Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury.

OBJECTIVE: To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS). DESIGN: Secondary analysis including linear and logistic regressions were performed. SETTING: Data were collected in a previous clinical trial. PARTICIPANTS: One hundred eighty-four participants across 3 countries (N=184). MAIN OUTCOME MEASURES: Disability Rating Scales. RESULTS: Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks. CONCLUSIONS: This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.

Antibiotic prophylaxis with urodynamic studies in spinal cord injury: Assessing practice patterns and outcomes to guide future practice in a single center.

CONTEXT/OBJECTIVE: Despite urinary tract infections (UTIs) being a common problem in patients with spinal cord injuries (SCIs), and a well-known complication of invasive urologic procedures, little consensus exists regarding the standard of care for peri-procedural antibiotic use for SCI patients undergoing urodynamics studies (UDS). Our research seeks to evaluate local antibiotic prophylaxis pattern in SCI patients undergoing UDS, assess incidence of post-procedural UTI, describe local antibiotic resistance trends, and provide antibiotic stewardship considerations to guide future practice. DESIGN/SETTING/PARTICIPANTS: Retrospective cohort study of SCI patients undergoing UDS from January 2010 to January 2020 at a Veterans Affairs SCI Center. Data on patient demographics, UTI risk factors, pre-procedural urinalysis and culture, and peri-procedural antibiotics was extracted. Incidence of post-procedural UTI was tabulated. Findings were summarized using descriptive statistics. RESULTS: 331 patients were studied. Pre-procedural urine culture was done in 73% of cases, with positive results in 49%. E. coli was the most commonly isolated organism (19%). Antibiotics were used in 86% of cases, 26% of which had a negative culture. A onetime dose of intramuscular gentamicin given immediately pre-procedure was the most common practice (53%; N = 152). No cases of post-procedural UTIs were identified during the study period. CONCLUSION: No post-UDS UTIs occurred under current local practice where most patients received a one-time dose of intramuscular gentamicin as prophylaxis. Though routine gentamicin prophylaxis may play a role in reducing UTI incidence, the low rate of post-UDS UTI in this population, including patients with positive cultures who received no antibiotics, suggests the possibility of refining practice patterns to improve antibiotic stewardship.

Factors Influencing Physical Medicine and Rehabilitation Trainee Research Engagement.

ABSTRACT: Research engagement during physical medicine and rehabilitation residency and fellowship training is essential for advancing evidence-based medicine and fostering the development of clinician-scientists. Current Accreditation Council for Graduate Medical Education guidelines regarding research requirements during physical medicine and rehabilitation training are ambiguous, and it is unknown whether physical medicine and rehabilitation trainees receive adequate support to pursue research at the level they desire. This anonymous survey study aimed to identify perceived barriers and facilitators to research engagement among US physical medicine and rehabilitation residents and fellows. Our findings suggest that physical medicine and rehabilitation trainees value research engagement. However, research productivity during physical medicine and rehabilitation residency is limited, with many trainees reporting inadequate support and time to participate in research in a meaningful way. Additional support from residency and fellowship programs, including protected time for research, as well as research-specific education and mentorship should be considered to enhance physical medicine and rehabilitation trainee research engagement.

Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from disorders of consciousness.

Background: Disorders of consciousness (DoCs) after severe brain injury are considered to be conditions with dire prognosis. Despite the accumulating evidence, inpatient rehabilitation is often denied by payers referring to the Medicare/Medicaid criteria, under the assumption that such patients will not "actively" participate in therapy or make "measurable improvements." Objective: This study aimed to report on the effectiveness and efficiency of a specialized inpatient DoC rehabilitation program based on measurable clinical parameters. Methods: A retrospective cohort study was conducted. The cohort comprised 137 patients with DoC admitted to a specialized acute inpatient rehabilitation program between January 2014 and October 2018. Patients were categorized as having been admitted at the acute stage (<=28 days post-injury), subacute stage (29-365 days following a traumatic brain injury (TBI) or 29-90 days following a non-TBI), or chronic stage (>365 days following a TBI or >90 days following a non-TBI). Outcomes included changes in level of consciousness (based on the Coma Recovery Scale-Revised (CRS-R), while also acknowledging scenarios beyond those captured by the CRS-R via Individualized Qualitative Behavioral Assessment and team consensus); Functional Independence Measure (FIM) levels; achievements in decannulation and initiation of oral diet; and time to those achievements. Results: The rates of emergence from a minimally conscious state were 90, 62, and 18% among patients admitted at the acute, subacute, and chronic stages, respectively. Among patients who emerged, 100, 85, and 67%, respectively, had measurable FIM scores. Approximately 60 and 20% of patients at the acute and subacute stages, respectively, required moderate assistance or less in transfer/communication/eating/grooming/upper body dressing by the time of discharge from Phase I admission. The decannulation rates were 94, 67, and 17%. The oral diet initiation rates were 70, 23, and 6%. The time to reach these achievements lengthened as chronicity increased. There was a weak positive correlation (r s = 0.308) in the case of decannulation and a strong positive correlation (r s = 0.606, both p < 0.01) in the case of oral diet between days since injury on admission and days to the achievement after admission. Patients with TBI and hypoxic brain injury had comparable recovery rates when admitted at the acute and subacute stages. Conclusion: Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from DoC caused by TBI and hypoxic-ischemic brain injury. Specific goals and different outcome measures need to be developed to appraise the benefits of acute inpatient rehabilitation for DoC.

Incorporating Holistic Review in Recruitment in a Physical Medicine and Rehabilitation Residency Program.

ABSTRACT: Traditional residency recruitment practices are vulnerable to unconscious biases, inequity, lack of diversity, and have limited ability to predict future clinical competency. Holistic review and evidence-based strategies, such as structured interviews and situational judgment tests, can mitigate these limitations. A physical medicine and rehabilitation residency program restructured its residency recruitment process using holistic review principles and evidence-based strategies during the 2020-2021 academic year. A subcommittee developed a weighted screening rubric based on Association of American Medical Colleges core competencies and semistructured interview questions targeting specific domains. Formal implicit bias training was provided. Screening scores determined interview invitations. Applicants participated in three different domain-focused semistructured interviews. Screening and interview scores were combined to form the program rank list. A postinterview anonymous questionnaire was sent to interviewees to obtain feedback. Four hundred eighty-nine applicants were screened (82 interview invitations, 80 interviewed, 8 matched). The respondents to the postinterview questionnaire found that interviews evaluated them objectively (90%) and improved their impression of the program (90%). The program's match was consistent with previous matches. Interviewed applicants represented a racially diverse group. Most questionnaire respondents had a positive impression of the interview process. This article demonstrates incorporating holistic review into residency recruitment and provides specific resources to aid other institutions pursuing similar goals.

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.

Hydrodissection as a therapeutic and diagnostic modality in treating peroneal nerve compression.

A 51-year-old man presented with pain in the region of his left patellar tendon and fibular head. He had previously undergone three L5 epidural steroid injections and physical therapy without relief. Prior magnetic resonance imaging was significant only for fat pad impingement, and electromyography and nerve conduction studies were negative. Ultrasound demonstrated an enlarged peroneal nerve suggestive of peroneal nerve entrapment. Three ultrasound-guided hydrodissection procedures offered symptomatic improvement and identified an area posterior to the fibular head that was unable to be hydrodissected, indicating scar tissue causing peroneal nerve compression. The patient was referred for peroneal nerve decompression at the area of entrapment with complete symptom relief. This case is unique in describing the ability of hydrodissection to identify nerve compression not visualized with other diagnostic tests.

Immersive Virtual Reality for Pain Relief in Upper Limb Complex Regional Pain Syndrome: A Pilot Study.

Objective: This pilot study explored the effects of therapeutic immersive virtual reality (VR) on pain in upper limb complex regional pain syndrome (CRPS). While acute pain relief with VR has been studied in multiple populations, there is little data on the use of this modality in treating chronic pain, especially CRPS. Participants: Volunteer participants were recruited from outpatient rehabilitation services. Inclusion criteria required the diagnosis of CRPS in at least one upper limb and the ability to communicate in English to receive instructions from study personnel. A total of eight participants were recruited, with six fully completing the study. Interventions: An immersive virtual three-dimensional interactive kitchen environment was designed that allowed visualization of and object manipulation with virtual hands. Participants performed tasks representative of daily activities, as well as guided visualization exercises for a total of 10 sessions. Main Outcome Measure: Preand post-session pain scale measurements (Short Form McGill Pain Questionnaire, Visual Analog Scale, and Wong-Baker FACES) and subjective feedback were collected with each session. Results: Four of the six participants that completed the study reported subjective improvement of their pain and daily function. However, objective pain scales had limited correlation to reported subjective relief. Conclusions: Immersive virtual reality might provide subjective analgesia and functional improvement in select patients with upper limb complex regional pain syndrome, but objective data is lacking.

Virtual Reality Neurorehabilitation for Mobility in Spinal Cord Injury: A Structured Review.

Objective: The goal of this review was to evaluate the evidence regarding the use of virtual reality (VR) therapy for improvement of mobility in patients with spinal cord injury (SCI). Methods: A comprehensive literature search was conducted utilizing PubMed, CINAHL, EMBASE, and PsycINFO databases in April 2018. The phrase "virtual reality" and a combination of "spinal cord injury," "tetraplegia," "quadriplegia," or "paraplegia" were used as search terms. References included selected articles were reviewed as well. Articles were filtered based on the following inclusion criteria: 1) written in English, 2) peer-reviewed, 3) VR used for patients with SCI, and 4) changes in motor function evaluated. Main outcome measurements: Common outcomes of mobility assessment used in the studies included the Functional Reach Test (FRT), Functional Independence Measure (FIM), Limit of Stability (LOS), Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Walking Index for Spinal Cord Injury II (WISCI II) scale. Results: Seven of the nine reviewed articles were case series, while two were randomized, controlled trials. Reviewed literature demonstrated significant benefit in FRT, BBS, gait speed, muscle strength, SCIM, and WISCI-II using VR therapy. Voluntary muscle control improvement was also observed. However, no significant differences were found with regard to finehand motor movement. Conclusion: This literature review demonstrated mostly positive outcomes for the use of VR for SCI rehabilitation but were limited in quality and scope. Larger, multicenter trials are still needed.

Decreasing pediatric pain and agitation during botulinum toxin injections for spasticity with virtual reality: Lessons learned from clinical use.

PURPOSE: Recurrent botulinum toxin (BoNT) injections are used in the pediatric population for management of spasticity, but the procedure is often associated with significant pain and anxiety for patients. Non-pharmacologic treatment alternatives for procedural discomfort are limited. Immersive virtual reality (VR) has shown efficacy in treatment of procedural discomfort in pediatric patients. A retrospective chart review was performed to assess feasibility and use of treating BoNT procedure-related discomfort in pediatric patients with VR. METHODS: Fourteen patients undergoing elective BoNT injections viewed VR videos using a mobile VR headset during the procedure. Face, Legs, Activity, Cry, Consolability scale (FLACC) scores were obtained and feedback was elicited following injections. RESULTS: The VR intervention was well tolerated, and patients' guardians requested that it be used again in 9/14 cases. The remainder either had high FLACC scores despite VR and neutral or negative guardian impressions of intervention, or were unable to utilize the device. CONCLUSION: VR was helpful in reducing BoNT procedure-related discomfort in a majority of patients. Challenges with VR setup, patient tolerance, and selecting viewing experiences were identified to guide further research and use of VR in a clinical environment.

The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.

Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA). Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21-85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA. Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R2 = 0.588; P < 0.001) and discriminated between the older and younger subgroups (P < 0.001). Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.