), 77% asked about instrumental activities of daily living (IADL) and 47% of students evaluated skin health. Students demonstrated respectful (99%) and non-judgmental (99%) attitudes with SCI standardized patients (SPs) and 91% interacted with the SP's caretaker appropriately. Themes emerged from the student survey including: the value of having real patients present during the session, exposure to physical medicine and rehabilitation (PM&R) as a specialty, and the advantage of a small group format. This session provided students with tools necessary to care for patients with SCI. Corresponding author: Janice Thomas John, DO, MS, MPH, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, Phone: 516-463-7577 Fax: 516-463-5631; email: janice.t.john@hofstra.edu Author disclosures:Janice Thomas John DO, MS, MPH- nothing to disclose. Lauren Block MD, MPH - nothing to disclose. Adam Stein MD- nothing to disclose. Elizabeth Vasile, MPH- nothing to disclose. Maria-Louise Barilla-LaBarca MD-nothing to disclose Sources of funding: None Previous presentations: 2017 data was presented at: 1. Directors of Clinical Skills (DOCS) Annual Meeting, 2017. Boston, MA (poster). 2. Association of Academic Physiatrist (AAP) Annual Meeting, 2018 Atlanta, GA (platform presentation) Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Does performance on the American Board of Physical Medicine and Rehabilitation initial certification examinations predict future physician disciplinary actions? Objective To determine the relationship between performance on the American Board of Physical Medicine and Rehabilitation (ABPMR) primary certification examinations and the risk of subsequent disciplinary actions (DAs) by state medical boards over a physician's career. The hypothesis is that physicians who do not pass either or both of the two initial specialty certification examinations are at higher risk of disciplinary action (DA) from a state medical licensing board. Design This is a retrospective cohort study which analyzed board certification examination data from all physicians who completed Physical Medicine and Rehabilitation (PM&R) residency between 1968 and 2017. Results Matching examination and license data were available for 9,889 PM&R physicians, who received a total of 547 DA reports through the Federation of State Medical Boards. The results showed a significant correlation between failing an ABPMR certification examination and the risk of subsequent DA by a state medical board. Failure to pass either the written (Part I) or oral (Part II) examination increased the risk of subsequent DA by 5.77-fold (p< 0.0001, 95% Cl 4.07, 8.18). Conclusion Physicians in PM&R who do not pass initial certification examinations and become Board Certified are at higher risk of DA from a state medical licensing board throughout their careers. Dr. Kinney and Dr. Raddatz are employees of the American Board of Physical Medicine and Rehabilitation. No other disclosures. No funding was received for this study. Corresponding author: Carolyn L. Kinney, MD, American Board of Physical Medicine and Rehabilitation, 3015 Allegro Park Ln SW, Rochester, MN 55902, 507-282-1776, Ext. 1743, Email : ckinney@abpmr.org, Fax : 507-282-9242 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Vague Posterior Knee Discomfort in a Soccer Player: A Case Report A 24-year-old male soccer player presented with a 7-year history of left posterior knee "looseness." Evaluation 7 years ago, at the time of initial injury, revealed atraumatic ACL and PCL sprains. On re-presentation, the patient described the pain as a constant, dull ache, 3/10, but his biggest complaint was this feeling of "instability" and "looseness" where his knee would "buckle" 3-4 times a week. Physical exam was positive for grade 1 posterior drawer and grade 1 posterior sag signs. Reverse KT-1000 testing showed a 3 mm side-to-side difference. Sonographic evaluation confirmed MRI findings of PCL laxity and buckling and a small cystic lesion abutting the posteromedial margin of the distal 1/3 of the PCL. After a trial of physical therapy, the patient elected to undergo experimental injection of dextrose hyperosmolar solution. This resulted in resolution of the cyst and reverse KT-1000 measurements improved to a side-to-side difference of 1 mm. The patient's subjective feeling of "looseness" and "instability" resolved by 7 weeks. No funding was received for this study. Corresponding Author: Allison Schroeder, 2626 Tunnel Boulevard Apt 326, Pittsburgh, PA 15203, Email: aschroe1@alumni.nd.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Subtle dysmetria after a hemorrhage in the basal ganglia and lentiform nucleus No abstract available

Rapid decline of a 52-year old female with brain injury during acute rehabilitation A 52-year-old African American female suffered a spontaneous right middle cerebral artery (MCA) aneurysm rupture treated with emergent right craniectomy and MCA artery clipping. She was admitted to inpatient rehabilitation (IPR) 6 weeks after her initial injury and was requiring maximum to total assistance for functional tasks. She made significant functional gains during the first 17 days of IPR admission, she developed headaches, new cognitive deficits, and increased difficulty with standing and eating. Her symptoms worsened at the end of the day. Physical examination demonstrated sunken craniectomy flap. Imaging revealed medialization of the craniectomy flap with local mass effect causing a 4 mm leftward shift with interval decrease in ventricular size consistent with syndrome of the trephined. While in IPR she was placed in the Trendelenburg position during rest breaks and overnight and was transferred to the neurosurgical service for definitive treatment with cranioplasty. After an additional IPR stay and subsequent outpatient therapy, she improved to a modified independent level of function. Corresponding Author: Allison Schroeder, 3471 Fifth Ave, Pittsburgh, PA 15213, Phone: (412) 692-4400, schroederan@upmc.edu The authors of this manuscript, Allison Schroeder, Justin Weppner, and Gary Galang, have nothing to disclose. No funding was received for this study. Justin Weppner is in training. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The relation between loss of consciousness, severity of traumatic brain injury and injury of ascending reticular activating system in patients with traumatic brain injury Objective Loss of consciousness(LOC) is an indicator of the severity of traumatic brain injury(TBI) and the ascending reticular activating system(ARAS) has been considered as a main structure for consciousness. However, no study on the relation between LOC and ARAS injury in TBI has been reported. We investigated the relation between LOC, severity of TBI, and ARAS injury using diffusion tensor tractography(DTT). Design 120 patients were recruited. Three components of ARAS, fractional anisotropy(FA) and tract volume(TV) were measured. Results In lower dorsal and ventral ARAS, FA and TV value in mild group were higher than those of moderate and severe groups, and there was no difference between moderate and severe groups. In upper ARAS, FA value in mild group was higher than in moderate group, and in moderate group was higher than in severe group. TV value in mild group was higher than that of severe group. LOC showed moderate negative correlations with TV value of lower dorsal ARAS(r=-0.348), FA value of lower ventral ARAS(r=-0.343), and FA value of upper ARAS(r=-0.416). Conclusion Injury severity was different among three TBI groups in upper ARAS but did not differ between moderate and severe groups in lower dorsal and ventral ARAS. Corresponding author: Jong Bum Kim, MD, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyung dong, Namku, Daegu, 705-717, Republic of Korea, Tel: 82-53-620-4098, FAX: 82-53-625-3508, e-mail: bum9839@naver.com CONFLICTS OF INTEREST. All authors report no conflict of interest All authors report no funding, grants, or equipment for this project All authors report no financial benefits All authors report no previous research, manuscript, or abstract in any form Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Interventions for Individuals with Neurological Disorders: A Systematic Review of Systematic Reviews Fall prevention requires a multifaceted approach that should include individual risk assessment and intervention strategies. Exercise interventions may mitigate most risk factors for falls (e.g., balance impairment, gait impairment, and muscle weakness). Numerous systematic reviews (SRs) or meta-analyses have assessed the effectiveness of exercise interventions among people with various types of neurological disorders; however, the evidence obtained has not been synthesized into an overview. Therefore, the present SR assessed SRs of exercise intervention for fall prevention among people with neurological disorders. The research sources were the Cochrane Database of Systematic Reviews, PubMed, and Embase. Eligible studies were selected, and data were extracted independently by two reviewers. A total of 15 studies (6 SRs and 9 meta-analyses) were included. These SRs examined in this study have demonstrated that exercise interventions reduced the number, frequency, and rate of falls among people with neurological disorders, including cognitive impairment, dementia, and Parkinson disease. Furthermore, the current study presented insufficient evidence regarding the effectiveness of exercise interventions for fall prevention among people with stroke, multiple sclerosis (MS), and diabetes mellitus with polyneuropathy (DMP). Therefore, additional investigations are necessary to evaluate the effectiveness of exercise for fall prevention among people with MS, stroke, and DMP. Correspondence to: Shih-Ching Chen, Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, No. 252, Wu-Hsing St., Taipei City 110, Taiwan, Tel: 886-2-27372181 ext. 3538; Fax: 886-2-55589880; E-mail: csc@tmu.edu.tw Conflicts of Interest/Disclosure: The authors have no conflicts of interest to report. Funding: This study received no funding. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Not Always as it Seems: A Case of Ascending Paralysis No abstract available

Evaluation of Service Delivery Effectiveness through Patient Reported Outcome Measures Objective To report the demographic characteristics and functional mobility for individuals accessing an academic medical center mobility device clinic, and to compare functional mobility data across demographic characteristics and mobility device type. Design This study utilized a retrospective, cross-sectional design. Demographic, mobility type and patient reported outcome measure data for 833 clients was analyzed. The Functional Mobility Assessment (FMA) was utilized as the patient reported outcome measure to determine satisfaction. Results The average baseline FMA score was .59 (SD .25) on a 0-1 scale. Significant differences with the FMA scores were found across the mobility device types, with scooter and power wheelchair (PWC) groups reporting higher satisfaction scores than those in the cane/crutch/walker (CCW) or manual wheelchair (MWC) groups. Device type, gender, and age were each found to be significant predictors of satisfaction scores, p=<0.01. Conclusion Mobility device type is associated with satisfaction level. Mobility devices that offer higher levels of assistance are associated with increased satisfaction. The FMA, mobility device type, and demographic data provide baseline information for evaluating the effectiveness of an academic medical center mobility device clinic. Corresponding Author: Carmen P. DiGiovine, PhD, ATP/SMS RET, The Ohio State University, 453 W. 10th Avenue, Suite 406, Columbus OH 43210, carmen.digiovine@osumc.edu, Phone: 614-293-7876 Author Disclosures: Mark Schmeler receives royalties on the Functional Mobility Assessment (FMA) which was licensed to the Van G. Miller Group. Funding: The authors did not receive funding for this study. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Lifestyle risk behaviors among stroke survivors with and without diabetes Objective History of stroke and diabetes increase risk for cardiometabolic disease, which can be mitigated through lifestyle management. To evaluate lifestyle risk behaviors among stroke survivors, we compared the prevalence of three lifestyle risk behaviors—physical inactivity, consuming ≤1 fruit and ≤1 vegetable daily, and overweight/obesity—between stroke survivors with and without diabetes. Design Data from the 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS) were examined. Weighted and age-adjusted prevalence estimates, and crude and adjusted odds ratios (adjusted for sociodemographic characteristics), were calculated to compare lifestyle risk behaviors between U.S. stroke survivors with and without diabetes. Results Prevalence and adjusted odds ratios (AOR) for lifestyle risk behaviors were higher in participants with diabetes compared to those without diabetes for consuming ≤1 fruit and ≤1 vegetable daily (58.8% vs. 53.7%, AOR:1.14), physical inactivity (65.7% vs. 54.6%, AOR: 1.41), and overweight/obesity (87.2% vs. 63.1%, AOR: 2.42). Conclusion Prevalence of select lifestyle risk behaviors exceeds 50% in adults with stroke, but are higher in adults with diabetes compared to adults without diabetes. Effective interventions, community programs, and healthcare policy are needed to promote lifestyle management in adults with stroke, particularly among those with diabetes. CORRESPONDENCE: Ryan Bailey, PhD, OTR/L; Campus Box 1196, One Brookings Drive, St. Louis MO, 63110; Phone: 314-935-3073; Fax: (314) 935-4859; Email: baileyr@wustl.edu. AUTHOR DISCLOSURES: The authors report no conflicts of interest. This work was supported by the National Institutes of Health under Grant P30DK092950 and Grant 5T32HL130357-02. The contents of this work are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The authors report no financial benefit to the authors from this study. At the time of submission, this work has not been previously presented in any form. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
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