Integrating Cardiac Rehabilitation in Stroke Recovery.

Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.

Burnout and Wellness Strategies Used by Academic Physiatry Programs: An Analysis and Perspective From the AAP Chairs Council.

ABSTRACT: Physiatrists are at elevated risk of burnout, a work-related exhaustion syndrome resulting from chronic stress associated with emotionally draining work demands. The high reported rate of burnout in physical medicine and rehabilitation led the Association of Academic Physiatrists Chair Council to convene a workgroup to address burnout among academic physical medicine and rehabilitation physicians. The council recognizes that leaders of departments are accountable for all organizational stakeholders, including faculty, trainees, and staff. Department leaders are expected to understand and effectively manage the drivers of burnout among stakeholders. The workgroup identified several opportunities, including identifying and disseminating effective burnout mitigation across US academic medical center physical medicine and rehabilitation programs. As a result, in 2019, a work group conducted a survey of US academic physical medicine and rehabilitation program leaders to ascertain the use of strategies for reducing physician burnout. With the aim of identifying, educating, and advancing the development of effective interventions to address burnout among academic physical medicine and rehabilitation departments, the Association of Academic Physiatrists Chair Council advocates for increased education and utilization of effective strategies aimed at promoting physician well-being across organizational levels (national, organizational, work unit, and individual).

Factors Associated With Burnout in Physical Medicine and Rehabilitation Residents in the United States.

OBJECTIVES: The aims of the study were to determine the prevalence of burnout in physical medicine and rehabilitation residents in the United States and to identify the personal- and program-specific characteristics most strongly associated with residents reporting burnout. DESIGN: This was a cross-sectional survey of US physical medicine and rehabilitation residents. Emotional exhaustion, depersonalization, and burnout were assessed using two validated items from the Maslach Burnout Inventory. Associations of burnout with demographics and personal factors, residency program characteristics, perceived program support, and work/life balance were evaluated. RESULTS: The survey was completed by 296 residents (22.8%), with 35.8% of residents meeting the criteria for burnout. Residents' perception of not having adequate time for personal/family life was the factor most strongly associated with burnout (χ2 = 93.769, P < 0.001). Residents who reported inappropriate clerical burden and working more than 50 hrs/wk on inpatient rotations were most likely to report that they did not have adequate time for personal/family life. Faculty support (χ2 = 41.599, P < 0.001) and performing activities that led residents to choose physical medicine and rehabilitation as a specialty (χ2 = 93.082, P < 0.001) were protective against burnout. CONCLUSIONS: Residents reporting having inadequate time for their personal/family life was most strongly associated with physical medicine and rehabilitation resident burnout, although many personal and program characteristics were associated with burnout.

Stroke Recovery Program with Modified Cardiac Rehabilitation Improves Mortality, Functional & Cardiovascular Performance.

BACKGROUND: Physical activity and exercise after stroke is strongly recommended, providing many positive influences on function and secondary stroke prevention. The purpose of this study was to investigate the effect of a stroke recovery program (SRP) integrating modified cardiac rehabilitation on mortality and functional outcomes for stroke survivors. METHODS: This study used a retrospective analysis of data from a prospectively collected stroke rehabilitation database which followed 449 acute stroke survivors discharged from an inpatient rehabilitation facility between 2015 and 2020. For 1-year post-stroke, 246 SRP-participants and 203 nonparticipants were compared. The association of the SRP including modified cardiac rehabilitation with all-cause mortality and functional performance was assessed using the following statistical techniques: log rank test, Cox proportional hazard model and linear mixed effect models. Cardiovascular performance over 36 sessions of modified cardiac rehabilitation was assessed using linear effect model with Tukey procedure. The primary outcome measure was 1-year all-cause mortality rate. Secondary outcomes were functional performance measured in Activity Measure of Post-Acute Care scores and cardiovascular performance measured in metabolic equivalent of tasks times minutes. RESULTS: The SRP-participants had: (1) a significantly reduced 1-year post-stroke mortality rate from hospital admission corresponding to a four-fold reduction in mortality (P = 0.005, CI for risk ratio = [0.08, 0.71]), (2) statistically and clinically significant improvement of function in all Activity Measure of Post-Acute Care domains (P < 0.001 for all, 95% CI for differences in Basic Mobility [5.9, 10.1], Daily Activity [6.2, 11.8], and Applied Cognitive [3.0, 6.8]) compared to the matched cohort and (3) an improvement in cardiovascular performance over 36 sessions with an increase of 78% metabolic equivalent of tasks times minutes (P < 0.001, 95% CI [70.6, 85.9%]) compared to baseline. CONCLUSIONS: Stroke survivors who participated in a comprehensive stroke recovery program incorporating modified cardiac rehabilitation had decreased all-cause mortality, improved overall function, and improved cardiovascular performance.

Focal Peripheral Neuropathies Observed in Patients Diagnosed With COVID-19: A Case Series.

ABSTRACT: A growing number of studies have documented a wide variety of neurological manifestations associated with the novel SARS-CoV-2 (COVID-19). Of the available literature, cranial neuropathies and central nervous system disorders, such as encephalopathy and ischemic strokes, remain the predominant discussion. Limited investigations exist examining peripheral neuropathies of those with COVID-19. This case series discusses eight patients who tested positive for COVID-19 and presented with localized weakness after a prolonged course of mechanical ventilation (>21 days). We retrospectively reviewed all patients' charts who received electrodiagnostic evaluation between March and November 2020 in the outpatient clinic or in the acute care hospital at the JFK Medical Center/JFK Johnson Rehabilitation Institute and Saint Peter's University Hospital of New Jersey. A total of eight COVID-19-positive patients were identified to have a clinical presentation of localized weakness after a prolonged course of mechanical ventilation. All patients were subsequently found to have a focal peripheral neuropathy of varying severity that was confirmed by electrodiagnostic testing. Patient demographics, clinical, and electrodiagnostic findings were documented. The findings of local weakness and focal peripheral neuropathies after diagnosis of COVID-19 raise significant questions regarding underlying pathophysiology and overall prognosis associated with COVID-19.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions.

OBJECTIVE: A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported. DESIGN: This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs. RESULTS: A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion. CONCLUSION: Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization.

OBJECTIVE: The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions. DESIGN: For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned. RESULTS: The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data. CONCLUSIONS: The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

Physical Medicine and Rehabilitation Milestone Evaluation Project: Development of Standardized Rotation-Specific Milestone-Incorporated Faculty-of-Resident Evaluation Tools.

ABSTRACT: This tri-institutional study describes the outcomes of utilization of newly developed, standardized, rotation-specific evaluations for faculty assessment of resident achievement of the physical medicine and rehabilitation milestones. Thirty-six physical medicine and rehabilitation faculty, representing three distinct academic institutions, completed a prestudy survey on the adequacy of the rotation-generic resident evaluation tools historically in use at each institution. During the 2016-2017 academic year, faculty in all three institutions consistently used a new set of rotation-specific milestone-incorporated evaluation tools. The same faculty completed surveys assessing the new evaluation tools 6 and 12 months later. Ordinal logistic regression was used to compare survey results before and after implementation of the rotation-specific milestone-incorporated evaluation tools. Results demonstrate high tool satisfaction scores, and a statistically significant improvement in the adequacy and specificity of the new evaluation tools compared with the old ones. There was also a statistically significant improvement in both faculty understanding of the milestones and faculty ability to assess the milestones with use of the new tools compared with the old ones. The implementation of standardized physical medicine and rehabilitation rotation-specific milestone-incorporated faculty-of-resident evaluation tools across three institutions improves faculty ability to assess resident overall performance specifically related to resident achievement of the milestones in each rotation.

Association of Academic Physiatrists Women's Task Force Follow-up Report.

ABSTRACT: The Association of Academic Physiatrists convened a Women's Task Force in 2016, under the leadership of then Association of Academic Physiatrists President Gerard Francisco, MD, to evaluate data and metrics pertaining to the representation and inclusion of female physiatrists in the society. An initial published report focused on a retrospective analysis of data in categories such as leadership, conference presentations, and recognition awards. The findings, which highlighted areas in which the Association of Academic Physiatrists had been successful in supporting gender equity as well as areas in which female physiatrists were underrepresented, provided a base from which to strategically focus on closing gaps in representation. The task force developed an action plan that was approved by the Board of Trustees and included strategies aimed at closing gaps and collecting data to determine corresponding effectiveness. Because most of the categories fell under the supervision of various Association of Academic Physiatrists committees, an appointee from each committee ("diversity steward") liaised with the Women's Task Force. The diversity stewards reviewed the plan with their respective committees and collected data within their committee's purview. This task force follow-up report documents recent progress, consistent with the Association of Academic Physiatrists Board of Trustees commitment to transparency and gender equity.

Pulmonary Embolism After Acute Spinal Cord Injury and COVID-19.

The coronavirus virus disease 2019 is best known for its pulmonary sequelae. Understanding of the disease process is rapidly growing, and the medical community already appreciates a hypercoagulable state associated with coronavirus virus disease 2019. Acute spinal cord injury has an inherent increased risk for venous thromboembolism. In this case report, the patient presented with bilateral lower limb weakness and sensory loss secondary to thoracic disc herniation. Incidentally, at the same time as the initial presentation, the patient was also found to have coronavirus virus disease 2019 without significant respiratory symptoms. During hospitalization, the patient developed extensive bilateral lower limb deep vein thrombosis despite chemoprophylaxis. Therapeutic anticoagulation was initiated, yet several days later, he developed pleuritic chest pain. Computed tomography angiography revealed bilateral pulmonary emboli. This case highlights the need for clinicians to have elevated vigilance with regard to screening and treatment for venous thromboembolism in high-risk patients, such as spinal cord injury with a concurrent diagnosis of coronavirus virus disease 2019.

The Vital Role of Professionalism in Physical Medicine and Rehabilitation.

Professionalism in medicine is universally embraced, and it is the foundation for core competencies in medical education, clinical practice, and research. Physical medicine and rehabilitation physicians must master a complex body of knowledge and use this to responsibly care for patients. Rehabilitation professionals work in various settings; however, each one must establish and maintain ethical standards consistent with the specialty and national standards. For example, the Accreditation Council for Graduate Medical Education lists professionalism as one of its six core competencies, which trainees must master. There is a growing interest in professionalism and some of the ethical issues that it encompasses. This report provides a general overview of professionalism. Future reports are needed, and there is an opportunity to consider many facets of professionalism in greater detail.

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-Cause Mortality, Cardiovascular Performance and Functional Performance.

OBJECTIVE: Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors. DESIGN: This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function. RESULTS: The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001). CONCLUSIONS: Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function.

Association of Academic Physiatrists Women's Task Force Report.

The Association of Academic Physiatrists (AAP) convened a women's task force in 2016, and the members agreed on a list of metrics that would permit retrospective data review pertaining to the representation and inclusion of women physicians in the society. Examples of categories examined included leadership positions (i.e., board membership, board presidents, committee membership, committee chairs, and resident fellow physician chairs), conference presentations (i.e., annual meeting session proposals, annual meeting faculty, annual meeting plenary speakers), and recognition awards (i.e., recognition award nominations and recipients). The findings highlight areas in which the Association of Academic Physiatrists has been successful in supporting gender equity and other areas in which women physiatrists have been underrepresented. The task force worked with the Board of Trustees to construct an action plan, asking the respective committees to address areas of underrepresentation. A volunteer from each committee was deemed a "diversity steward" and going forward will work directly with the task force as a liaison to document an action plan and collect data. The board plans to transparently report progress to members and other stakeholders, and the task force aims to publish a follow-up report within the next 5 years.

Gait and balance in the aging population: Fall prevention using innovation and technology.

On a global basis, adults 65 years of age and older experience falls more frequently than younger individuals, and these often result in severe injuries as well as increased healthcare costs. Gait and balance disorders in this population are among the most common causes of falls and negatively influence quality of life and survivorship. Although falls are a major public health problem and guidelines/recommendations are available to physicians, many are fully aware of different assessments, tools, and resources available for intervention. Given the risk for potentially devastating outcomes if severe injuries occur secondary to a fall, fall prevention strategies in clinical offices is a timely consideration in today's health care landscape. This paper presents a three-tier model, comprising assessment, prevention, and intervention, to highlight methods, proactive programs, and innovative tools and technology that have been developed for fall prevention. Awareness of these resources will enhance the clinician's ability to accurately assess balance and gait, which can improve physical function, and decrease the risk of falls for both average-risk and high-risk older adults.