Medical rehabilitation after natural disasters: why, when, and how?

Natural disasters can cause significant numbers of severe, disabling injuries, resulting in a public health emergency and requiring foreign assistance. However, since medical rehabilitation services are often poorly developed in disaster-affected regions and not highly prioritized by responding teams, physical and rehabilitation medicine (PRM) has historically been underemphasized in global disaster planning and response. Recent development of the specialties of "disaster medicine" and "disaster rehabilitation" has raised awareness of the critical importance of rehabilitation intervention during the immediate postdisaster emergency response. The World Health Organization Liaison Sub-Committee on Rehabilitation Disaster Relief of the International Society of Physical and Rehabilitation Medicine has authored this report to assess the role of emergency rehabilitation intervention after natural disasters based on current scientific evidence and subject matter expert accounts. Major disabling injury types are identified, and spinal cord injury, limb amputation, and traumatic brain injury are used as case studies to exemplify the challenges to effective management of disabling injuries after disasters. Evidence on the effectiveness of disaster rehabilitation interventions is presented. The authors then summarize the current state of disaster-related research, as well as lessons learned from PRM emergency rehabilitation response in recent disasters. Resulting recommendations for greater integration of PRM services into the immediate emergency disaster response are provided. This report aims to stimulate development of research and practice in the emerging discipline of disaster rehabilitation within organizations that provide medical rehabilitation services during the postdisaster emergency response.

A Conversation Between Past and Present Chairs of the American Board of Physical Medicine and Rehabilitation: Four Decades of History and the Future of Board Certification.

ABSTRACT: On the 75th anniversary of the founding of the American Board of Physical Medicine and Rehabilitation, 11 of the surviving chairs of the board convened virtually to reflect on the past 40 years of major trends for the accrediting body of physiatrists. The field rapidly expanded in the 1980s, driven by changes in the reimbursement environment. This rapid expansion drove an improvement in the caliber of residents choosing the field and in the quality of training programs. As physical medicine and rehabilitation evolved from a small- to medium-sized specialty, the board addressed many challenges: securing a credible position within the American Board of Medical Specialties; addressing a rising demand for subspecialty certification; improving training and exposure to physiatry; enhancing the quality of the accreditation process; and reducing the burden of accreditation on diplomates. The future development of physiatry includes improving diversity, equity, and inclusion, while restoring provider morale, well-being, and meaningfulness in work. Although challenges remain, physiatry as a field has grown to be well established through the board's efforts and respected within the larger medical community.

Best research evidence for physical medicine and rehabilitation.

Evidence-based medicine is a strong movement in this century, and randomized clinical trials continue to be the best level of evidence for establishing cause-effect relationships between treatment interventions and outcomes. The field of physical medicine and rehabilitation has many excellent research questions on the effects of treatment but seems to rely mostly on weak observational methods (eg, chart review, case series, and single-group designs) for answers. This paper highlights 3 basic and relatively simple principles of good experimental design: control, randomization, and replication that were developed by R. A. Fisher for large, complex, agricultural field trials. The principles diffused readily into many scientific arenas, and Fisher even applied the principles in his backyard studies into Mendelian genetics. The thoughts of R. A. Fisher, arguably the most influential statistician of the 20th century, on the promise and challenges of randomized clinical trials in medicine should motivate rehabilitation clinicians to do their own small-scale controlled trials, with Institutional Review Board approval, when faced with equally realistic and plausible treatment options for their patients.

Learning from Physicians with Disabilities and Their Patients.

Although progress has been made in diversifying medical school admissions and faculty, this has not extended to physicians with physical disabilities. To improve our understanding of medical students and physicians with physical and sensory disabilities, the authors propose systematically gathering information on the needs and experiences of four groups: physicians who had disabilities before beginning practice, physicians whose disabilities were incurred during their medical careers, physicians drawn from those two groups, and patients of physicians with disabilities. It is hoped these data would be used by counselors, administrators, and admissions committees in advising medical school applicants with disabilities and in revising institutional policies with a view to increasing matriculation and graduation rates of medical students with disabilities.

Improving resident research in physical medicine and rehabilitation: impact of a structured training program.

OBJECTIVE: This study describes a research training program that implemented several processes and structures with the aim of increasing the quality and quantity of resident research in physical medicine and rehabilitation. Another aim of the program was to address the Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency. DESIGN: Educational program. RESULTS: Data on resident research activity for 11 years before the implementation of the research program were compared with 4 years of data after implementation. There were statistically significant increases in both the total number of publications (P = 0.03) and the number of empirical, data-based publications after implementation of the program (P = 0.03). CONCLUSIONS: The findings from this study suggest that a structured research training program may have a salutary effect on increasing the quality and quantity of resident research.

Gabapentin in the treatment of neuropathic pain after spinal cord injury: a prospective, randomized, double-blind, crossover trial.

BACKGROUND: Neuropathic pain is a common complaint after traumatic spinal cord injury (SCI). Gabapentin, a synthetic structural analogue of GABA, has been shown to have beneficial effects in the treatment of neuropathic pain in other diagnostic groups; however, no standardized clinical trial has been performed to evaluate its efficacy after SCI. DESIGN: A 10-week, prospective, randomized, double-blind, crossover, and placebo-controlled clinical trial. OBJECTIVE: To determine the efficacy of gabapentin in the treatment of SCI-related neuropathic pain. METHODS: Seven subjects with neuropathic pain, who were more than 30 days post-SCI, completed the study. Two groups received a 4-week course of gabapentin and placebo in a randomized crossover design with a 2-week washout period. The Neuropathic Pain Scale was used to record daily pain levels. Data were analyzed using the Wilcoxon signed rank test. RESULTS: Gabapentin has some beneficial effects on certain types of neuropathic pain. There was a significant decrease of "unpleasant feeling" and a trend toward a decrease in both the "pain intensity" and "burning sensation" at the fourth week of gabapentin treatment compared with those on the placebo. No significant difference was found among other pain descriptors during the gabapentin and placebo treatment, although this may have been limited by the small sample size and low maximum dosage of gabapentin. CONCLUSIONS: Gabapentin reduces certain types of neuropathic pain in the SCI population. Future studies with larger sample sizes, higher dosages, and quicker titration will help further determine the efficacy of gabapentin in the treatment of SCI-related neuropathic pain.

Efficacy of a checklist as part of a physical medicine and rehabilitation clerkship to teach medical students musculoskeletal physical examination skills: a prospective study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of a checklist as part of a physical medicine clerkship to teach medical students physical examination maneuvers. DESIGN: This is a prospective study performed on fourth year medical students enrolled in a 2-wk mandatory clerkship of the Department of Physical Medicine and Rehabilitation. At the start and end of the rotation, the participating students were tested by performing 20 physical examination maneuvers on an investigator who was both the standardized patient and the evaluator. At the end of the rotation, the students also completed a survey. Data were analyzed using the Bernoulli trial model, with the percentage of students who performed the maneuver correctly on the pretest as the a priori probability. A full Bonferroni correction was applied. RESULTS: The authors enrolled 141 of the 176 fourth year medical students; 121 completed testing. At prerotation, approximately 35% of the physical examination maneuvers were performed correctly; at postrotation, 82%. For 19 of 20 maneuvers, the improvement was statistically significant at P < 0.01. The survey results indicated that the students felt that they had limited exposure to musculoskeletal examination skills at prerotation, that this rotation helped them achieve competency in performing the maneuvers, and that this would improve their future patient care irrespective of field of choice. CONCLUSIONS: Considering the high prevalence of musculoskeletal disorders and the anticipated rise in the future, the authors strongly recommend teaching musculoskeletal physical examination maneuvers in medical school, which can be accomplished via a mandatory physical medicine and rehabilitation rotation. The authors conclude that checklists as part of this rotation can effectively help in teaching physical examination skills to medical students.

Commentary: reflections on diversity and inclusion in medical education.

The authors discuss how the strategy of fostering greater diversity and inclusion regarding minorities can help decrease health disparities and improve health outcomes. They propose that examining admission to medical school of qualified individuals with physical disabilities and fostering better communication with these individuals should be part of that strategy. Whereas people with disabilities constitute about 20% of the population, only between 2% and 10% are practicing physicians. The two major barriers to having more persons with disabilities as medical students are the cost of accommodating these persons and medical schools' technical standards. The authors offer suggestions for overcoming these barriers, and the additional barrier of communication with persons with various disabilities, such as deafness or visual impairment.The authors also discuss some of the issues involved in having greater representation of minorities in medicine. In addition, they stress the need for more training in cultural awareness for students and residents and for physicians well along in their careers. Medical educators will be increasingly called on to create new models designed to sensitize students and faculty to racial, ethnic, and other types of diversity, while documenting the efficacy and costs of extant ones, from the standpoint of both practitioner and consumer.The authors hope that the moves toward greater diversity and more training in cultural awareness will increase the efficacy of health care while reducing its cost. The demands of these efforts will require the commitment of diverse, intellectually capable, and compassionate people at many levels of academic medicine.

Promoting appreciation of the study and practice of medicine: inner workings of a Mini-Med program.

Dissatisfaction with the restrictions of the health care system, diminished reliance on the word of health care professionals, increased costs of medical care, and access to information online have increased consumers' interest in their own health care as well as their thirst for medical literacy. Mini-Med programs run by medical schools offer a more reliable method of learning about disease and disorders than does the indiscriminate surfing of the Internet. This article describes the efforts of the University of Medicine and Dentistry of New Jersey - the largest public university of the health sciences in the nation - to run and maintain such a program. The Mini-Med course provides lay students with insight into what a student undergoes while studying medicine and guides them through complex topics that range from anatomy and basic life support to the latest in stem cell research. It also provides early guidance for potential medical students, addresses patients' concerns, and gives some insight into the levels of comprehension of current medical students.

Designing the objective structured clinical examination to cover all major areas of physical medicine and rehabilitation over 3 yrs.

The Accreditation Council for Graduate Medical Education requires that training programs comprehensively evaluate residents in the six core Accreditation Council for Graduate Medical Education competencies. One of the ways we do this in our residency is by administering a nine-station Objective Structured Clinical Examination (OSCE) at the end of each year, which evaluates tasks such as history taking, focused physical examination, communication, professionalism, procedural skills, management, prescription writing, and understanding systems-based practice. We have classified our OSCE stations into what we consider key areas in our field and assessed these on a rotating basis over 3 yrs. This results in the assessment of 27 areas over the 3 yrs of residency. Structuring the OSCE as a series of stations over 3 yrs is an efficient method to evaluate residents' competencies that are required by the Accreditation Council for Graduate Medical Education and certifying boards. An analysis of OSCE scores when compared with American Board of Physical Medicine & Rehabilitation parts 1 and 2 scores and final summative resident evaluation scores reveals that OSCE results correlate with part 1 scores and final evaluation scores but do not show the same strong correlations with part 2 scores. We discuss the way the OSCE can complete other assessment techniques and ways to improve cases in the future.

Disability and health-related rehabilitation in international disaster relief.

BACKGROUND: Natural disasters result in significant numbers of disabling impairments. Paradoxically, however, the traditional health system response to natural disasters largely neglects health-related rehabilitation as a strategic intervention. OBJECTIVES: To examine the role of health-related rehabilitation in natural disaster relief along three lines of inquiry: (1) epidemiology of injury and disability, (2) impact on health and rehabilitation systems, and (3) the assessment and measurement of disability. DESIGN: Qualitative literature review and secondary data analysis. RESULTS: Absolute numbers of injuries as well as injury to death ratios in natural disasters have increased significantly over the last 40 years. Major impairments requiring health-related rehabilitation include amputations, traumatic brain injuries, spinal cord injuries (SCI), and long bone fractures. Studies show that persons with pre-existing disabilities are more likely to die in a natural disaster. Lack of health-related rehabilitation in natural disaster relief may result in additional burdening of the health system capacity, exacerbating baseline weak rehabilitation and health system infrastructure. Little scientific evidence on the effectiveness of health-related rehabilitation interventions following natural disaster exists, however. Although systematic assessment and measurement of disability after a natural disaster is currently lacking, new approaches have been suggested. CONCLUSION: Health-related rehabilitation potentially results in decreased morbidity due to disabling injuries sustained during a natural disaster and is, therefore, an essential component of the medical response by the host and international communities. Significant systematic challenges to effective delivery of rehabilitation interventions during disaster include a lack of trained responders as well as a lack of medical recordkeeping, data collection, and established outcome measures. Additional development of health-related rehabilitation following natural disaster is urgently required.