Development and Implementation of an International Virtual Didactic Series for Physical Medicine and Rehabilitation Graduate Medical Education During COVID-19.

ABSTRACT: Coronavirus disease of 2019 presented significant challenges to residency and fellowship programs. Didactic lectures were particularly affected as redeployment of faculty and trainees, limitations on in-person gathering, and other barriers limited opportunities for educational engagement. We sought to develop an online didactic series to address this gap in graduate medical education.Lecturers were recruited via convenience sample and from previous Association of Academic Physiatrists presenters from across the United States and Canada; these presented via Zoom during April and May 2020. Lecturers and content reflected the diverse nature of the specialty. Learning objectives were adapted from the list of board examination topics provided by the American Board of Physical Medicine and Rehabilitation.Fifty-nine lectures were presented. Maximum concurrent live viewership totaled 4272 and recorded lecture viewership accounted for an additional 6849 views, for a total of at least 11,208 views between the date of the first lecture (April 9, 2020) and May 1, 2021. Live viewers of one of the lectures reported participating from several states and 16 countries.The Association of Academic Physiatrists-led virtual didactics augmented graduate medical education during the coronavirus disease of 2019 pandemic, and data confirm that the lectures have continued to enjoy a high level of viewership after the cessation of live lectures.

Rationale for a preliminary operational definition of physical frailty and sarcopenia in the SPRINTT trial.

In the present article, the rationale that guided the operationalization of the theoretical concept of physical frailty and sarcopenia (PF&S), the condition of interest for the "Sarcopenia and Physical Frailty in Older People: Multicomponent Treatment Strategies" (SPRINTT) trial, is presented. In particular, the decisions lead to the choice of the adopted instruments, and the reasons for setting the relevant thresholds are explained. In SPRINTT, the concept of physical frailty is translated with a Short Physical Performance Battery score of ≥3 and ≤9. Concurrently, sarcopenia is defined according to the recent definitions of low muscle mass proposed by the Foundation for the National Institutes of Health-Sarcopenia Project. Given the preventive purpose of SPRINTT, older persons with mobility disability (operationalized as incapacity to complete a 400-m walk test within 15 min; primary outcome of the trial) at the baseline are not included within the diagnostic spectrum of PF&S.

Quantity of dietary protein intake, but not pattern of intake, affects net protein balance primarily through differences in protein synthesis in older adults.

To examine whole body protein turnover and muscle protein fractional synthesis rate (MPS) following ingestions of protein in mixed meals at two doses of protein and two intake patterns, 20 healthy older adult subjects (52-75 yr) participated in one of four groups in a randomized clinical trial: a level of protein intake of 0.8 g (1RDA) or 1.5 g·kg(-1)·day(-1) (∼2RDA) with uneven (U: 15/20/65%) or even distribution (E: 33/33/33%) patterns of intake for breakfast, lunch, and dinner over the day (1RDA-U, 1RDA-E, 2RDA-U, or 2RDA-E). Subjects were studied with primed continuous infusions of L-[(2)H5]phenylalanine and L-[(2)H2]tyrosine on day 4 following 3 days of diet habituation. Whole body protein kinetics [protein synthesis (PS), breakdown, and net balance (NB)] were expressed as changes from the fasted to the fed states. Positive NB was achieved at both protein levels, but NB was greater in 2RDA vs. 1RDA (94.8 ± 6.0 vs. 58.9 ± 4.9 g protein/750 min; P = 0.0001), without effects of distribution on NB. The greater NB was due to the higher PS with 2RDA vs. 1RDA (15.4 ± 4.8 vs. -18.0 ± 8.4 g protein/750 min; P = 0.0018). Consistent with PS, MPS was greater with 2RDA vs. 1RDA, regardless of distribution patterns. In conclusion, whole body net protein balance was greater with protein intake above recommended dietary allowance (0.8 g protein·kg(-1)·day(-1)) in the context of mixed meals, without demonstrated effects of protein intake pattern, primarily through higher rates of protein synthesis at whole body and muscle levels.

Exercise recommendations in patients with newly diagnosed fibromyalgia.

OBJECTIVE: To evaluate exercise recommendations in patients newly diagnosed with fibromyalgia. DESIGN: A retrospective chart review. SETTING: A public university rheumatology clinic. PATIENTS: Patients newly diagnosed with fibromyalgia (N = 122). MAIN OUTCOME MEASUREMENTS: Frequency and type of exercise recommendations. RESULTS: The mean (standard deviation) age of these patients with fibromyalgia was 45 ± 12 years; 91% were women. Exercise was recommended as part of the documented treatment plan in 47% of these patients (57/122); only 3 patients had a documented contraindication for exercise. Aquatic exercise was most frequently recommended (56% [32/57]), followed by combined aquatic-aerobic exercise (26% [15/57]), and, infrequently, aerobic exercise only (5% [3/57]); only 7% of these patients (4/57) were referred for physical therapy. The primary method of communication was verbal discussion (94% [54/57]). CONCLUSIONS: Although there is well-documented evidence that exercise is beneficial for patients with fibromyalgia, we found that less than half of patients with newly diagnosed fibromyalgia in our study were provided recommendations to initiate an exercise program as part of their treatment plan. Further investigation of these findings are warranted, including evaluation of other university and community rheumatology practices as well as that of other physicians caring for patients with fibromyalgia. However, our findings indicate that there appears to be an opportunity to provide more specific and practical education regarding the implementation of an exercise regimen for patients with newly diagnosed fibromyalgia. Physiatrists may be particularly well suited to manage the exercise component of patients with fibromyalgia because of their specialized training in exercise prescription.

Implementation of rehabilitation medicine consultant recommendations in acute care: a pilot evaluation.

Limited data exist regarding rehabilitation medicine consultation services in the acute-care hospital setting. We examined implementation rates of rehabilitation consultant recommendations in a university hospital with either a rotating physician service or a single advanced-practice nurse. We performed a retrospective chart review of all patients evaluated by a rehabilitation consultation service for 2 months at a single 300-bed hospital: The first month with rotating physicians (MP) and the second month with a single advanced-practice nurse (SP). Total consultations/recommendations were similar during the 2 months (MP-63/251, SP-68/240, respectively). The overall implementation rate was greater during the month with the SP (SP-74%, MP-47%), although implementation was similar for discharge disposition (MP-82%, SP-85%). In this university hospital, rehabilitation consultation recommendations were more frequently implemented with a single-provider consultation service. Further study of rehabilitation consultation services is needed, including evaluation of nonphysician consultants.

Inpatient rehabilitation outcomes for older adults with nondebility generalized weakness.

OBJECTIVE: This study aimed to compare the functional outcomes and discharge locations of older adults admitted to inpatient rehabilitation with debility (International Classification of Diseases, 9th Revision, Clinical Modification, [ICD-9-CM] code 799.3) with those of patients with a nondebility generalized weakness diagnosis (ICD-9-CM codes 728.2, 728.87, and 780.79). DESIGN: This is a retrospective cohort study using 2002-2003 information from the Uniform Data System for Medical Rehabilitation. Patients were 65 yrs or older admitted to inpatient rehabilitation with a primary diagnosis of debility (n = 14,835) and nondebility generalized weakness (n = 6,403). Primary outcome measures were change in functional status, including efficiency (functional status change divided by length of stay in days), and discharge setting. RESULTS: The efficiency of the patients with nondebility generalized weakness (1.8 ± 1.9) was statistically greater than that of patients with debility (1.7 ± 2.1, P = 0.002), and significantly more patients with nondebility generalized weakness were discharged home (70% vs. 68%, P = 0.003). CONCLUSIONS: From a clinical standpoint, the functional recovery and rate of discharge to home of inpatient rehabilitation patients with nondebility generalized weakness are nearly identical to those of patients with debility. Although it would require a policy change, we recommend using a single diagnostic code for all of these patients to further research in this area of rehabilitation.

Palmar fasciitis with polyarthritis syndrome in a patient with breast cancer.

Palmar fasciitis and polyarthritis syndrome (PFPAS) is a rare paraneoplastic syndrome often associated with ovarian and pancreatic cancers, and rarely lung and breast cancers. A 39-year-old patient with breast cancer underwent neoadjuvant chemotherapy, radical mastectomy, and radiation therapy. Subsequently, the patient developed PFPAS coinciding with progression of the breast cancer. The rheumatological symptoms were severe causing significant distress and handicap. The patient had a partial response to treatment with corticosteroids. A literature review of PFPAS and its relation to breast cancer is discussed.

EAA supplementation to increase nitrogen intake improves muscle function during bed rest in the elderly.

BACKGROUND & AIMS: Older individuals are more likely to experience extended hospitalization and become protein malnourished during hospitalization. The concomitant compulsory inactivity results in functional decline. Increasing protein intake in hospitalized patients improves nitrogen balance, but effects on function are unknown. In the present study, we examined the effects of increasing protein intake by essential amino acid (EAA) supplementation in older individuals subjected to 10 d bed rest on LBM and muscle function. METHODS: Subjects were given a placebo (n=12, 68+/-5 (SD) yrs, 83+/-19 kg) or 15 g of EAA (n=10, 71+/-6, 72+/-8 kg) 3 times per day throughout 10d of bed rest. LBM, muscle protein synthesis, and muscle function were determined before and after bed rest. Due to an imbalance in randomized gender distribution between groups, gender and beginning functional and LBM measures were utilized for analyses by repeated measures analysis of covariance (RMANCOVA). RESULTS: Analyses revealed the potential for the preservation of functional outcomes with EAA supplementation. CONCLUSIONS: Increasing protein intake above the RDA may preserve muscle function in the elderly during compulsory inactivity. EAA supplementation is potentially an efficient method of increasing protein intake without affecting satiety.

The impact of exercise training compared to caloric restriction on hepatic and peripheral insulin resistance in obesity.

CONTEXT: It has been difficult to distinguish the independent effects of caloric restriction versus exercise training on insulin resistance. OBJECTIVE: Utilizing metabolic feeding and supervised exercise training, we examined the influence of caloric restriction vs. exercise training with and without weight loss on hepatic and peripheral insulin resistance. DESIGN, PARTICIPANTS, AND INTERVENTION: Thirty-four obese, older subjects were randomized to: caloric restriction with weight loss (CR), exercise training with weight loss (EWL), exercise training without weight loss (EX), or controls. Based on an equivalent caloric deficit in EWL and CR, we induced matched weight loss. Subjects in the EX group received caloric compensation. Combined with [6,6(2)H(2)]glucose, an octreotide, glucagon, multistage insulin infusion was performed to determine suppression of glucose production (SGP) and insulin-stimulated glucose disposal (ISGD). Computed tomography scans were performed to assess changes in fat distribution. RESULTS: Body weight decreased similarly in EWL and CR, and did not change in EX and controls. The reduction in visceral fat was significantly greater in EWL (-71 +/- 15 cm(2)) compared to CR and EX. The increase in SGP was also almost 3-fold greater (27 +/- 2%) in EWL. EWL and CR promoted similar improvements in ISGD [+2.5 +/- 0.4 and 2.4 +/- 0.9 mg x kg fat-free mass (FFM)(-1) x min(-1)], respectively. CONCLUSIONS: EWL promoted the most significant reduction in visceral fat and the greatest improvement in SGP. Equivalent increases in ISGD were noted in EWL and CR, whereas EX provided a modest improvement. Based on our results, EWL promoted the optimal intervention-based changes in body fat distribution and systemic insulin resistance.

A comparative evaluation of inpatient rehabilitation for older adults with debility, hip fracture, and myopathy.

OBJECTIVE: To compare the functional outcomes and discharge location of older adults admitted to inpatient rehabilitation for debility, hip fracture, and myopathy. DESIGN: Retrospective cohort study from 2002 to 2003 with information from the Uniform Data System for Medical Rehabilitation (UDSMR). SETTING: United States inpatient rehabilitation facilities subscribing to the UDSMR. PARTICIPANTS: Patients 65 years or older (N=84.701) with primary diagnoses of debility (n=14,835), hip fracture (n=68,915), and myopathy (n=951). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in functional status, including efficiency (change in functional status divided by length of stay in days) and discharge setting. RESULTS: The efficiency of the patients with debility (1.7+/-2.1) was significantly lower than that of the patients with hip fracture (1.9+/-1.6; P<.001), but not different from the patients with myopathy (1.6+/-1.4; P=.3). Significantly more patients with debility (68%) were discharged home than the hip fracture and myopathy groups (66% and 65%, respectively; P<.001). CONCLUSIONS: Although statistical differences exist, the functional recovery and rate of discharge home of older adult patients admitted to inpatient rehabilitation with a primary debility diagnosis are essentially the same clinically as those of patients with a diagnosis of either hip fracture or myopathy. Given these findings, and given that hip fracture and myopathy are approved medical conditions according to the Centers for Medicare and Medicaid Services 75% rule, the medical condition debility warrants consideration for inclusion as a qualifying medical diagnosis under this rule. However, further research is needed to develop relatively objective criteria for the debility diagnosis, and to identify those patients with debility who are most likely to benefit from inpatient rehabilitation.

Muscle expression of genes associated with inflammation, growth, and remodeling is strongly correlated in older adults with resistance training outcomes.

A group (n = 8) of healthy older (68 +/- 6 yr) adults participated in a 36-session progressive resistance exercise training program targeting the thigh muscles to determine the relationship between muscle gene expression and gains in muscle size and strength. Biopsies were obtained from the vastus lateralis at baseline 72 h after an acute bout of exercise and 72 h after completion of the training program. Training increased thigh muscle size (7%) and strength for the three exercises performed: knee extension (30%) and curl (28%) and leg press (20%). We quantified 18 transcripts encoding factors that function in inflammation, growth, and muscle remodeling that were demonstrated previously to be regulated by aging and acute exercise. The gain in extension strength and muscle size showed a high number of significant correlations with gene expression. These gains were most strongly correlated (P < or = 0.003, R > or = 0.89) with the baseline mRNA levels for insulin-like growth factor-1, matrix metalloproteinase-2 and its inhibitor TIMP1, and ciliary neurotrophic factor. Moreover, strength gains were inversely correlated with the change in these mRNA levels after training (P < or = 0.002 and R < or = -0.90). Changes in gene expression after acute exercise were not associated with training outcomes. These results suggest that higher baseline expression for key genes in muscle conveys an adaptive advantage for certain older adults. Individuals with lower baseline expression of these genes show less adaptation to exercise despite increased gene expression in response to training. These genes hold promise as useful predictors of training outcomes that could be used to design more effective exercise regimens for maintaining muscle function in older adults.