Research Accelerator Program: A Strategic Initiative to Facilitate Interdisciplinary Collaboration That Advances Translational Research.

ABSTRACT: Developing a culture of innovative thinking and one that emphasizes clinician-researcher interaction is critical for the future of rehabilitation. We designed and implemented a strategy to build a culture of interdisciplinary communication and collaboration that facilitates translational research across several disciplines in our inpatient rehabilitation hospital. We colocated clinicians and researchers in workspaces within a new hospital and created the Research Accelerator Program-a collection of team-focused initiatives that promote communication and collaboration among researchers, clinicians, and other staff. The purpose of this article is to disseminate this strategy, which has increased staff participation in research activities and increased scientific productivity of interdisciplinary research teams over the past 8 yrs.

Improving Patient Safety and Quality in Physical Medicine and Rehabilitation Through Participation in the American Board of Physical Medicine and Rehabilitation Continuing Certification Program.

ABSTRACT: The American Board of Medical Specialties Continuing Certification Program's Improvement in Medical Practice Standard requires physicians to participate in practice improvement activities. Despite this universal requirement, there has been no assessment of this requirement or its potential impact on patient care. Because of its continuing certification oversight structure, the American Board of Physical Medicine and Rehabilitation is in a unique position to provide this assessment. Review of quality improvement projects submitted to the American Board of Physical Medicine and Rehabilitation for continuing certification compliance revealed that most diplomates (70.1%) used available topic-specific options. These projects are designed to be directive and easy to use for physicians with limited quality improvement experience. Examples of topic-directed project potential impact on patient care include preventing wrong-site injections through implementing a preprocedure timeout or decreasing opioid prescribing risk through implementation of an opioid risk assessment tool. Thirty percent of submissions described improvement efforts in other areas of practice. These projects were directed toward areas of patient care including safety, communication/education, satisfaction, processes, and outcomes. This study demonstrates the efforts of physiatrists to improve care and the potential impact of these efforts on patient care and safety through participation in continuing certification.

Anticoagulant-Related Intramuscular Hematomas in an Inpatient Acute Rehabilitation Population: A Case Series.

ABSTRACT: Anticoagulant-related intramuscular hematomas are uncommon. However, when they do occur, the clinical consequences can be significant. The authors describe nine patients on anticoagulation undergoing rehabilitation who experienced an intramuscular hematoma. In all cases, activity in therapy before the intramuscular hematoma was considered normal therapeutic activity and consistent with activity commonly performed during rehabilitation. The study found that the anticoagulated rehabilitation population is at risk for intramuscular hematomas and poses a diagnostic challenge because many are insensate and, therefore, present atypically.

A Mobility Measure for Inpatient Rehabilitation Using Multigroup, Multidimensional Methods.

BACKGROUND AND PURPOSE: Inpatient rehabilitation facilities (IRFs) report patient functional status to Medicare and other payers using Quality Indicators (QI). While the QI is useful for payment purposes, its measurement properties are limited for monitoring patient progress. A mobility measure based on QI items and additional standardized assessments may enhance clinicians' ability to track patient improvement. Thus, we developed the Mobility Ability Quotient (Mobility AQ) to assess mobility during inpatient rehabilitation. METHODS: For 10 036 IRF inpatients, we extracted assessments from electronic health records, used confirmatory factor analysis to define subdimensions of mobility, and then applied multidimensional item response theory (MIRT) methods to develop a unidimensional construct. Assessments included the QI items and standardized measures of mobility, motor performance, and wheelchair and transfer skills. RESULTS: Confirmatory factor analysis resulted in good-fitting models (root-mean-square errors of approximation ≤0.08, comparative fit indices, and nonnormed fit indices ≥0.95) for 3 groups defined by anticipated primary mode of locomotion at discharge-walking, wheelchair propulsion, or both. Reestimation as a multigroup, MIRT model yielded scores more sensitive to change compared with QI mobility items (dlast-first = 1.08 vs 0.60 for the QI; dmax-min = 1.16 vs 1.05 for the QI). True score equating analysis demonstrated a higher ceiling and lower floor for the Mobility AQ than the QI. DISCUSSION AND CONCLUSIONS: The Mobility AQ demonstrates improved sensitivity over the QI mobility items. This MIRT-based mobility measure describes patient function and progress for patients served by IRFs and has the potential to reduce assessment burden and improve communication regarding patient functional status.Video Abstract available for more insights from authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A341).

Association of Participation in the American Board of Physical Medicine and Rehabilitation Maintenance of Certification Program and Physician Disciplinary Actions.

OBJECTIVE: The study analyzed the relationship between participation in the American Board of Physical Medicine and Rehabilitation maintenance of certification program and the incidence of disciplinary actions by state medical boards over a physician's career. The hypothesis is that physicians who do not maintain their board certification have a higher likelihood of state medical board disciplinary actions. DESIGN: This retrospective cohort study analyzed American Board of Physical Medicine and Rehabilitation maintenance of certification data from all board-certified physiatrists who were enrolled in the American Board of Physical Medicine and Rehabilitation maintenance of certification program from 1993 to 2007. RESULTS: Matching examination and license data were available for 4794 physicians, who received a total of 212 disciplinary action reports through the Federation of State Medical Boards. The results showed that physicians who have a lapse in completing the American Board of Physical Medicine and Rehabilitation maintenance of certification program have a 2.5-fold higher incidence of receiving a disciplinary action report through the Federation of State Medical Boards (95% confidence interval = 1.76-3.63) and had higher severity violations (χ = 7.14, P < 0.05) than physicians whose certificate never lapsed. CONCLUSIONS: For physicians in physical medicine and rehabilitation, loss of board certification through failure to fulfill the maintenance of certification program requirements is associated with an increased risk of disciplinary action from a state medical licensing board.

Allopathic (MD) and Osteopathic (DO) Performance on the American Board of Physical Medicine and Rehabilitation Initial Certifying Examinations.

BACKGROUND: Osteopathic physicians (DOs) represent over 30% of residents in allopathic (MD) Accreditation Council for Graduate Medical Education (ACGME) accredited physical medicine and rehabilitation (PM&R) training programs. However, some have questioned the quality of osteopathic medical school training and the graduates of osteopathic medical schools. The performance of osteopathic physicians in allopathic PM&R training programs has not been assessed. OBJECTIVE: To compare allopathic (MD) and osteopathic (DO) physician performance on American Board of Physical Medicine and Rehabilitation (ABPMR) initial certifying examinations. DESIGN: Retrospective cross-sectional study. SETTING: Board-eligible PM&R physicians. PARTICIPANTS: MDs and DOs who completed an allopathic ACGME-accredited PM&R residency training program. METHODS: MD and DO pass rates and mean scaled scores on the ABPMR initial certifying examinations were compared. MD versus DO degrees and training program 6 years aggregate board pass rates were independent variables. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: MD and DO pass rates and mean scaled scores on the ABPMR initial certifying examinations. RESULTS: Of the 2187 physicians who were first-time ABPMR initial certifying examination takers, there were 1596 MDs (73%) and 591 DOs (27%). No statistically significant difference was found in pass rates between MDs and DOs on Part I (94.9% vs. 93.9%, P = .35) or Part II (87.8% vs. 88%, P = .83) of the ABPMR certifying examination. Analysis of mean scaled scores demonstrated higher MD scores on both Part I ( 526, SD = 31, vs. 516, SD = 67, P = .002) and Part II ( 6.73, SD = .83 vs. 6.62, SD = .77, P = .005), significant only in programs with a 90%-100% pass rate. These differences, however, were of very small magnitude and likely not meaningful from a clinical or educational perspective. CONCLUSION: This study did not find meaningful differences in performance on the ABPMR certifying examinations between MDs and DOs.

Does Performance on the American Board of Physical Medicine and Rehabilitation Initial Certification Examinations Predict Future Physician Disciplinary Actions?

OBJECTIVE: The aim of the study was to determine the relationship between performance on the American Board of Physical Medicine and Rehabilitation primary certification examinations and the risk of subsequent disciplinary actions by state medical boards over a physician's career. The hypothesis is that physicians who do not pass either or both of the two initial specialty certification examinations are at higher risk of disciplinary action from a state medical licensing board. DESIGN: This is a retrospective cohort study that analyzed board certification examination data from all physicians who completed physical medicine and rehabilitation residency between 1968 and 2017. RESULTS: Matching examination and license data were available for 9889 physical medicine and rehabilitation physicians, who received a total of 547 disciplinary action reports through the Federation of State Medical Boards. The results showed a significant correlation between failing an American Board of Physical Medicine and Rehabilitation certification examination and the risk of subsequent disciplinary action by a state medical board. Failure to pass either the written (Part I) or oral (Part II) examination increased the risk of subsequent disciplinary action by 5.77-fold (P < 0.0001, 95% confidence interval = 4.07-8.18). CONCLUSIONS: Physicians in physical medicine and rehabilitation who do not pass initial certification examinations and become board certified are at higher risk of disciplinary action from a state medical licensing board throughout their careers.

Should There Be A Part II ABPMR Examination?: A Psychometric Inquiry.

BACKGROUND: Certification by the American Board of Physical Medicine and Rehabilitation (ABPMR) requires passing both a written multiple choice examination (Part I) and an oral examination (Part II), but it has been unclear whether the two examinations measure the same or different dimensions of knowledge. OBJECTIVE: To evaluate the concordance between the Part I and Part II examinations for ABPMR initial certification with regard to candidate performance on the examinations and their subsets. Our question is whether the Part II examination provides additional assessment of a candidate beyond what Part I provides. DESIGN: Retrospective psychometric evaluation of deidentified board examination scores. SETTING: ABPMR database of Part I and Part II examination scores. PARTICIPANTS: Candidates for the ABPMR Part I and Part II examinations after 2005, with a more detailed analysis of candidates for the Part I examination from 2014 to 2016. Examination scores of candidates who took the Part II examination both before and after the examination was standardized in 2005 were also used for an additional analysis. METHODS: Correlations, simple linear regressions, and principal components analysis. MAIN OUTCOME MEASUREMENTS: Correlation coefficients, variance analysis, and unexplained variance in the principal components analysis. RESULTS: There is a weak to moderate correlation between performance on the Part I and Part II examinations: r = 0.33, P < .001. There is an additional dimension of assessment that is demonstrated on the Part II examination, with this being primarily in the domains of systems-based practice and interpersonal communication skills. CONCLUSION: The Part I and Part II examinations, although with some overlap, contribute different and meaningful components to the overall evaluation of candidates for board certification in PM&R. LEVEL OF EVIDENCE: III.

Burnout in Diplomates of the American Board of Physical Medicine and Rehabilitation-Prevalence and Potential Drivers: A Prospective Cross-Sectional Survey.

BACKGROUND: Physician burnout is of growing concern. Burnout among physical medicine and rehabilitation (PM&R) physicians has shown a significant increase, positioning PM&R as one of the most "burned out" of specialties. Little has been written about potential factors contributing to physiatrist burnout or potential interventions. OBJECTIVE: To determine the prevalence of burnout among physiatrists and identify risk factors for burnout and potential strategies to decrease burnout among physiatrists. DESIGN: Prospective cross-sectional survey. SETTING: National survey of board certified physiatrists. PARTICIPANTS: One thousand five hundred thirty-six physiatrists certified by the American Board of PM&R. OUTCOME: The Mini-Z Burnout Survey, 1 question from the Maslach Burnout Scale on callousness toward patients, and several potential drivers of burnout. The probability of burnout, identified by question 3 on the Mini-Z, was the dependent variable. Other questions on the Mini-Z were explored as independent variables using logistic regression. RESULTS: Seven hundred seventy physiatrists (50.7%) fulfilled the definition of burnout. Only 38% of physiatrists reported not becoming more callous toward patients. The top 3 causes of burnout identified by physiatrists were increasing regulatory demands, workload and job demands, and practice inefficiency and lack of resources. Higher burnout rate was associated with high levels of job stress and working more hours per week. Lower burnout rates were associated with higher job satisfaction, control over workload, professional values aligned with those of department leaders, and sufficient time for documentation. There was no significant association between burnout and sex, years in practice, practice focus, or practice area. CONCLUSION: Burnout is a significant problem among PM&R physicians and is pervasive throughout the specialty. Opportunities exist to address major contributing drivers of burnout relating to practice patterns and efficiency of care within PM&R. These opportunities are, to varying degrees, under the control of hospital leaders, practice administrators, and practitioners.

Robot-guided ankle sensorimotor rehabilitation of patients with multiple sclerosis.

BACKGROUND: People with multiple sclerosis (MS) often develop symptoms including muscle weakness, spasticity, imbalance, and sensory loss in the lower limbs, especially at the ankle, which result in impaired balance and locomotion and increased risk of falls. Rehabilitation strategies that improve ankle function may improve mobility and safety of ambulation in patients with MS. This pilot study investigated effectiveness of a robot-guided ankle passive-active movement training in reducing motor and sensory impairments and improving balance and gait functions. METHODS: Seven patients with MS participated in combined passive stretching and active movement training using an ankle rehabilitation robot. Six of the patients finished robotic training 3 sessions per week over 6 weeks for a total of 18 sessions. Biomechanical and clinical outcome evaluations were done before and after the 6-week treatment, and at a follow-up six weeks afterwards. RESULTS: After six-week ankle sensorimotor training, there were increases in active range of motion in dorsiflexion, dorsiflexor and plantar flexor muscle strength, and balance and locomotion (p<0.05). Proprioception acuity showed a trend of improvement. Improvements in four biomechanical outcome measures and two of the clinical outcome measures were maintained at the 6-week follow-up. The study showed the six-week training duration was appropriate to see improvement of range of motion and strength for MS patients with ankle impairment. CONCLUSION: Robot-guided ankle training is potentially a useful therapeutic intervention to improve mobility in patients with MS.

Cancer Rehabilitation: Do Functional Gains Relate to 60 Percent Rule Classification or to the Presence of Metastasis?

BACKGROUND: Literature supporting the benefits of inpatient rehabilitation for cancer patients is increasing. Many cancer patients, however, do not qualify for inclusion in the Centers for Medicare and Medicaid 60% rule and consequently may not receive services. The benefit of inpatient rehabilitation in this specific cancer group has not been investigated and is the focus of this study. OBJECTIVE: To investigate functional gains made during inpatient rehabilitation by patients impaired by cancer, and to compare the functional gains made during inpatient rehabilitation for patients impaired by cancer in relation to the presence or absence of metastatic disease and compliance or noncompliance with the Medicare 60% rule. SETTING: Freestanding university-affiliated rehabilitation hospital. PARTICIPANTS: A total of 176 adult patients admitted for inpatient rehabilitation due to cancer. METHODS: Retrospective chart review of patients admitted for inpatient rehabilitation with deficits identified related to cancer. MAIN OUTCOME MEASURES: Demographic data including cancer type, presence of metastasis, age, gender, marital status, ethnicity, length of stay (LOS), discharge destination, and transfer to acute care. Functional status including admission and discharge Functional Independence Measure Score (FIM), total, motor, and cognitive FIM gains, total, motor, and cognitive FIM efficiency for the study sample, for patients with and without a diagnosis compliant with the 60% rule and for patients with and without metastatic disease. RESULTS: In all, 176 cases met inclusion criteria. An admission coded diagnosis that was compliant with the 60% rule was present in 97 cases (55.1%). In 153 cases, the presence or absence of metastatic disease was known. Metastatic disease was present in 69 cases (45%). All groups (total sample, metastatic versus nonmetastatic, compliant versus noncompliant) made significant functional gains. Patients with a diagnosis noncompliant with the 60% rule had higher admission total FIM (P = .001), discharge total FIM (P = .014), admission motor FIM (P = .005), admission cognitive FIM (P = .008), and discharge cognitive FIM (P < .001) scores than those with a compliant diagnosis. Patients with metastatic disease had higher admission total FIM (P = .026) and admission (P = .001) and discharge (P = .02) cognitive FIM scores than patients with nonmetastatic disease. There were no significant differences between groups regarding total, motor, or cognitive FIM gains or total motor or cognitive FIM efficiencies. Differences in age, length of stay, and admission motor and discharge FIM scores between groups were related to cancer types and source of impairment. CONCLUSION: Patients with functional limitations resulting from cancer or its treatment made significant functional gains in inpatient rehabilitation. There were no significant differences in functional gains made by those with or without metastatic disease or those compliant versus noncompliant with the 60% rule. The presence of metastatic disease or a diagnosis not compliant with the 60% rule does not preclude cancer patients from making significant functional gains.

Outcomes of acute inpatient rehabilitation of patients with left ventricular assist devices.

OBJECTIVE: To investigate the benefits of comprehensive inpatient rehabilitation for patients after left ventricular assist device (LVAD) implantation. DESIGN: A retrospective cohort study. SETTING: An urban academic inpatient rehabilitation hospital. PATIENTS: This study included 58 patients admitted to inpatient rehabilitation after LVAD implantation between 2009 and 2012. METHODS: Chart review of demographic, clinical, and functional data for patients admitted to inpatient rehabilitation after LVAD implantation was performed. MAIN OUTCOME MEASUREMENTS: Length of stay, admission and discharge Functional Independence Measure (FIM), and FIM efficiency. RESULTS: The study included 47 male and 11 female patients ages 21.8-84.1 years (mean [standard deviation {SD}], 64.2 ± 11.2 years). The mean (SD) length of time between LVAD implantation and admission to rehabilitation was 27.0 ± 15.3 days. Twenty-one patients (36%) required transfer to an acute care hospital. Ten patients returned after transfer and completed inpatient rehabilitation. For the 47 total patients who completed inpatient rehabilitation, the mean (SD) length of stay was 20.3 ± 10.8 days (range, 7-50 days). Mean (SD) admission and discharge FIM scores were 68.4 ± 13.6 and 91.7 ± 11.8, respectively, with a mean (SD) difference between admission and discharge FIM scores of 23.4 ± 11.2. The mean (SD) FIM efficiency was 1.33 ± 0.65. Complications during rehabilitation included anemia that required transfusion, respiratory distress, epistaxis, gout flare, automated implantable cardioverter defibrillator firing, and gastrointestinal bleeding. CONCLUSIONS: Patients with LVADs demonstrate functional gains in inpatient rehabilitation. However, there is a high incidence of complications in this population, which often requires transfer to an acute care setting.

Characterizations of reflex and nonreflex changes in spastic multiple sclerosis.

BACKGROUND: Spasticity, an increased resistance of a limb to movement, is associated with functional limitations and a major source of disability in neurological disorders, including multiple sclerosis (MS) and stroke. Despite the clinical significance of spasticity in brain and spinal cord injuries, it is often not clear whether the spasticity is due to reflex or non-reflex changes. NEW METHOD: Reflex and nonreflex properties of the human knee joint were studied in eight MS patients with spasticity and ten healthy subjects. A digitally controlled joint driving device was used to apply small-amplitude, and band-limited white-noise perturbations to the knee to manifest the reflex and nonreflex properties. The subjects were asked to maintain a steady level of background muscle torque during the perturbation. A nonlinear delay differential equation model was used to characterize the reflex and intrinsic properties of the knee in terms of phasic stretch reflex gain, tonic stretch reflex gain, joint elastic stiffness, and coefficient of viscosity. RESULTS: It was found that joint coefficient of viscosity and tonic stretch reflex gain of the spastic MS patients were significantly lower than those of normal controls. On the other hand, spastic MS patients showed higher phasic stretch reflex gains than normal controls and a trend of increased joint stiffness. CONCLUSIONS: Simultaneous characterizations of changes in tonic and phasic reflexes and nonreflex changes in joint elastic stiffness and viscosity in neurological disorders may help us gain insight into mechanisms underlying spasticity and develop impairment-specific treatment.

Inpatient rehabilitation of patients with cancer: efficacy and treatment considerations.

Although cancer can affect a great number of individuals and is the second leading cause of death in the United States, the number of individuals admitted to acute inpatient rehabilitation units with impairments primarily as the result of cancer diagnoses remains small. There is a lack of awareness among health care providers as to the functional loss that can be associated with cancer and the potential benefits of inpatient rehabilitation. Furthermore, financial pressures from third-party payors may dissuade the admission of patients with cancer for inpatient rehabilitation. This is a narrative review of the literature with respect to the efficacy and potential benefits of inpatient rehabilitation for patients with cancer. The findings of studies on the rehabilitation of general cancer populations are presented, with a focus on functional outcomes, medical complications and transfer rates, and common symptoms encountered during inpatient rehabilitation. Studies that focus on tumors involving the brain and spinal cord are separately analyzed. Functional outcomes by tumor location are reviewed with respect to tumor type, recurrence, and comparison with nontumor diagnoses. In addition, the effects of concomitant treatments on functional outcomes and possible correlations of survival with functional outcome are presented. Justification for admission of patients with cancer diagnoses to inpatient rehabilitation units, as well as implications for management of these patients during their rehabilitation stay, will be summarized.

Reliability of the physical medicine and rehabilitation resident observation and competency assessment tool: a multi-institution study.

OBJECTIVES: To assess the psychometric qualities of a method of resident physician evaluation by faculty. DESIGN: Multicenter study by seven Physical Medicine and Rehabilitation training programs. Faculty physicians observed residents in brief patient encounters or teaching sessions, rated specific competencies, and provided residents with immediate feedback. The resident observation and competency assessment form included competencies in patient care, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement. Residents and faculty rated satisfaction with the process. RESULTS: Three hundred sixty-two ratings were completed on 88 different residents. Each resident received an average of 3.8 ratings across two academic years. Overall internal consistency reliability was high (0.98); reliability of the individual competencies ranged from 0.74 to 0.76. Item means were correlated with year of training for two skill sets, with higher means for more experienced residents. The majority of participants gave high ratings of satisfaction; correlation between satisfaction ratings of attending and resident physicians was 0.63 (P < 0.01). CONCLUSIONS: The resident observation and competency assessment is a reliable method to assess resident skills in five of six general competencies. Construct validity of the tool is supported by the fact that faculty rated two skill sets higher for senior residents.

Charcot spine in a person with congenital insensitivity to pain with anhydrosis: a case report of re-diagnosis.

We report the case of a 43-year-old woman referred for evaluation of worsening gait. Her initial evaluation led to a diagnosis of a Charcot spine and 2 spinal stabilization surgeries. Because no clear cause for the Charcot spine could be determined from the patient's history or initial evaluation, an extensive diagnostic work-up was undertaken, which ultimately led to a diagnosis of congenital insensitivity to pain with anhydrosis (CIPA). This diagnosis was known and confirmed by the patient's parents but was unknown to the patient and her treating physicians. Unique to this case is not only the significant medical implications and the value of the re-diagnosis and confirmation of this rare condition, but also the rarer occurrence of a Charcot spine in a person with CIPA.

Inpatient rehabilitation following burn injury: patient demographics and functional outcomes.

OBJECTIVE: To identify demographic characteristics of burn patients referred for inpatient rehabilitation, the benefits of rehabilitation in this population, and factors that influence functional outcome. DESIGN: Retrospective chart review. SETTING: Free-standing rehabilitation hospital. PARTICIPANTS: Patients (N=129) admitted for inpatient rehabilitation after a burn injury. INTERVENTION: Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURES: Demographic data and the FIM instrument on admission and discharge for all patients. RESULTS: Linear measures of functional status derived by Rasch analysis of the FIM showed significant improvements from admission to discharge for all patients. There was no correlation between total body surface area (TBSA), premorbid psychiatric alcohol or drug abuse history, and change between admission and discharge FIM score. There was a significant correlation between TBSA burn and age and between TBSA and length of stay. CONCLUSIONS: Burn patients referred for inpatient rehabilitation are either older or have large TBSA burns. All patients made significant functional improvements and consequently inpatient rehabilitation can be considered an important component of care after a burn injury.

Phantom breast pain as a source of functional loss.

Although physicians are aware of phantom limb pain, which can occur in up to 85% of patients who undergo amputation, and its potential effect on functional status, the presence of phantom pain after amputation of other body parts such as the breast and its effect on function may be less appreciated. We report the case of a 63-yr-old woman with multiple sclerosis who underwent a modified radical mastectomy for left intraductal breast carcinoma. After her mastectomy, she required a brief course of inpatient rehabilitation and was discharged from rehabilitation independent, with feeding, dressing, hygiene, and transfers. Two months after her mastectomy, she had difficulty with these tasks because of phantom breast pain. Accurate diagnosis of her pain and successful treatment resulted in a return to premorbid functional status.