Clinical ethics in rehabilitation medicine: core objectives and algorithm for resident education.

Described as the balance of values on either side of a moral dilemma, ethics and ethical issues are of increasing importance in the changing practice of rehabilitation medicine. Because the substance of ethics and true ethical issues can be difficult to identify, the education of rehabilitation residents in ethics can similarly be challenging. This article discusses topics pertinent to an understanding of clinical ethics in rehabilitation medicine and provides a method of teaching residents through an algorithm of ethical issues, learning objectives, and illustrative cases.

Functional outcomes of persons with brain tumors after inpatient rehabilitation.

OBJECTIVE: To assess the extent of functional gains measured before and after inpatient rehabilitation in patients who have primary or metastatic brain tumors, and to identify whether the tumor type, recurrent tumor, or ongoing radiation influences outcomes. DESIGN: Retrospective, descriptive study. SETTING: A free-standing university-affiliated rehabilitation hospital. PARTICIPANTS: A referred sample of 132 persons, all with functional impairments from a brain tumor and discharged from inpatient rehabilitation during a 3-year time period. INTERVENTION: Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURES: Functional status and rate of functional improvement (gain) as measured by the FIM instrument and FIM efficiency. RESULTS: Mean FIM efficiencies +/- standard deviation for motor (.82 +/-.69) and cognitive (.15 +/-.24) functions were equivalent across primary and metastatic tumor types (F =.42, df = 3,103, p = NS; F =.45, df = 2,104, p = NS, respectively); patients with metastatic disease had a significantly shorter length of stay at 18 +/- 12.3 days (t30,6 = 2.3, p =.03). Patients who received radiation during rehabilitation had a significantly greater (F = 4.1, df = 1,105, p <.05) motor efficiency score (1 +/-.79) than those who did not (.78 +/- 0.7). Patients with recurrent tumors made FIM cognitive changes equivalent to those of persons undergoing rehabilitation after their initial diagnosis, but their motor efficiency scores were significantly smaller (.55 +/-.39 vs.98 +/-.68, respectively) (F = 5.77, df = 1,85, p =.018), which reflected a significantly smaller FIM motor change. CONCLUSIONS: Metastatic or primary brain tumor type does not affect the efficiency of functional improvement during inpatient rehabilitation. Patients receiving concurrent radiation therapy make greater functional improvement per day than those not receiving radiation. Patients with recurrent tumors make significantly smaller functional motor gains than those completing inpatient rehabilitation after the tumor's initial diagnosis.

Hyperactive tendon reflexes in spastic multiple sclerosis: measures and mechanisms of action.

OBJECTIVE: To develop new measures of tendon reflexes and evaluate hyperactive reflexes in patients with spastic multiple sclerosis (MS). DESIGN: With the subject relaxed, a hand-held instrumented hammer was used to tap the patellar tendon and record the tapping force, while knee extension torque and quadriceps EMG were recorded isometrically as measures of the reflex response. SETTING: Research laboratory in a rehabilitation hospital. SUBJECTS: Ten spastic MS and 14 healthy subjects. MAIN OUTCOME MEASURES: Tendon tapping force (designated as system input), reflex torque (as output), their dynamic relationship (characterized as system parameters tendon reflex gain, contraction rate, and reflex loop delay), Ashworth scale, and tendon reflex scale. RESULTS: The system parameters provide more repeatable measures than do input or output parameters alone because they quantify the input and output simultaneously and dynamically. Compared with control subjects, MS patients had a significantly lower threshold in tapping force (p = .026), yet their evoked reflex torque was significantly higher (p = .033). Despite significant quadriceps weakness (p < .0001), MS patients had a significantly higher reflex gain (p = .0002) and contraction rate (p = .0002), and shorter reflex loop delay (p = .0046), indicating hyperexcitability of motoneurons and peripheral receptors, and indicating that relatively more of the muscle was activated reflexively, with greater recruitment of larger fast-twitch fibers. Both the reflex gain and rate measures correlated more closely with the Ashworth scale and tendon reflex scale than did the output measures, indicating their potential clinical value. CONCLUSIONS: With appropriate simplification, the method may be used in clinical practice to quantify more precisely the tendon jerk than is currently feasible with standard clinical tests.

Neuromuscular rehabilitation and electrodiagnosis. 1. Central neurologic disorders.

This self-directed learning module highlights the medical treatment and rehabilitation intervention of certain central neurologic disorders encountered in physiatric practice. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on multiple sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis. Information covered in these sections includes discussions of the current medical management and the benefits of comprehensive rehabilitation and interventions for specific impairments seen in these conditions.

Neuromuscular rehabilitation and electrodiagnosis. 4. Specialized neuropathy.

This self-directed learning module briefly highlights the differential diagnosis for acute weakness in patients with acute respiratory failure requiring prolonged mechanical ventilation. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article includes a discussion on the role of exercise in the treatment of patients with the late effects of poliomyelitis or with acute inflammatory demyelinating polyradiculoneuropathy.

Acute weakness syndromes in the critically ill patient.

Over the past three decades there has been increasing interest in acute weakness syndromes in critically ill mechanically ventilated patients. Many of these patients require rehabilitation, and some understanding of potential etiologies and functional outcomes for these syndromes is useful to rehabilitation practitioners. A clearer understanding of these syndromes has evolved over time, as has the terminology to describe these conditions. This article will review commonly encountered causes of acute weakness in critically ill patients, including disorders of the peripheral nerves, the neuromuscular junction, and muscle.

System identification of tendon reflex dynamics.

Patellar tendon reflexes were evaluated in 12 healthy adult subjects using several measures of the reflex responses and of the system input-output relationship. A hand-held instrumented hammer was used to tap the patellar tendon and to elicit the reflex response. Tendon reflex dynamics were estimated using the recorded tapping force (as input) and the quadriceps muscle electromyogram and knee joint extension torque signals (as output). A dome-shaped rubber pad was mounted onto the most sensitive spot on the patellar tendon, where it served as a tapping target, and helped to reduce the reflex variability significantly (p < 0.01). The input-output properties of the system relating the reflex torque to the tapping force were characterized using several measures: the tendon reflex gain (Gtr), contraction rate (Rc), and half-relaxation rate (Rhr). Reflex loop delay (t(d)) was estimated using the delay from the onset of tapping force to the onset of reflex torque. We determined that these system parameters provided significantly more repeatable and consistent characterization of tendon reflexes than did reflexive torque or EMG signals alone (p < 0.025). The input-output relationship relating the EMG signals of the stretched muscle to the tapping force was also identified to help characterize neuromuscular dynamics of tendon reflexes. The observed sensitivity and consistency of the reflex system measures suggest that with appropriate simplification of the instrumentation, these methods may prove useful in routine clinical practice, and may allow more precise quantification of the tendon jerk than is currently feasible with standard clinical tests.

Physical rehabilitation of the cancer patient.

Significant numbers of cancer patients have physical limitations as a result of their cancer or its treatment. Most commonly, this impairment results from prolonged bed rest and deconditioning syndrome or neurologic loss frequently coupled with deconditioning. What few studies have been done show that functional improvement through rehabilitation does occur. For many cancer patients, rehabilitation is an appropriate option, viewed favorably by patients and their families. However, as opposed to other causes of impairment, the benefits and goals of rehabilitation must be carefully weighed in concert with the goals of the cancer patient, all in an effort to add to his or her quality of life.

Transcutaneous electrical nerve stimulator-induced electrocardiogram artifact. A brief report.

Transcutaneous electrical nerve stimulation (TENS) is an effective modality for the treatment of pain. TENS use is well tolerated and has relatively few complications. Potentially serious complications of TENS use include disruption of cardiac pacemaker function and electrical artifact during electrocardiographic monitoring. Electrical interference with cardiac monitoring using parasternal electrodes and electrocardiographic (EKG) artifact with an epidural stimulator has been reported. We report the case of EKG artifact produced by surface TENS electrodes applied to the thoracic and lumbar regions. The electrical signal produced by the TENS unit created an electrocardiographic artifact resembling a pacemaker spike on routine EKG. This was interpreted as a malfunctioning cardiac pacemaker. The easily misinterpreted electrical spikes that can result from TENS use as seen in this case highlights the need for physician awareness of this potential complication.

Upper urinary tract abnormalities in multiple sclerosis patients with urinary symptoms.

OBJECTIVE: To determine the prevalence of upper urinary tract complications in multiple sclerosis (MS) patients with urinary symptoms, and to determine if an association exists between degree of physical impairment and upper urinary tract complications. DESIGN AND SETTING: A cohort study of MS patients seeking treatment at a freestanding, university-affiliated rehabilitation hospital. PARTICIPANTS: A referred sample of 48 patients with MS, exacerbation-free for 6 months with symptoms of neurogenic bladder dysfunction. For each patient, demographic data, disease characteristics, and urologic history was obtained. Using the Kurtzke Expanded Disability Status Scale (EDSS), participants were divided into a control (EDSS < 7) and study (EDSS >/= 7) group. INTERVENTION: Ultrasound examination of the upper urinary tract. MAIN OUTCOME MEASURE: Significant MS-related abnormalities of the upper respiratory tract. RESULTS: Ten of 48 patients (21%) had significant MS-related upper urinary tract abnormalities, which were evenly distributed between control and study groups. In the more disabled study group, abnormalities were associated with the symptom of urinary hesitancy (p < .05) and form of bladder management (p < .05). CONCLUSIONS: Routine screening for upper urinary tract complications appears indicated in a select group of MS patients with urinary symptoms.

Functional outcome following rehabilitation of the cancer patient.

OBJECTIVE: To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING: A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS: A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION: Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE: Functional status as measured by the motor score of the Functional Independence Measure. RESULTS: Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION: Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.

Physician personality types in physical medicine and rehabilitation as measured by the Myers-Briggs Type Indicator.

Personality is one variable that correlates with specialty selection and practice type. To test our hypothesis that there has been a change in the personality type of those entering Physical Medicine and Rehabilitation (PM&R) and to identify the academic potential of those in rehabilitation, we invited all residents and graduates of our training program to participate in a study of personality types within PM&R by completing a Myers-Briggs Type Indicator (MBTI). Thirty residents and 48 graduates completed the questionnaire. A wide range of personality types were represented in our sample. The most common types are shared by a number of other people-oriented, primary care specialties. There was a statistically significant difference between residents and graduates on two of the four MBTI indexes, with graduates more introverted (P < 0.05) and judging (P < 0.001) than the present residents. Intuition, previously correlated with research and academic practice, was the dominant process for the majority of graduates and residents. This would confirm, according to type theory, the academic potential of both graduates and residents in our training program.

The value of routine chest roentgenograms on admission for rehabilitation after traumatic spinal cord injury.

The value of routine chest roentgenograms has come under increasing scrutiny in the medical literature. In this retrospective study we investigated the value of routine chest radiographs obtained on admission to a rehabilitation unit after an acute spinal cord injury. The charts of all patients admitted for rehabilitation after a traumatic spinal cord injury during a 1-year period were reviewed and 79 patients fulfilled criteria for inclusion into the study. Of the 79 patients, 12 had findings on routine admission films, 9 of which were felt to be significant (11.4%). All 9 patients with abnormal admission films had experienced cardiopulmonary complications during their acute hospitalization (P < 0.001). Fourteen patients with normal chest roentgenograms on admission had repeat films performed during their rehabilitation stay, 4 of which were abnormal. All 4 had experienced cardiopulmonary complications during their acute hospitalizations (P < 0.01). Our findings would support the selective use of admission chest roentgenograms in spinal cord-injured patients with clinical indications or a history of cardiopulmonary complications during their acute care stay.

Paraneoplastic subacute cerebellar degeneration: functional improvement and the role of rehabilitation.

Paraneoplastic syndromes, or the remote effects of cancer on the nervous system, can result in significant functional impairment. One syndrome in particular, paraneoplastic subacute cerebellar degeneration (PSCD), may be severely disabling. Patients with PSCD can experience severe ataxia resulting in an inability to ambulate or perform their activities of daily living. Little has been written about the value of rehabilitation in cases of paraneoplastic syndrome. We report the case of a 51-year-old woman with PSCD who experienced improvements in all functional activities after comprehensive inpatient rehabilitation. She has maintained her improved functional status after discharge; her case is testimony to the value of rehabilitation in paraneoplastic syndrome.

Drug-induced dysphagia.

Dysphagia is a problem commonly treated and frequently diagnosed on the rehabilitation unit. It can be caused by trauma, injury, or diseases of the nervous system and can result in potentially serious and life threatening complications. The disruption of normal swallowing has also been reported to occur in psychiatric patients treated with psychotropic medication. Relatively unappreciated by physicians, and unreported by the rehabilitation patient, drug-induced dysphagia can likewise result in serious complications. This report describes a case of drug-induced dysphagia and aspiration pneumonia during the rehabilitation of a traumatically brain injured male who received psychotropic medication to control aggressive behavior. The course of his dysphagia was followed and documented both clinically and with videofluoroscopic studies.

A second traumatic spinal cord injury: associated risk factors. Case report and review.

Despite advances in acute care and long term management, traumatic spinal cord injury remains a devastating and disabling event. This report describes the case of a second traumatic spinal cord injury in a previously rehabilitated and functionally independent paraplegic. Factors potentially associated with the second spinal cord injury in this patient include wheelchair use, previous spinal fusion, alcohol use and sensation-seeking behavior. These factors, which are common to many spinal cord injured patients, could potentially be risk factors for a second traumatic spinal injury.

Ischemic myelopathy: a review of spinal vasculature and related clinical syndromes.

This article provides a comprehensive review of spinal vascular anatomy (arterial and venous) and clinical syndromes that result from the disruption of blood flow to or from the spinal cord. Blood is supplied to the spinal cord through three longitudinal channels: one anterior and two posterior spinal arteries. These vessels, which originate as branches of the vertebral arteries and run caudally along the spinal cord, are augmented by a variable number of medullary arteries. A vascular ring, or vasa coronae, surrounds the cord and connects these longitudinal channels. Central arteries from the anterior spinal artery and penetrating vessels from the vasa coronae provide blood directly to the cord. Venous flow from the spinal cord is also accomplished through a system of anterior and posterior spinal vessels draining through a variable number of medullary veins and an extensive valveless vertebral venous plexus. The disruption of blood flow to or from the spinal cord can result in infarction, with permanent neurologic loss and physical impairment. The clinical presentation in cases of ischemic myelopathy can be variable. Discrete syndromes based on the occlusion of specific vessels are reported and include venous infarction, anterior and posterior spinal artery syndrome, and central infarction.

Rehabilitation of neurologic disability related to human immunodeficiency virus.

Acquired immunodeficiency syndrome (AIDS) is globally fatal; before death, it often causes a multitude of medical complications leading to significant physical impairment and functional loss. Specifically, the neuropathology associated with AIDS can be diverse, and it ranges from inconsequential cerebrovascular insults to rapidly progressive neuronosis. Moreover, physical impairments may present any time during the course of the disease and even before knowledge of seropositivity. We present three patients infected with human immunodeficiency virus (HIV), each with a different form of neuropathology, who were treated by rehabilitative services and who gained reasonable functional benefits within moderate time periods. The growing number of HIV-infected persons with physical debilitation mandates a rational, knowledgeable approach to rehabilitation intervention. This article highlights the importance of a thorough understanding of the neurologic complications of AIDS in setting realistic goals and in improving the quality of life for these individuals.

Cardiovascular response to gait training and ambulation in a hemiparetic heart recipient.

Little has been reported about the rehabilitation of heart recipients who experience disabling neurologic complications. This is of particular interest to physiatrists because the number of cardiac transplants is increasing and the cardiovascular response of the denervated heart to exercise is altered. The case reported here describes a 42-year-old woman who underwent heart transplantation for ischemic cardiomyopathy. One year after transplantation, the patient was hospitalized for evaluation of headaches and mental status changes. A lymphoma involving the left basal ganglia was diagnosed and the patient underwent a course of radiation therapy. She was transferred for rehabilitation of a left hemiparesis and made functional gains in mobility and self-care skills. Weekly recordings of heart rate and blood pressure were obtained before and after ambulation. Small increases in both heart rate and blood pressure were recorded after ambulation to the point of fatigue. In both parameters, the patient's maximum response was below that reported for nondisabled cardiac recipients, highlighting the need for symptom-oriented exercise guidelines in these patients.