Effect of Adding a Wheelchair Immersion Program to a Physical Medicine and Rehabilitation Clerkship on Emotions, Behavior, and Attitude: A Prospective Pilot Study.

ABSTRACT: People with disabilities encounter significant barriers in health care and report that healthcare providers often lack an understanding in caring for them. Currently, there is limited disability awareness training in medical school curricula. This mixed-methods pilot study examined the effects of integrating a short wheelchair immersion program in a physical medicine and rehabilitation clerkship, versus the clerkship alone, on attitudes toward people with disabilities, comfort in treating people with disabilities, knowledge of wheelchair etiquette, and understanding of wheelchair-associated challenges. The standard training group underwent the physical medicine and rehabilitation clerkship, consisting of a 2-wk clinical rotation and didactic program. The intervention group additionally underwent a newly developed 1-hr wheelchair program where they simulated mobility and some activities of daily living as a "wheelchair user" and "caregiver." Quantitative analysis demonstrated that all students who completed the clerkship had significantly improved attitudes toward and comfort in treating people with disabilities, knowledge of wheelchair etiquette, and understanding of wheelchair-associated challenges, whereas students in the wheelchair immersion program had a greater change in understanding wheelchair-associated challenges. Qualitative analysis revealed that the intervention resulted in positive attitudinal changes. These findings suggest that integrating a brief wheelchair immersion program with a physical medicine and rehabilitation clerkship may enhance disability awareness training in medical school curricula.

Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia.

OBJECTIVE: To determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time. DESIGN: Retrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019. SETTING: SCIMS centers. PARTICIPANTS: Individuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Conversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores. RESULTS: Mean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores. CONCLUSIONS: While UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.

Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization.

OBJECTIVE: The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions. DESIGN: For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned. RESULTS: The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data. CONCLUSIONS: The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

Effect of an interventional educational wheelchair program on medical students' understanding of manual wheelchair use.

BACKGROUND: There is limited literature exploring the benefits of interactive wheelchair educational programs in medical student curricula. OBJECTIVE: To identify the effect of an educational interactive wheelchair program on medical students' understanding of wheelchair use. Researchers hypothesized that the program would increase understanding. DESIGN: Repeated-measures survey study with postintervention comparison. SETTING: Inpatient acute rehabilitation center. PARTICIPANTS: Out of 123 eligible fourth-year medical students on a mandatory physical medicine and rehabilitation clerkship, 79 students participated. INTERVENTION: All participants underwent a 2-hour educational wheelchair program consisting of (1) a disability lecture; (2) a video on the importance of proper wheelchair type and fit, wheelchair prescription, as well as recreational wheelchair use; and (3) an interactive wheelchair experience. MAIN OUTCOME MEASURES: Pre- and postsurvey Likert scale questions measured medical students' understanding of four main areas: (1) impact of manual wheelchair use, (2) challenges of manual wheelchair use, (3) manual wheelchair skills, and (4) wheelchair etiquette. RESULTS: A two-tailed sign test demonstrated a highly significant increase from pre- to postsurvey scores in each survey section (P < .001). Presurvey and postsurvey mean scores for impact of manual wheelchair use, challenges of manual wheelchair use, manual wheelchair skills, and wheelchair etiquette survey sections were 3.9 and 4.4, 3.1 and 4.4, 2.4 and 4.4, and 2.5 and 4.0, respectively. CONCLUSIONS: This study demonstrates that an interactive educational wheelchair program effectively increases medical students' understanding of manual wheelchair use. The addition of an educational interactive wheelchair program to medical student curricula is recommended to improve medical students' understanding of manual wheelchair use and its impact on users.

A Comparison of Diagnostic Stability of the ASIA Impairment Scale Versus Frankel Classification Systems for Traumatic Spinal Cord Injury.

OBJECTIVE: To determine whether the "sacral sparing" definition for completeness of traumatic spinal cord injury (SCI) is a more stable definition than the previously used Frankel Classification. DESIGN: Retrospective analysis of individuals enrolled in the Spinal Cord Injury Model Systems (SCIMS) database between 2011 and 2018. SETTING: SCIMS centers. PARTICIPANTS: Individuals (N=804) with traumatic SCI who were at least 16 years old at time of injury, were admitted to rehabilitation within 30 days, had American Spinal Injury Association Impairment Scale (AIS) grades A-D at admission, and had complete neurologic data at the time of admission and 1 year. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Frankel and AIS scores were computed for a cohort of 804 eligible cases. Stability was compared between the 2 classification systems by calculating the proportions of cases in which regression (conversion to a more severe impairment level) was observed. RESULTS: A larger proportion of individuals classified with "incomplete" injuries (grades B-D) at the time of admission using the Frankel system regressed to complete status at 1 year compared with the AIS criteria (9.4% vs 2.0%). Those with grade B injuries regressed to grade A more often using the Frankel system compared with the AIS system (19.7% to 5.4%). A larger proportion of people diagnosed as Frankel grade C or D regressed to Frankel grade A compared with individuals diagnosed as AIS grade C or D who regressed to AIS grade A (5.0% to 1.1%). CONCLUSIONS: More individuals diagnosed with neurologically incomplete SCI regressed to complete status at 1 year when using the Frankel system compared with AIS classification, which is based on sacral sparing. This reinforces the finding that the "sacral sparing" definition is a more stable classification in traumatic SCI.

Trends in Rates of ASIA Impairment Scale Conversion in Traumatic Complete Spinal Cord Injury.

Recent studies of persons with spinal cord injury (SCI) report higher conversion rates of the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades, especially for complete injuries. We examined the rate of conversion over time after complete SCI, accounting for demographic and injury characteristics. Subjects were 16 years of age and older with a complete SCI injury between 1995 and 2015, enrolled in the National SCI Database as day-1 admissions. We grouped subjects into 3-year intervals and assessed trends in conversion for the total sample and by tetraplegia (Tetra), high paraplegia (levels T1-9, HPara), and low paraplegia (levels T10-12, LPara).We used logistic regression to identify factors related to conversion such as age, sex, etiology, and level of injury. Of 2036 subjects, 1876 subjects had a follow-up examination between 30 and 730 days post-injury. Average age at injury was 34.2 ± 14.6 years; 79.8% were male, 44.6% Tetra, 35.3% HPara, and 20.1% LPara. There was a strong trend toward increased rates of conversion over time (p < 0.01 for all groups), especially for Tetra (to incomplete from 17.6% in 1995-1997 to 50% in 2013-2015, and to motor incomplete from 9.4% to 28.1%). Conversion rates for Para were less dramatic. There were increased odds of converting to incomplete for year of injury, level of injury (Tetra >LPara >HPara), non-violent etiology, and age (older is better). We found similar factors for conversion to motor incomplete, except sex was significant and etiology was not. Conversion rates from complete to incomplete and motor incomplete injury have been increasing, particularly for persons with tetraplegia. This has implications for acute clinical trials and for prognostication early after SCI.

Diagnosis and rehabilitation of a pregnant woman with spinal cord disorder due to spinal cord tumor.

Introduction: Spinal cord tumors are a rare cause of spinal cord disorder (SCD). Early diagnosis can be challenging, especially in patient populations with other potential etiologies for back pain, such as pregnant women. Case presentation: A 28-year-old female presented at 8 weeks gestation with thoracic back pain initially diagnosed as gestational low back pain. Her symptoms progressed to lower extremity weakness. After diagnosis and resection of a spinal cord ependymoma, we collaborated with the inpatient interdisciplinary team to devise a rehabilitation program focused on minimizing pregnancy-related complications and optimizing care of a newborn in the setting of a new paraplegia. Discussion: Providers should not assume all pregnant women with low back pain have gestational back pain, as it can be due to more insidious causes. The rehabilitation course for women who develop an SCD during gestation should be carefully tailored toward their pre- and post-natal care and with the education of how the disorder can affect pregnancy and parenting.

Charcot Spine following chronic spinal cord injury: an analysis of 201 published cases.

STUDY DESIGN: Analysis of published cases OBJECTIVES: To identify and describe symptoms, radiologic findings, treatment strategies, and reoccurrence of Charcot spine in individuals with spinal cord injury (SCI). METHODS: This analysis included all English articles published prior to October 2017, describing Charcot spine after SCI as identified by multiple reviewers. Articles were excluded if Charcot spine was attributed to alternative conditions. Individual level data were available for 94% of reported cases. Outcomes included demographic factors, injury characteristics, clinical presentation, radiologic findings, management, and reoccurrence. RESULTS: Fifty included papers described 201 individuals with SCI who developed Charcot spine. 86% of individuals had paraplegia and 93% of individuals had a neurologically complete injury. Mean length of initial spinal fusion spanned 7.7 vertebral bodies (SD = 3.9). The most common presenting symptoms were back pain (56%), spinal deformity (48%), and crepitus (34%). Vertebral body destruction (83%), osteophytes (61%), and endplate destruction (57%) were commonly reported on radiographs. Reoccurrence of Charcot spine was described in 19% of cases after initial treatment. CONCLUSION: Charcot spine after SCI commonly presents with low back pain and radiologic evidence of vertebral body destruction. Cases have been described more often in individuals with paraplegia and neurologically complete injuries. Surgical management is often pursued. A high rate of reoccurrence of Charcot spine in individuals with SCI after initial treatment has been reported.

Clinical Trials in Traumatic Spinal Cord Injury.

Traumatic spinal cord injury (SCI) results in impaired neurologic function that for many individuals is permanent and significantly impacts health, function, quality of life, and life expectancy. Many efforts have been taken to develop effective treatments for SCI; nevertheless, proven therapies targeting neurologic regeneration and functional recovery have been limited. Existing therapeutic approaches, including early surgery, strict blood pressure control, and consideration of treatment with steroids, remain debated and largely focus on mitigating secondary injury after the primary trauma has occurred. Today, there is more research being performed in SCI than ever before. Current clinical trials are exploring pharmacologic, cell-based, physiologic, and rehabilitation approaches to reduce secondary injury and also overcome barriers to neurorecovery. In the future, it is likely that tailored treatments combining many of these strategies will offer significant benefits for persons with SCI. This article aims to review key past, current and emerging neurologic and rehabilitation therapeutic approaches for adults with traumatic SCI.

Implementation of a Multifaceted Interactive Electrodiagnostic Medicine Workshop in a Physical Medicine and Rehabilitation Residency Program.

Electrodiagnostic medicine is a required component of Physical Medicine and Rehabilitation residency education, but limited resources exist to guide curriculum development. Our objective was to create a focused workshop to enhance our residency program's electrodiagnostic curriculum. We created two separate 1.5-day workshops, one basic and one advanced, for all residents. Each workshop included didactic sessions, case discussion, question and answer sessions, demonstrations, and hands-on participation with direct supervision and feedback. Presurveys and postsurveys were administered to evaluate the value of the workshops. We also assessed trends in electrodiagnostic self-assessment examination scores. Residents reported clinical electrodiagnostic rotations to be more valuable to their education than previous didactic sessions and independent learning. Self-reported knowledge of electrodiagnostic concepts, resident comfort level in planning, performing, and interpreting studies, and perceived value in independent learning of electrodiagnostic medicine improved after implementation of the workshops. There was a 7% improvement in the American Association of Neuromuscular and Electrodiagnostic Medicine electrodiagnostic self-assessment examination score compared with the previous year and a 15% improvement in the Physical Medicine and Rehabilitation self-assessment examination electrodiagnostic subscore compared with the previous 5 yrs. All participants recommended similar educational experience for other residents. This successful workshop may serve as a resource for other training programs.

Multiple sclerosis and sexual dysfunction: A need for further education and interdisciplinary care.

BACKGROUND: Multiple sclerosis (MS) is an autoimmune condition affecting young women and men, resulting in varied disabilities, including sexual dysfunction. OBJECTIVE: This narrative review aims to describe the prevalence, pathophysiology, and impact of sexual dysfunction in people with MS (PwMS); provide a review of current assessment and treatment strategies; and offer considerations for future care. METHODS: Literature review was performed to identify primary and secondary sources discussing sexual dysfunction in PwMS. RESULTS: Sexual dysfunction is common in PwMS and can occur throughout the disease course. Sexual dysfunction is associated with depression, reduced quality of life, and may have broader implications related to relationships, fertility, pregnancy, and parenting. The etiology is often multifactorial and can be classified as primary, secondary, or tertiary dysfunction. Sexual dysfunction in PwMS is underdiagnosed and undertreated; however, many healthcare providers may already have the skills required to care for PwMS with sexual dysfunction. CONCLUSIONS: Additional education for providers regarding the approach to assessment and management of sexual dysfunction, their potential role in treatment, and available specialized resources is needed. The role of interdisciplinary care with collaboration among providers should be considered. Further research should evaluate the impact of specific assessment tools and treatments on sexual dysfunction in PwMS.

Resident-Perceived Benefit of a Diagnostic and Interventional Musculoskeletal Ultrasound Curriculum: A Multifaceted Approach Using Independent Study, Peer Teaching, and Interdisciplinary Collaboration.

Musculoskeletal ultrasound (MSUS) training is now a required component of physiatry residency, but formal curriculum guidelines are not yet required or established. The authors' objective was to assess the educational value of a collaborative residency MSUS training program. The authors designed a structured MSUS training curriculum for residents based on the authors' experience and previous literature. Twenty-five residents participated in this MSUS curriculum designed by faculty and chief residents. Resident volunteers were trained by the faculty as "table trainers" who taught their peers in small groups. Hands-on MSUS training sessions were led by a Physical Medicine and Rehabilitation faculty MSUS expert. A Likert scale-formatted questionnaire assessed resident-perceived value of the curriculum. Response rate was 96% (22 of 23). Self-reported MSUS knowledge comparing precurriculum and postcurriculum implementation resulted in significant improvement (P = 0.001). Peer teaching was highly valued, with 86% of residents rating it "very" or "extremely" beneficial (mean [SD] score, 3.9 [1.1]). Self-guided learning, by supplemental scanning and reading, was rated "beneficial" or "very beneficial" by 73% of residents (3.0 [0.7]). The authors' successful pilot program may serve as a teaching model for other residency programs.

Association between alendronate, serum alkaline phosphatase level, and heterotopic ossification in individuals with spinal cord injury.

CONTEXT/OBJECTIVE: Only sparse evidence exists regarding the effectiveness of oral alendronate (ALN) in the prevention of heterotopic ossification (HO) in patients with spinal cord injury (SCI). The objective of this study is to investigate the protective effect of oral ALN intake on the appearance of HO in patients with SCI. STUDY DESIGN: Retrospective database review. SETTING: A Spinal Cord Unit at a Rehabilitation Hospital. PARTICIPANTS: Two hundred and ninety-nine patients with SCI during acute inpatient rehabilitation. INTERVENTIONS: Administration of oral ALN. OUTCOME MEASURES: The incidence of HO during rehabilitation was compared between patients with SCI receiving oral ALN (n = 125) and patients with SCI not receiving oral ALN (n = 174). The association between HO and/or ALN intake with HO risk factors and biochemical markers of bone metabolism were also explored. RESULTS: HO developed in 19 male patients (6.35%), however there was no significant difference in the incidence of HO in patients receiving oral ALN or not. The mean odds ratio of not developing versus developing HO given ALN exposure was 0.8. Significant correlation was found between abnormal serum alkaline phosphatase (ALP) levels and HO appearance (P < 0.001) as well as normal serum ALP and ALN intake (P < 0.05). CONCLUSION: Even though there was no direct prevention of HO in patients with SCI by oral ALN intake, abnormal serum ALP was found more frequently in patients with HO development and without oral ALN intake. This evidence could suggest that ALN may play a role in preventing HO, especially in patients with acute SCI with increasing levels of serum ALP.

Adiponectin is a candidate biomarker of lower extremity bone density in men with chronic spinal cord injury.

Adipose tissue is a major regulator of bone metabolism and in the general population obesity is associated with greater bone mineral density (BMD). However, bone-fat interactions are multifactorial, and may involve pathways that influence both bone formation and resorption with competing effects on the skeleton. One such pathway involves adipocyte production of adipokines that regulate bone metabolism. In this study we determined the association between BMD, walking status, and circulating adipokines (adiponectin and leptin) in 149 men with chronic spinal cord injury (SCI). Although adipokine levels did not vary significantly based on walking status, there was a significant inverse association between adiponectin and BMD in wheelchair users independent of body composition. We found no association between adiponectin and BMD in the walkers and no association between leptin and BMD in either group. These findings suggest that for subjects with chronic SCI, walking may mitigate the effect of adiponectin mediated bone loss. For wheelchair users, adipose-derived adiponectin may contribute to SCI-induced osteoporosis because the osteoprotective benefits of obesity appear to require mechanical loading during ambulation.