Outreach physiatry clinics in remote Manitoba communities: an economic cost analysis.

BACKGROUND: One in 5 people in Canada have a disability affecting daily activities, and, for rural patients, accessing lifelong physiatry care to improve function and manage symptoms requires complex and expensive travel. We compared the costs of new outreach physiatry clinics with those of conventional urban clinics in Manitoba. METHODS: Six outreach clinics were held from January 2018 to September 2019 in the remote communities of St. Theresa Point and Churchill, Manitoba. A general physiatry population was seen in these clinics, including patients with musculoskeletal and neurologic conditions seen in consultation and follow-up. We performed a societal cost-minimization analysis comparing outreach clinic costs to estimated costs of standard care at conventional outpatient clinics in Winnipeg. Outcomes of interest included direct costs to government health services and patients, and indirect opportunity cost of travel time. We calculated total costs, average cost per clinic visit and incremental costs for outreach clinics compared to conventional urban clinics. Costs were inflated to 2020 Canadian dollars. RESULTS: Thirty-one patients (48 visits) were seen at the outreach clinics. The total cost of providing outreach clinics, $33 136, was 21% of the estimated cost of standard care, $158 344. When only direct costs were included, outreach clinics cost an estimated 24% of conventional care costs. The average unit cost per outreach visit was $690, compared to $3299 per conventional visit, for an incremental cost of -$2609 per outreach visit. INTERPRETATION: An outreach physiatry visit in Manitoba cost an estimated 21% of a conventional urban outpatient visit, or 24% when only direct costs were included, with costs savings largely related to travel. Outreach physiatry care in this model provides substantial cost savings for the public health care system as the primary payer, and can reduce the travel cost burden for patients who do not have public travel funding.

A randomized double-blind, placebo-controlled, cross-over trial assessing the effect of tadalafil (Cialis) on the cardiovascular response in men with complete spinal cord injury above the sixth thoracic level: A Pilot Study.

STUDY DESIGN: Double-blind, randomized cross-over placebo-controlled pilot study. OBJECTIVES: To determine the effects of tadalafil on systolic blood pressure (SBP), heart rate (HR), and dizziness of men with American Spinal Injury Association Impairment Scale-A (AIS-A) spinal cord injury (SCI) between cervical-4 (C4) and thoracic-5 (T5) levels. SETTING: Outpatient rehabilitation clinic. DESIGN: Double-blind, randomized cross-over placebo-controlled pilot study. METHODS: 20 males with AIS-A SCI, C4-T5 received either tadalafil 20 mg or placebo for the first arm, and then were crossed-over after 1 week to the second arm. SBP, HR, and Visual Analogue Scale (VAS) for dizziness upon sitting up from lying were measured at baseline and again 1, 2, 4, 12, 22, 29, and 36 h post dose administration. The change in each outcome measure (SBP, HR, VAS dizziness) was observed from pre-dose to each time point. A change in VAS dizziness of 2 cm or greater (scale 0-10 cm) was considered positive. RESULTS: SBP did not change significantly in either group. However, HR increased significantly in the tadalafil group at several time points (12 h p < 0.05, 22 h p <0.05, 29 h p <0.01, and 36 h p <0.05), with no change in the placebo group. The VAS dizziness significantly increased (range 2-6 cm changes) at some time point in 1/4 of the subjects after tadalafil, but not in the placebo group; all reports of dizziness were at 12 h or later. CONCLUSIONS: Tadalafil use in people with SCI above T6 is safe with respect to not causing hypotension; hemodynamic changes that occurred 12-36 h post administration were compensated for by elevations in HR. SPONSORSHIP: The Manitoba Medical Services Foundation and the Health Sciences Centre Foundation.

Barriers to wheelchair use in the winter.

OBJECTIVES: To test the hypothesis that challenges to community participation posed by winter weather are greater for individuals who use scooters, manual and power wheelchairs (wheeled mobility devices [WMDs]) than for the general ambulatory population, and to determine what WMD users identify as the most salient environmental barriers to community participation during the winter. DESIGN: Cross-sectional survey organized around 5 environmental domains: technological, natural, physical, social/attitudinal, and policy. SETTING: Urban community in Canada. PARTICIPANTS: Convenience sample of WMD users or their proxy (N=99). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Forty-two percent identified reduced outing frequency in winter months, associated with increased age (χ(3)=6.4, P=.04), lack of access to family/friends for transportation (χ(2)=8.1, P=.04), and primary type of WMD used in the winter (scooter χ(2)=8.8, P=.003). Most reported tires/casters becoming stuck in the snow (95%) or slipping on the ice (91%), difficulty ascending inclines/ramps (92%), and cold hands while using controls or pushing rims (85%); fewer identified frozen wheelchair/scooter batteries, seat cushions/backrests, or electronics. Sidewalks/roads were reported to be problematic by 99%. Eighty percent reported needing additional help in the winter. Limited community access in winter led to a sense of loneliness/isolation, and fear/anxiety related to safety. Respondents identified policies that limited participation during winter. CONCLUSIONS: People who use WMDs decrease their community participation in cold weather because of multiple environmental barriers. Clinicians, researchers, and policymakers can take a multidimensional approach to mitigate these barriers in order to enhance community participation by WMD users in winter.

Exercise stress testing in subacute stroke patients using a combined upper- and lower-limb ergometer.

OBJECTIVE: To assess functional cardiopulmonary exercise tolerance in a subset of patients with residual neurologic deficits after stroke by exercise stress testing using the Power Trainer, a combined upper- and lower-limb ergometer. DESIGN: Prospective, observational study using a convenience sample. SETTING: Clinical locomotor laboratory in a tertiary rehabilitation hospital. PARTICIPANTS: Thirty subjects undergoing rehabilitation an average of 7.3 weeks after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Percentage of age-predicted maximal heart rate (APMHR) achieved and rate-pressure product (RPP). RESULTS: Thirty subjects completed stress tests. Twelve of the 30 subjects were taking beta-blocker medications. Mean maximum heart rate +/- standard deviation achieved was 119+/-21 beats/min, equal to 75%+/-11% of APMHR. Ten subjects achieved 85% of APMHR or greater. Those not taking a beta-blocker attained 80%+/-10% of APMHR. The percentage increase in RPP from rest to maximal exercise for the whole group was 117%+/-44%. Four subjects developed cardiopulmonary signs or symptoms. Exercise prescriptions were provided to patients using the Karvonen formula. Overall subject satisfaction with the Power Trainer was high. CONCLUSION: The Power Trainer can be used safely to assess cardiopulmonary exercise tolerance in a select subset of patients with neurologic impairments secondary to stroke. This information can be extrapolated for proper exercise prescription and may contribute to the investigation of coronary artery disease in this high-risk population.

Efficacy and safety of tolterodine in people with neurogenic detrusor overactivity.

OBJECTIVE: To compare tolterodine with oxybutynin and placebo in people with neurogenic detrusor overactivity. DESIGN: Prospective, randomized, double-blind, crossover trial plus open-label comparative stage. PARTICIPANTS: Ten participants with neurogenic detrusor overactivity due to spinal cord injury or multiple sclerosis who used intermittent catheterization. METHODS: Bladder capacity on cystometrogram, a 10-day record of catheterization volumes, number of incontinent episodes per day, and perceived dry mouth using a visual analog scale (VAS) were measured for the following: (a) a blinded comparison: tolterodine, 2 mg twice daily, vs placebo, twice daily; and (b) an unblinded comparison: oxybutynin vs tolterodine, each at self-selected doses (SSDs). RESULTS: Tolterodine, 2 mg twice daily, was superior to placebo in enhancing catheterization volumes (P < 0.0005) and reducing incontinence (P < 0.001), but was comparable with placebo in cystometric bladder capacity. Efficacy of tolterodine SSD was comparable with oxybutynin SSD with regard to catheterization volumes, degree of incontinence, and cystometric bladder capacity. The side effect profile (dry mouth) was comparable between tolterodine, 2 mg twice daily, and placebo, but differed significantly when comparing tolterodine SSD with oxybutynin SSD (P < 0.05). CONCLUSION: Tolterodine, when used at SSDs, is comparable with oxybutynin at SSDs in enhancing bladder volume and improving continence, but with less dry mouth. Tolterodine at the recommended dosage of 2 mg twice daily improves incontinence and bladder volumes compared with placebo, and without significant dry mouth. Larger doses of tolterodine may be needed to achieve best effect in this population, but further studies are required.

The effects of sildenafil on the cardiovascular response in men with spinal cord injury at or above the sixth thoracic level.

BACKGROUND: Sildenafil is efficacious for erectile dysfunction in men with spinal cord injury (SCI), but can induce hypotension in neurologically intact people. Those with SCI at or above the sixth thoracic level (T6) often have pre-existing hypotension, yet the cardiovascular response to sildenafil has not been studied in this group. OBJECTIVE: To evaluate the effect of sildenafil on the cardiovascular response in men with complete SCI at or above T6. METHODS: This was a randomized, double-blind, placebo-controlled, cross-over study. Twenty-three SCI participants were each randomly given placebo; sildenafil, 50 mg; and sildenafil, 100 mg; separated by at least 1 week. The following were measured before administration, and hourly for 4 hours afterward: (a) blood pressure (BP) and heart rate (HR), both supine and sitting; and (b) perceived dizziness on a visual analog scale upon sitting. RESULTS: Analysis was done using a 4-way repeated-measures analysis of variance. No significant changes occurred with placebo. Sildenafil caused the following changes. Systolic BP changed little in thoracic spinal cord-injured (TSCI) participants, but decreased significantly (P < 0.005) in cervical spinal cord-injured (CSCI) participants. Diastolic BP decreased in all participants (P < 0.005). HR increased in the TSCI participants for 1 hour (P < 0.05), but was not altered in the CSCI participants. Dizziness increased in the TSCI participants after administration of 100 mg (P < 0.05) and in the CSCI participants after administration of 50 mg (P < 0.05). There were no adverse events or outcomes. CONCLUSION: Sildenafil induces significant hypotension in people with cervical-level injuries--more so than in thoracic-level injuries--and can cause dizziness in both populations. It should be prescribed with caution and informed consent from the patient.