Physiatry as a Leader for Postacute Care in Integrated Healthcare Systems.

Because health care is being moved to a higher level of accountability, there has been a focus on improving outcomes through improving postacute care. The issues of cost and readmissions to acute care settings are very important, but the focus on patient function has not been foremost. Because of the fact that most postacute care needs are based on functional limitations and that physiatrists are well versed in transitions of care, rehabilitation of patients back to community settings, team building, and leadership, it is appropriate for rehabilitation medicine to take a leadership role in the planning and development of postacute care services in the new integrated healthcare systems that are becoming prevalent in healthcare. This review discusses some of the issues in postacute care, the growth of the integrated health system model, and how there are opportunities and challenges for physiatric leadership to help develop these new models of care.

Rehabilitation for Cancer Survivors: How We Can Reduce the Healthcare Service Inequality in Low- and Middle-Income Countries.

Cancer diagnosis often substantially affects patient's physical, psychological, and emotional status. Most patients with cancer experience declining of energy, activity levels, social-cultural participation, and relationships. In addition, cancer progression and adverse effects of aggressive cancer treatment often cause debilitating pain, fatigue, weakness, joint stiffness, depression, emotional instability, limited mobility, poor nutritional status, skin breakdown, bowel dysfunction, swallowing difficulty, and lymphedema leading into functional impairment and disability that can be addressed through rehabilitation care. Comprehensive care models by involving cancer rehabilitation have resulted in significant improvement of patient's quality of life. Although cancer rehabilitation has been implemented in many high-income countries, it is either not yet or suboptimally delivered in most low- and middle-income countries. In this review, we discussed gaps regarding cancer rehabilitation services and identified opportunities to improve quality of cancer care in developing countries. Future collaborations among international organizations and stakeholders of health care delivery systems are required to initiate and improve high-quality cancer rehabilitation in the developing countries.

Evaluating Disability Insurance Assistance as a Specific Intervention by Physiatrists at a Cancer Center.

Because of their expertise, physiatrists provide disability insurance assistance for cancer survivors. In this brief report, we perform a descriptive retrospective analysis of all new (354) outpatient physiatry consultations from January 1, 2009, to December 31, 2013, at a National Cancer Institute Comprehensive Cancer Center. Disability and/or work accommodations were brought up at some point with the physiatrist during the duration of their care for 131 (37%) of 354 patients. More than 90% of the discussions took place during the first visit. Of those patients who had a documented disability/employment discussion, 58 (44.3%) of 131 patients were originally referred for disability assistance specifically, and 58 (44.3%) of 131 also had disability insurance paperwork completed by the physiatrist. Outcomes of initial physiatry disability insurance assistance were 45 (77.6%) of 58 approved/renewed, 5 (8.6%) of 58 denied, and 8 (13.8%) of 58 unknown/died during the disability application process. The median form size was 33 (SD, 25.95) items. This study is the first of its kind and provides an initial look at work-related discussions and support with disability insurance paperwork as a specific intervention provided by physiatrists at a cancer center. The results are compelling and demonstrate that physiatrists frequently provide these interventions. These interventions take considerable time and effort but are generally successful.

Epidemiological data on acupuncture and physical and rehabilitation medicine in the European Union.

OBJETIVE: To know the prevalence of acupuncturists within physical and rehabilitation medicine specialists in Europe and their characteristics, as well as to analyze the pathologies treated and therapeutic techniques used. METHODS: This is a cross-sectional descriptive study based on a structured and closed questionnaire. The study was carried out from October 2011 to May 2014. RESULTS: A total of 115 specialists from 19 countries completed the questionnaire. The mean characteristics of the physical and rehabilitation medicine (PRM) specialists who are also acupuncturists in Europe were: women (62.6 %); mean age of 47.91 years old; 4.20 years of physical and rehabilitation medicine school and 2.00 years of acupuncture training; 15.03 years of mean time of clinical practice as physical and rehabilitation medicine specialists and 10.42 years of experience as acupuncturists; 35.65 % had a doctorate (PhD) degree, obtained at a mean age of 33.55 years old; working in a public hospital (80%); treating mainly neurological conditions (48.1% ) and using mainly techniques such as kinesiotherapy (11.81%), orthosis (10.40%) and electrotherapy (9.92%). Acupuncture was applied by 32.2% of the participants mainly in musculoskeletal conditions (27.38%). A mean number of more than 20 patients a day were treated by 47.04% of the specialists, being 41.8% of the patients (adults and children). Significant differences were found between the variables, acupuncture and gender (Pearson's correlation Index = 0.007). However, no differences were observed in relation to acupuncture and age, doctorate degree, years of clinical practice and workplace (all with P values > 0.05). CONCLUSION: In the European area, physical and rehabilitation medicine specialists who are also acupuncturists are mainly female, middle-aged, with 15 years of professional experience, PhD holders, working in public hospitals, treating mainly neurological conditions with kinesiotherapy and acupuncture, and treating over 20 patients a day (adults and children) during a 7 h shift. Further epidemiological studies on PRM to provide more information regarding the real situation of this medical specialty and the possibility to open to Chinese traditional medicine techniques such as acupuncture are necessary.

Regenerative principles enrich cardiac rehabilitation practice.

Cardiovascular morbidity imposes a high degree of disability and mortality, with limited therapeutic options available in end-stage disease. Integral to standard of care, cardiac rehabilitation aims on improving quality-of-life and prolonging survival. The recent advent of regenerative technologies paves the way for a transformative era in rehabilitation medicine whereby, beyond controlling risk factors and disease progression, the prospect of curative solutions is increasingly tangible. To date, the spectrum of clinical experience in cardiac regenerative medicine relies on stem cell-based therapies delivered to the diseased myocardium either acutely/subacutely, after a coronary event, or in the setting of chronic heart failure. Application of autologous/allogeneic stem cell platforms has established safety and feasibility, with encouraging signals of efficacy. Newer protocols aim to purify cell populations in an attempt to eliminate nonregenerative and enrich for regenerative cell types before use. Most advanced technologies have been developed to isolate resident cell populations directly from the heart or, alternatively, condition cells from noncardiac sources to attain a disease-targeted lineage-specified phenotype for optimized outcome. Because a multiplicity of cell-based technologies has undergone phase I/II evaluation, pivotal trials are currently underway in larger patient populations. Translation of regenerative principles into clinical practice will increasingly involve rehabilitation providers across the continuum of patient care. Regenerative rehabilitation is thus an emerging multidisciplinary field, full of opportunities and ready to be explored.

Therapeutic ultrasound in physical medicine and rehabilitation: characterization and assessment of its physical effects on joint-mimicking phantoms.

The aim of the study described here was to quantitatively assess thermal and mechanical effects of therapeutic ultrasound (US) by sonicating a joint-mimicking phantom, made of muscle-equivalent material, using clinical US equipment. The phantom contains two bone disks simulating a deep joint (treated at 1 MHz) and a superficial joint (3 MHz). Thermal probes were inserted in fixed positions. To test the mechanical (cavitational) effects, we used a latex balloon filled with oxygen-loaded nanobubbles; the dimensions of the oxygen-loaded nanobubbles were determined before and after sonication. Significant increases in temperature (up to 17°C) with fixed field using continuous waves were detected both in front of and behind the bones, depending on the US mode (continuous wave vs. pulsed wave) and on the treatment modality (fixed vs. massage). We found no significant differences in mechanical effects. Although limited by the in vitro design (no blood perfusion, no metabolic compensation), the results can be used to guide operators in their choice of the best US treatment modality for a specific joint.

Factors influencing interest in providing MS patient care among physiatry residents.

BACKGROUND: Rehabilitation care is an important part of comprehensive care for MS patients. Little is known about the number of physiatry residents who are interested in providing care to individuals with multiple sclerosis [MS]. OBJECTIVE: This study examines factors that influence physiatry residents' interest in providing care to MS patients. METHODS: We randomly sampled half of all Accreditation Council for Graduate Medical Education-certified physical medicine and rehabilitation residency programs in the continental United States and Puerto Rico. Surveys were received from 74% of programs (Stage 1 response rate) and from 221 residents (45% Stage 2 response rate). RESULTS: Residents expressing interest in providing MS care were more likely to be female, Asian, and to select statements emphasizing multidisciplinary care approaches and a community of dedicated professional colleagues as positive features of MS patient care. Residents interested in teaching and with more education debt were marginally more likely to express interest in MS care. CONCLUSIONS: Medical education should emphasize the need for physical medicine and rehabilitative care among individuals with MS, the ability of physiatrists to improve the functional status and quality of life for MS patients, and the team-based nature of MS care.

Variable criteria for patellofemoral bracing among sports medicine professionals.

OBJECTIVE: To examine whether the frequency of bracing, geographic region, clinical specialty, or percentage of practice devoted to knee pain influences the criteria used by sports medicine professionals to determine whether a brace should be prescribed for treating patients with nontraumatic patellofemoral pain syndrome. DESIGN: Cross-sectional study. SETTING: Sports medicine practices in the United States. PARTICIPANTS: A total of 1307 athletic trainers, physical therapists, and sports medicine physicians recruited from the e-mail listings of the American Medical Society for Sports Medicine, the American Osteopathic Academy of Sports Medicine, the American Physical Therapy Association Sports Physical Therapy Section, the International Patellofemoral Study Group, the International Patellofemoral Retreat list, and National Collegiate Athletic Association Division 1 athletic team registries. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Thirty-seven potential patellofemoral bracing criteria encompassing history and function, alignment, physical examination, previous treatments, and radiographic evidence. RESULTS: A total of 1307 of 7999 providers replied (response rate, 16.3%). Mean bracing frequencies were 19.8% for athletic trainers, 13.4% for physical therapists, and 25.1% for physicians. The mean number of total bracing criteria used was 10.5. The 10 most commonly cited criteria for prescribing a patellofemoral brace in descending order of frequency were: (1) hypermobile patella on physical examination; (2) positive J sign on physical examination; (3) failure of previous rehabilitation; (4) pain when performing squats or going up/down stairs on history; (5) success with previous taping; (6) pain with running activities on history; (7) pain with jumping activities on history; (8) increased dynamic Q angle; (9) vastus medialis oblique deficiency in timing or strength; and (10) positive apprehension sign on physical examination. No statistically significant trends were noted with regard to experience or percentage of practice devoted to knee pain. Increased bracing frequency was significantly associated with an increased number of bracing criteria (r = 0.89, P < .0001). CONCLUSIONS: This study identified little overall consensus and showed that significant differences exist in the criteria used to prescribe a brace for patellofemoral pain syndrome among specialties and in relation to bracing frequency.

Local soft tissue musculoskeletal disorders and injuries. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. Soft tissue musculoskeletal disorders (MSDs) and injuries are associated with significant pain and loss of function that may lead to significant disability. The aim of this paper is to define the role of PRM physician in the management of local soft tissue MSDs and injuries with their specific focus on assessing and improving function as well as participation in the community. The training of PRM specialists make them well equipped to successfully treat MSDs including soft tissue MSDs and injuries. PRM specialists may well meet the needs of patients with soft tissue MSDs and injuries using PRM approaches including 1) assessment based on the comprehensive model of functioning, the International Classification of Functioning, Disability and Health (ICF), that enable them to identify the areas of impaired functioning in order to apply necessary measures; 2) accurate diagnosis using instrumental diagnostic procedures in addition to clinical examination; 3) outcome measurements available to them; 4) evidence-based pharmacological and nonpharmacological treatments; and finally 5) maintenance of social involvement including "return to work" based on restoration of function, all of which will eventually result in improved quality of life for patients with soft tissue MSDs and injuries.

Generalised and regional soft tissue pain syndromes. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. Generalised and regional soft tissue pain syndromes constitute a major problem leading to loss of function and disability, resulting in enormous societal burden. The aim of this paper is to describe the unique role of PRM physicians in the management of these disabling conditions that require not only pharmacological interventions but also a holistic approach including the consideration of body functions, activities and participation as well as contextual factors as described in the ICF. Evidence-based effective PRM interventions include exercise and multicomponent treatment including a psychotherapeutic intervention such as cognitive behavioural therapy (CBT) in addition to exercise, the latter based on strong evidence for reducing pain and improving quality of life in fibromyalgia syndrome (FMS). Balneotherapy, meditative movement therapies, and acupuncture have also been shown as efficacious in improving symptoms in FMS. Emerging evidence suggests the use of transcranial magnetic or direct current stimulation (rTMS or tDCS) in FMS patients with intractable pain not alleviated by other interventions. Graded exercise therapy and CBT are evidence-based options for chronic fatigue syndrome. The use of some physical modalities and manipulation for myofascial pain syndrome is also supported by evidence. As for complex regional pain syndrome (CRPS), strong evidence exists for rTMS and graded motor imagery as well as moderate evidence for mirror therapy. Interventional techniques such as blocks and spinal cord stimulation may also be considered for CRPS based on varying levels of evidence. PRM physicians' functioning oriented approaches on the assessment and management, adopting the ICF as a reference, may well meet the needs of patients with soft tissue pain syndromes, the common problems for whom are loss of function and impaired quality of life. Available evidence for the effectiveness of PRM interventions serves as the basis for the explicit role of PRM specialists in the management of these health conditions.

Osteoarthritis. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the PRM interventions. Osteoarthritis (OA) is the most common joint disorder and the major cause of musculoskeletal pain and limited mobility in the elderly in the world. Therefore, proper management of persons with OA is of substantial importance. The goal of OA management is to reduce the impact of OA on the individual by reducing pain and improving function, activities and participation. The aim of this paper is to descibe the explicit role of PRM physicians in providing management for persons with OA. The optimal management of OA requires the combination of both non-pharmacological and pharmacological approaches, an issue most of the main guidelines on the evidence-based management of OA share in common. There is good level of evidence about the effectiveness of PRM interventions in the management of OA: high level of evidence about the effect of education, weight reduction and exercise and growing evidence about the effectiveness of physical agent modalities. PRM specialists are involved not only in diagnosis and medical and physical treatments of OA, but, as a rehabilitation strategy, they also deal with the problems of the person focusing on the improvement of all components of human functioning as defined in the ICF including personal and environmental factors with a holistic approach. ICF core sets for OA serve as excellent models for directing proper assessments as well as targeting interventions. PRM specialists well meet the needs of people with OA from the early stages of the disease to the stage of disability that could cause activity limitations and participation restrictions. In conclusion, PRM specialists can make substantial contributions to providing management of OA in order to improve the functioning of individuals with OA from both personal and societal perspective.

Utilidad del campo magnético en la cervicobraquialgia crónica / No disponible

La medicina física y rehabilitación consta con un arsenal terapéutico amplio para tratar afecciones crónicas, utilizando esencialmente agentes físicos naturales y artificiales. El tratamiento casi siempre es conservador y puede utilizarse la aplicación local de las corrientes eléctricas y el campo magnético como medidas de fisioterapia. Teniendo en cuenta los efectos biológicos de la terapia con campo magnéticoregional, se investigó su utilidad en la cervicobraquialgia crónica, que representa una de las formas más frecuentes de incapacidad que acuden a nuestras consultas. Objetivos: evaluar la eficacia del campo magnético regional en la cervico-braquialgia crónica con respecto a la corriente interferencial. Material y métodos: el estudio prospectivo y descriptivo se realizó en el Servicio de Fisiatría de la Clínica Central Cira García, en el periodo comprendido entre diciembre del 2008 a diciembre del 2009. El universo estuvo compuesto por 60 pacientes y la muestra por dos grupos de pacientes (30 cada uno) que cumplieron los requisitos de inclusión para la entidad. Se les aplicó la escala analógico visual y el test de McGill para la evaluación del dolor y la escala de incapacidad de Lee y Stanford en la consulta inicial y finalizado el tratamiento. Un grupo realizó tratamiento con corriente interferencial, y otro grupo recibió tratamiento con magnetoterapia regional. La información se procesó por paquete estadístico SPSS versión 11.5. Resultados y conclusiones: la evolución del dolor y la incapacidad entre los grupos no tuvieron diferencias significativas, para una p menor a 0,05; ambas terapias son efectivas en el abordaje de esta entidad. La Corriente Interferencial fue más efectiva para el alivio del dolor cuando se comparó con la Magnetoterapia regional. Solo se presentaron escasas reacciones adversas con la corriente interferencial (AU)

The Physical Medicine and Rehabilitation consists with a wide therapeutic arsenal to treat chronic affections, using natural and artificial physical agents essentially. The treatment is almost always conservative and it can be used the local application of the electric currents and the magnetic field as physiotherapy measures. Keeping in mind the biological effects of the therapy with regional magnetic field, their utility was investigated in the chronic cervical pain that represents one in the most frequent ways in inability that go to our consultations. Objectives: to evaluate the effectiveness of the regional magnetic field in the chronic cervical pain with regard to the application of interferential current. Material and methods: the prospective and descriptive study was carried out in the Service of Rehabilitation of the Central Clinic "Cira García", in the period understood among December 2008 to December 2009. The universe was compound for 60 patients and the sample for two groups of patient (30 each one) that completed the insertion requirements for the entity. They were applied the visual analogical scale and McGill's test for the evaluation of the pain and the scale of inability of Lee and Stanford in the initial and concluded consultation the treatment. A group carried out treatment with interferential current, and another group received treatment with regional magneto therapy. The information was processed by statistical package SPSS version 11.5. Results and conclusions: the evolution of the pain and the inability among the groups didn't have significant differences, or p less than 0.05; both therapies are effective in the boarding of this entity. The interferential current was more effective for the relief of the pain when it was compared with the regional magnetotherapy. Scarce adverse reactions were only presented with the interferential current (AU)

A theoretical framework for the role of fascia in manual therapy.

A theoretical framework for the role that fascia may play in apparently diverse passive manual therapies is presented. The relevant anatomy of fascia is briefly reviewed. Therapies are divided into myofascial ('soft tissue') and manipulative ('joint-based') and comparisons are made between them on a qualitative basis using measures of pain, function and 'autonomic activation'. When these three outcomes are evaluated between therapies it is observed that they are usually comparable in the quality, if not the quantity of the measures. Viewed from a patients' perspective alone the therapeutic benefits are hard to distinguish. It is proposed that a biologically plausible mechanism which may generate a significant component of the observed effects of manual therapies of all descriptions, is the therapeutic stimulation of fascia in its various forms within the body. Such considerations may help explain why diverse therapies apparently give comparable results.

The role of physical medicine and rehabilitation for patients in palliative and hospice care.

Veterinary patients in palliative and hospice care have progressive and often degenerative diseases that can cause pain as well as loss of function and decreased quality of life. These patients can often benefit from the application of physical medicine and rehabilitation techniques to maximize comfort and function. Physical medicine and rehabilitation are most effective as adjuncts to pharmacologic pain management. Physical medicine and rehabilitation can decrease the doses of analgesics required to keep these patients comfortable. The blend of physical and pharmacologic medicine allows an optimum balance between maximum comfort and maximum mentation.

An overview of CAM: components and clinical uses.

Complementary and alternative medicine (CAM), more recently known as integrative health or integrative medicine, is a diverse field comprising numerous treatments and practitioners of various levels of training. This review defines several of the main CAM modalities and reviews some of the research relevant to their clinical application. The goal is to provide healthcare providers with a basic understanding of CAM to start the incorporation of proven treatments into their clinical practice as well as guide them to working with CAM providers; ultimately, such knowledge is a fundamental part of a collaborative approach to optimal patient health and wellness.

Technology to enhance physical rehabilitation of critically ill patients.

BACKGROUND: Neuromuscular complications after critical illness are common and can be severe and persistent. To ameliorate complications, there is growing interest in starting physical medicine and rehabilitation therapy immediately after physiologic stabilization. The introduction of physical medicine and rehabilitation-related technology into the intensive care unit may help facilitate delivery of this therapy. DISCUSSION: Neuromuscular electrical stimulation therapy creates passive contraction of muscles through low-voltage electrical impulses delivered through skin electrodes placed over target muscles. Although neuromuscular electrical stimulation has not been studied in patients with acute critical illness, published guidelines based on available evidence suggest that neuromuscular electrical stimulation may be considered in intensive care unit patients who are at high risk of developing muscle weakness. Bedside cycle ergometry can provide range of motion and muscle strength training for intensive care unit patients who are either sedated or awake, and may help preserve muscle architecture and improve strength and function. Finally, custom-designed technological aids to assist with ambulating mechanically ventilated patients may reduce the human resource requirements and improve the safety and effectiveness of early mobilization in the intensive care unit. CONCLUSION: Physical medicine and rehabilitation-related technologies may play an important role in preventing and treating intensive care unit-acquired neuromuscular complications. Future studies are needed to evaluate their efficacy in intensive care unit patients.

Effect of treatment with low-intensity and extremely low-frequency electrostatic fields (Deep Oscillation) on breast tissue and pain in patients with secondary breast lymphoedema.

OBJECTIVE: To investigate symptoms and functional impairment in women with secondary lymphoedema of the breast following surgical treatment and to assess the therapeutic benefit of treatment with low-intensity and extremely low-frequency electrostatic fields (Deep Oscillation), supplementing manual lymphatic drainage. METHODS: Twenty-one patients were randomized either to the treatment group (n=11): 12 sessions of manual lymphatic drainage supplemented by Deep Oscillation, or to the control group (n=10): manual lymphatic drainage alone. Assessment included subjective pain and swelling evaluation, range of motion of the shoulder and the cervical spine, and analysis of breast volume using a 3D measuring system. RESULTS: Patients had high pain and swelling scores at baseline. Shoulder mobility was impaired in all patients; restriction of cervical spine mobility was common at baseline and declined further in the control group. Deep Oscillation resulted in significant pain reduction in the treatment group. The subjective reported reduction of swelling in both groups was confirmed objectively by 3D measurement only in the treatment group. CONCLUSION: Additional Deep Oscillation supplementary to manual lymphatic drainage can significantly enhance pain alleviation and swelling reduction in patients with secondary breast lymphoedema compared with manual lymphatic drainage alone.

Physical medicine and complementary approaches.

Medical approaches to the treatment of spine pain are the cornerstone of therapy for neck and back pain. Although these techniques are used widely, seldom have they been subjected to the scrutiny of careful randomized and controlled clinical trials. The costs of complementary treatments, such as spinal manipulation, massage therapy, and acupuncture, now are reimbursed by many medical insurance providers, but these modalities lack much scientific support. Physical medicine and complementary treatment modalities and some of the scientific studies aimed at assessing their effectiveness are reviewed.