Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship.

Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.

Going Virtual: A Virtual Summer Physical Medicine and Rehabilitation Externship Experience for Medical Students.

ABSTRACT: Opportunities for early medical student exposure to the field of physical medicine and rehabilitation (PM&R) are desirable for promoting the field as a career choice and are useful for introducing students to the care of people with disabilities. The COVID-19 pandemic disrupted medical education and caused the cancellation of many in-person clinical programs, including the Medical Student Summer Clinical Externship in PM&R supported by the Association of Academic Physiatrists. This article describes the process by which an in-person summer clinical externship program was effectively converted into a Virtual PM&R Experience using a combination of independent assignments and small-group sessions. A total of 87 medical students completed the Virtual PM&R Experience over two summers. The participants of the program met the program learning objectives, including enhancing their understanding of physiatry as a career and recognizing the medical and social issues that affect persons with disability.

Scoping Review of Interventions and Experiences Increasing Medical Student Interest in Physical Medicine and Rehabilitation.

ABSTRACT: Increasing medical student exposure to physical medicine and rehabilitation is an important factor for future growth of the field. Therefore, it is important to determine which types of interventions during medical school have the greatest impact on medical students' decision to pursue a career in physical medicine and rehabilitation. The purpose of this study is to perform a scoping review of the current literature that has analyzed how different interventions and experiences impact medical school students' decision to pursue a career in physical medicine and rehabilitation. A systematic and comprehensive search strategy was implemented across five different journal databases and yielded 18 articles meeting the inclusion criteria. Most studies analyzing specific interventions looked only at presurvey and postsurvey comparisons of the immediate impact of the intervention on interest in physical medicine and rehabilitation, and few looked at longitudinal outcomes, such as match characteristics. The most frequently cited factor that was shown to positively impact interest in physical medicine and rehabilitation was early exposure. Participating in clinical rotations also had a positive impact but was most effective when combined with early exposure. This review highlights the need for national recommendations for integrating physical medicine and rehabilitation into all 4 yrs of medical education.

Evaluation of the Association of Academic Physiatrists Medical Student Summer Clinical Externship.

ABSTRACT: The Medical Student Summer Clinical Externship is an 8-wk program hosted by the Association of Academic Physiatrists and offered to first year medical students. Various institutions sponsor participants and provide clinical exposure and mentorship opportunities to promote interest in the field. The program has had more than 100 medical student participants. Students were asked to complete a preparticipation and postparticipation survey. Results revealed a statistically significant increase in interest in physiatry and participants' scores for comfort and experience level in obtaining a history of present illness, general physical examination, and managing developmental, musculoskeletal, and neurologic disabilities. The Medical Student Summer Clinical Externship program provides an opportunity for mentorship and exposure to various subspecialties that likely reinforces student interest in those who are predisposed to physiatry. Students' increased comfort level in treating patients with developmental, musculoskeletal, and neurologic disabilities may lead to improvements in the quality of and access to care received by these populations. All participants gain an increased awareness of the scope of practice of physiatry that will hopefully lead to the increased integration of physical medicine and rehabilitation into the care plans and as a standard of care for patients who might greatly benefit.

Competency-Based Curriculum Development to Meet the Needs of People With Disabilities: A Call to Action.

People with disabilities constitute 22.2% of the population in the United States, and virtually all physicians have people with disabilities in their clinical practice across a wide range of diagnostic groups. However, studies demonstrate that people with disabilities are inadequately served by the health care system, leading to high costs and poor outcomes. The authors argue that one cause of this discrepancy is that medical students receive limited training in the care of people with disabilities and may therefore not be able to adequately meet the competencies that underlie the Core Entrustable Professional Activities for Entering Residency. To address these gaps, the authors present practical examples of integrating concepts of disability into the curriculum with minimal additional time requirements. A comprehensive disability curriculum is suggested to include active classroom learning, clinical, and community-based experiences. At institutions that do not have a comprehensive curriculum, the authors recommend adding disability-related knowledge and skill acquisition to existing curricula through modifications to current case-based learning, simulated patients, and objective structured clinical examinations. To facilitate curriculum development, they recommend that the World Health Organization International Classification of Functioning, Disability, and Health be used as a tool to build disability concepts into active learning. The goal of these recommended curricular changes is to enhance student performance in the clinical management of people with disabilities and to better train all future physicians in the care of this population.

A Lean Six Sigma quality improvement project to increase discharge paperwork completeness for admission to a comprehensive integrated inpatient rehabilitation program.

Lean Six Sigma (LSS) process analysis can be used to increase completeness of discharge summary reports used as a critical communication tool when a patient transitions between levels of care. The authors used the LSS methodology as an intervention to improve systems process. Over the course of the project, 8 required elements were analyzed in the discharge paperwork. The authors analyzed the discharge paperwork of patients (42 patients preintervention and 143 patients postintervention) of a comprehensive integrated inpatient rehabilitation program (CIIRP). Prior to this LSS project, 61.8% of required discharge elements were present. The intervention improved the completeness to 94.2% of the required elements. The percentage of charts that were 100% complete increased from 11.9% to 67.8%. LSS is a well-established process improvement methodology that can be used to make significant improvements in complex health care workflow issues. Specifically, the completeness of discharge documentation required for transition of care to CIIRP can be improved.

Evidence-based venous thromboembolism prophylaxis is associated with a six-fold decrease in numbers of symptomatic venous thromboembolisms in rehabilitation inpatients.

OBJECTIVES: To measure the impact of a standardized risk assessment tool and specialty-specific, risk-adjusted venous thromboembolism (VTE) order sets on compliance with American College of Chest Physicians (ACCP) guidelines and the number of symptomatic VTE as assessed by administrative data. DESIGN: Prospective cohort study. SETTING: Academic hospital inpatient rehabilitation unit. PATIENTS AND PARTICIPANTS: All patients on the rehabilitation unit. METHODS AND INTERVENTIONS: Assessment of VTE risk factors and evaluated admission VTE prophylaxis orders before and after implementation of an ACCP guideline-based, specialty-specific VTE risk assessment, and prophylaxis order set by using a standardized data collection form. MAIN OUTCOME MEASURES: Discharge diagnostic codes for VTE and pulmonary embolism were tracked by ICD-9 (International Classification of Diseases, 9th edition) discharge diagnosis codes for the 12 months before and 36 months after the intervention. RESULTS: Before implementation of the VTE order set, 27% of patients received VTE prophylaxis in compliance with the 2004 ACCP VTE guidelines. By following implementation of specialty-specific, risk-adjusted VTE order sets, compliance increased to 98%. In the year before VTE order-set implementation, the number of VTEs per admission was 49 per 1000. By following implementation, the number of VTEs steadily decreased each year to 8 per 1000 in 2007 (χ(2) = 14.985; P = .0001). CONCLUSIONS: Implementation of a standardized VTE risk assessment tool and prophylaxis order set resulted in a substantial improvement in compliance with ACCP guidelines for VTE prophylaxis and was associated with a 6-fold reduction in the number of symptomatic VTEs in a hospital-based rehabilitation unit.

Musculoskeletal education for medical students.

Musculoskleletal conditions comprise the second most common reason for physician visits and have the greatest negative impact on health-related quality of life in the industrialized world. Therefore, all medical schools should provide education for their students in these disorders. Physiatrists play a unique role in musculoskeletal care and hence, should play a leading role in medical student education. The Association of Academic Physiatrists formed a task force in 2007 to make recommendations as to how physiatrists could contribute to musculoskeletal education for medical students. This report contains those recommendations.

Barriers to pain management in the rehabilitation of the surgical oncology patient.

Virtually every surgical oncology patient faces pain, and it can become a major barrier to rehabilitation and quality of life. Pain must be assessed as to its severity, etiology (somatic, visceral, or neuropathic), causation (directly from malignancy or from treatment side effects), and its impact on daily function. Treatments can include physical modalities, exercise, opioids, adjuvant medications, and interventional techniques. Barriers to treatment may include side effects, finances, and attitudes. New technologies in medication delivery systems, intrathecal pumps, injections, and surgery have greatly strengthened the armamentarium available to manage pain.

Management of diabetes during acute stroke and inpatient stroke rehabilitation.

OBJECTIVES: To summarize evidence on the impact of hyperglycemia on stroke outcomes and to present therapy algorithms for inpatient management in diabetic stroke patients. DATA SOURCES: Guidelines for inpatient management of diabetes were reviewed and extracted from a technical review and recommendations from 2 national diabetes and endocrine organizations. MEDLINE database searches were conducted using key words: stroke, diabetes, hyperglycemia, hypoglycemia, inpatient, hospitalized, treatment, outcomes, disability, self-management, and education. STUDY SELECTION: Studies were selected that specifically addressed the impact of the following in stroke patients: hyperglycemia and diabetes on rehabilitation outcomes, management strategies for hyperglycemia and diabetes, and strategies for facilitating diabetes self-management. DATA EXTRACTION: Two authors independently extracted data and management practices from selected articles and published practice guidelines. DATA SYNTHESIS: Diabetes is prevalent in stroke patients and results in poorer inpatient hospital and rehabilitation outcomes. Management of diabetes in stroke patients is further complicated by impairments in mobility and vision, necessitating accommodation strategies and tools for self-management. Optimal management of hyperglycemia using insulin or oral hypoglycemic agents results in reduced morbidity and mortality among diabetic inpatients. CONCLUSIONS: To achieve inpatient glycemic management targets, use of clinical management algorithms, self-management tools, and systems approaches such as diabetes management teams are useful.

Rehabilitation of hospital inpatients with visual impairments and disabilities from systemic illness.

OBJECTIVES: To describe the comorbidity of visual impairment and disability among patients hospitalized for systemic illness and to discuss rehabilitation. DESIGN: Retrospective study. SETTING: Hospital-based, academic tertiary medical center with referring neurology, ophthalmology, and rehabilitation units. PARTICIPANTS: Ninety-three hospitalized patients referred to the low vision rehabilitation clinic primarily by the physical medicine and rehabilitation and neurology units. INTERVENTIONS: Measurements of best-corrected visual acuity and other visual function testing. Referrals were made for prescriptive glasses, assistive devices, rehabilitation, resources, and ophthalmologic evaluation. MAIN OUTCOME MEASURES: Specialized services, presence of comorbidities, and visual function measurements. RESULTS: The mean admitting visual acuity revealed a moderate visual impairment. The primary diagnosis for admission (51%) was cerebrovascular accidents. There was a mean of 3.5 other comorbidities. CONCLUSIONS: The majority of patients admitted to the hospital for systemic diseases also had visual impairments. In many patients, this visual disability (either from the systemic and/or ocular disease) interfered with their activities of daily living.