Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health.

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

Integrating Cardiac Rehabilitation in Stroke Recovery.

Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.

Stroke Recovery Program with Modified Cardiac Rehabilitation Improves Mortality, Functional & Cardiovascular Performance.

BACKGROUND: Physical activity and exercise after stroke is strongly recommended, providing many positive influences on function and secondary stroke prevention. The purpose of this study was to investigate the effect of a stroke recovery program (SRP) integrating modified cardiac rehabilitation on mortality and functional outcomes for stroke survivors. METHODS: This study used a retrospective analysis of data from a prospectively collected stroke rehabilitation database which followed 449 acute stroke survivors discharged from an inpatient rehabilitation facility between 2015 and 2020. For 1-year post-stroke, 246 SRP-participants and 203 nonparticipants were compared. The association of the SRP including modified cardiac rehabilitation with all-cause mortality and functional performance was assessed using the following statistical techniques: log rank test, Cox proportional hazard model and linear mixed effect models. Cardiovascular performance over 36 sessions of modified cardiac rehabilitation was assessed using linear effect model with Tukey procedure. The primary outcome measure was 1-year all-cause mortality rate. Secondary outcomes were functional performance measured in Activity Measure of Post-Acute Care scores and cardiovascular performance measured in metabolic equivalent of tasks times minutes. RESULTS: The SRP-participants had: (1) a significantly reduced 1-year post-stroke mortality rate from hospital admission corresponding to a four-fold reduction in mortality (P = 0.005, CI for risk ratio = [0.08, 0.71]), (2) statistically and clinically significant improvement of function in all Activity Measure of Post-Acute Care domains (P < 0.001 for all, 95% CI for differences in Basic Mobility [5.9, 10.1], Daily Activity [6.2, 11.8], and Applied Cognitive [3.0, 6.8]) compared to the matched cohort and (3) an improvement in cardiovascular performance over 36 sessions with an increase of 78% metabolic equivalent of tasks times minutes (P < 0.001, 95% CI [70.6, 85.9%]) compared to baseline. CONCLUSIONS: Stroke survivors who participated in a comprehensive stroke recovery program incorporating modified cardiac rehabilitation had decreased all-cause mortality, improved overall function, and improved cardiovascular performance.

Focal Peripheral Neuropathies Observed in Patients Diagnosed With COVID-19: A Case Series.

ABSTRACT: A growing number of studies have documented a wide variety of neurological manifestations associated with the novel SARS-CoV-2 (COVID-19). Of the available literature, cranial neuropathies and central nervous system disorders, such as encephalopathy and ischemic strokes, remain the predominant discussion. Limited investigations exist examining peripheral neuropathies of those with COVID-19. This case series discusses eight patients who tested positive for COVID-19 and presented with localized weakness after a prolonged course of mechanical ventilation (>21 days). We retrospectively reviewed all patients' charts who received electrodiagnostic evaluation between March and November 2020 in the outpatient clinic or in the acute care hospital at the JFK Medical Center/JFK Johnson Rehabilitation Institute and Saint Peter's University Hospital of New Jersey. A total of eight COVID-19-positive patients were identified to have a clinical presentation of localized weakness after a prolonged course of mechanical ventilation. All patients were subsequently found to have a focal peripheral neuropathy of varying severity that was confirmed by electrodiagnostic testing. Patient demographics, clinical, and electrodiagnostic findings were documented. The findings of local weakness and focal peripheral neuropathies after diagnosis of COVID-19 raise significant questions regarding underlying pathophysiology and overall prognosis associated with COVID-19.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions.

OBJECTIVE: A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported. DESIGN: This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs. RESULTS: A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion. CONCLUSION: Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Physical Medicine and Rehabilitation Milestone Evaluation Project: Development of Standardized Rotation-Specific Milestone-Incorporated Faculty-of-Resident Evaluation Tools.

ABSTRACT: This tri-institutional study describes the outcomes of utilization of newly developed, standardized, rotation-specific evaluations for faculty assessment of resident achievement of the physical medicine and rehabilitation milestones. Thirty-six physical medicine and rehabilitation faculty, representing three distinct academic institutions, completed a prestudy survey on the adequacy of the rotation-generic resident evaluation tools historically in use at each institution. During the 2016-2017 academic year, faculty in all three institutions consistently used a new set of rotation-specific milestone-incorporated evaluation tools. The same faculty completed surveys assessing the new evaluation tools 6 and 12 months later. Ordinal logistic regression was used to compare survey results before and after implementation of the rotation-specific milestone-incorporated evaluation tools. Results demonstrate high tool satisfaction scores, and a statistically significant improvement in the adequacy and specificity of the new evaluation tools compared with the old ones. There was also a statistically significant improvement in both faculty understanding of the milestones and faculty ability to assess the milestones with use of the new tools compared with the old ones. The implementation of standardized physical medicine and rehabilitation rotation-specific milestone-incorporated faculty-of-resident evaluation tools across three institutions improves faculty ability to assess resident overall performance specifically related to resident achievement of the milestones in each rotation.

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-Cause Mortality, Cardiovascular Performance and Functional Performance.

OBJECTIVE: Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors. DESIGN: This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function. RESULTS: The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001). CONCLUSIONS: Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function.

Association of Academic Physiatrists Women's Task Force Report.

The Association of Academic Physiatrists (AAP) convened a women's task force in 2016, and the members agreed on a list of metrics that would permit retrospective data review pertaining to the representation and inclusion of women physicians in the society. Examples of categories examined included leadership positions (i.e., board membership, board presidents, committee membership, committee chairs, and resident fellow physician chairs), conference presentations (i.e., annual meeting session proposals, annual meeting faculty, annual meeting plenary speakers), and recognition awards (i.e., recognition award nominations and recipients). The findings highlight areas in which the Association of Academic Physiatrists has been successful in supporting gender equity and other areas in which women physiatrists have been underrepresented. The task force worked with the Board of Trustees to construct an action plan, asking the respective committees to address areas of underrepresentation. A volunteer from each committee was deemed a "diversity steward" and going forward will work directly with the task force as a liaison to document an action plan and collect data. The board plans to transparently report progress to members and other stakeholders, and the task force aims to publish a follow-up report within the next 5 years.

Interventional pain management skills competency in pain medicine fellows: a method for development and assessment.

The purposes of this project were to propose an educational module to instruct pain medicine fellows in the appropriate performance of interventional pain management techniques and to verify procedural competency through objective evaluation methodology. Eight board-certified pain medicine physicians spanning two fellowship programs trained seven fellows using a standardized competency-based module. Assessment tools address the basic competencies outlined by the Accreditation Council for Graduate Medical Education (American Board of Anesthesiology Pain Medicine Content Outline). The seven fellows demonstrated proficiency in every segment of the evaluation module. Objective measures compared the fellows' performance on standardized procedure checklists administered 9 mos into training; fellows in the 2012-2013 academic year also received testing at the 3-mo mark. Support for the assessment module is demonstrated by appropriate performance of interventional procedures, with improvement noted from 3-mo to 9-mo testing, successful completion of chart-stimulated oral examinations, proper performance of relevant physical examination maneuvers, and completion of program-specific medical knowledge written tests. The fellows were evaluated via patient surveys and 360-degree global rating scales, maintained procedure logs, and completed two patient-care reports; these were reviewed by program directors to ensure adequate completion. The standardized educational module and evaluation methodology presented provide a potential framework for the definition of baseline competency in the clinical skill area of interventional pain management.

Interventional spinal procedures in the presence of a Chiari malformation: a potential contraindication.

Although Chiari malformations are much more prevalent than once believed, no study has described treatment with an interventional spinal procedure. The purpose of this report was to discuss the clinical course of a patient who was diagnosed with a Chiari malformation and treated with three cervical epidural injections. In 2012, a 50-yr-old woman presented to a neurology clinic with chronic suboccipital headaches, diplopia, and increasing numbness/tingling in her upper extremities. Magnetic resonance imaging confirmed a type I Chiari malformation and a cervical syrinx. The patient was treated with three cervical epidural injections, after which her symptoms exacerbated. Consequently, a posterior fossa suboccipital craniectomy with C1 laminectomy and excision of extradural and intradural adhesions was performed. After surgical intervention, notable neurologic improvements were observed. Given the marked worsening of symptoms, the present report suggests that interventional spinal procedures may be a contraindication in the presence of a Chiari malformation with a syrinx.

Neuromuscular medicine competency in physical medicine and rehabilitation residents: a method of development and assessment.

This project endeavored to create an educational module including methodology to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients with neuromuscular disorders. It further sought to verify acquired competencies in neuromuscular rehabilitation through objective evaluation methodology. An American Association of Neuromuscular and Electrodiagnostic Medicine board-certified physician with 10 yrs of clinical experience in neuromuscular and general rehabilitation trained 19 residents using a standardized competency-based module. The residents were trained through clinical training, lectures, and review of self-assessment examination concepts from the American Academy of Physical Medicine & Rehabilitation syllabus provided in the Archives of Physical Medicine and Rehabilitation. After delivery of the educational module, knowledge acquisition and skill proficiency were measured in (1) completion of neuromuscular history and physical examination satisfactorily, (2) diagnosis and ability to design a patient care management plan via chart stimulated recall examinations, (3) physician-patient interaction via patient surveys, (4) physician-staff interaction via 360-degree global ratings, and (5) ability to write a comprehensive patient care report and to document a patient care management plan in accordance with Medicare guidelines via written patient reports. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. To test the success of the standardized educational module, data were collected on an ongoing basis. The objective measures compared resident self-assessment examination scores in neuromuscular rehabilitation before and after the institution of the comprehensive neuromuscular competency module in the residency program. Nineteen (100%) of 19 residents successfully demonstrated proficiency in every segment of the evaluation module by the end of the postgraduate year 2 inpatient neuromuscular rehabilitation rotation. Furthermore, the residents' proficiency, as demonstrated by the evaluation after the implementation of the standardized educational module, positively correlated with an increase in the residents' self-assessment examination scores in neuromuscular rehabilitation compared with the residents' scores before the educational module implementation throughout all 3 yrs of training. Resident proficiency in the skills and knowledge pertaining to neuromuscular rehabilitation were objectively verified after completion of the standardized educational module. Validation of the assessment tool is evidenced by the collected data correlating with significantly improved self-assessment examination scores, as outlined in the "RESULTS" section. In addition, the clinical development tool was validated by the residents being individually observed performing history and physical examinations and being deemed competent by the American Association of Neuromuscular and Electrodiagnostic Medicine board-certified physical medicine and rehabilitation physician. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical training area of neuromuscular rehabilitation.

Assessing competency in spasticity management: a method of development and assessment.

This project endeavored to create an educational module including methodology to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients with spasticity and other sequelae of the upper motor neuron syndrome. It further sought to verify acquired competencies in spasticity management through objective evaluation methodology. A physical medicine and rehabilitation board-certified physician with 10 yrs clinical experience in spasticity management trained 16 residents using a standardized competency-based module. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. The 16 residents successfully demonstrated proficiency in every segment of the evaluation module by the end of the Postgraduate Year 3 spasticity management rotation. Objective measures compared resident scores on an institution-specific standardized test administered before and after training. Resident proficiency in the skills and knowledge pertaining to spasticity management was objectively verified after completion of the standardized educational module. Validation of the assessment tool is evidenced by significantly improved postrotational institution-specific standardized test scores (mean pretest score, 61.1%; mean posttest score, 95.4%) as well as oral testing. In addition, the clinical development tool was validated by residents being individually observed performing skills and deemed competent by a board-certified physical medicine and rehabilitation physician specializing in spasticity management. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical skill area of spasticity management.

Tracheostomy management skills competency in physical medicine and rehabilitation residents: a method for development and assessment.

This educational unit was developed to instruct physical medicine and rehabilitation residents on tracheostomy management in non-ventilator-dependent patients and to implement an objective assessment format to measure the attainment of these skills. Thirty-one subjects participated in a 2-day didactic and hands-on workshop supervised by an attending physiatrist, certified speech pathologists, and registered nurses. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. To test the success of the standardized educational module, data have been collected on an ongoing basis for a period of 6 yrs. A before-and-after multiple-choice written examination, as well as simulated patient encounters consisting of eight segments divided into four stations, was used to assess knowledge acquisition and skill achievement. Before instruction, none of the 31 participants were able to perform appropriate tracheostomy care. After the workshop, 31 of 31 (100%) successfully demonstrated clinical proficiency in every segment of the evaluation element of the educational module. Furthermore, a significant increase in knowledge was observed in the multiple-choice examination from pretest to posttest (pretest, 52.7%; posttest, 84.5%). Participation in this module resulted in substantial acquisition of knowledge and skills regarding tracheostomy management for physical medicine and rehabilitation residents.