Inpatient rehabilitation of survivors of purpura fulminans with multiple limb amputations: a case series.

Purpura fulminans (PF) is a rare, rapidly progressive syndrome characterized by intravascular thrombosis and necrosis of the skin and subcutaneous tissues. Survivors are often left with considerable impairments, including organ dysfunction, adjustment disorder, extensive wounds, and amputations. This retrospective case series presents 4 adult patients who underwent multiple limb amputations secondary to acute infectious PF. All patients underwent acute inpatient rehabilitation, were fitted with prostheses during their stay, and achieved a minimal assistance level for most of their self-care and mobility skills. Rehabilitation management is discussed, including common medical issues, complications, and prosthetic considerations.

IT Is From Mars and Physicians From Venus: Bridging the Gap.

With increasing adoption of electronic health records (EHRs) and legislative mandates for its use within the United States, collaboration between physicians and information technology (IT) staff is essential. Current challenges that physicians face include addressing EHR usability, system performance, adequate training, issue resolution, regulatory compliance, and lack of awareness of IT roles. These challenges lead to gaps in communication between clinicians and IT staff. Strategies to improve collaboration between physicians and IT staff include increasing physician involvement with health information technology software development, involvement with legislative regulations and standards, IT project implementation, as well as system stabilization and optimization. Other key strategies to improve collaboration are also addressed, including proper leadership support, proper training, and proper issue triage. Improved collaboration can result in more effective EHR design and implementation which in turn can enhance the end user experience and patient care.

Update on Brain Tumors: New Developments in Neuro-oncologic Diagnosis and Treatment, and Impact on Rehabilitation Strategies.

Brain tumors can be a source of functional impairment to patients due to neurologic sequelae associated with the tumor itself as well as treatment side effects. As a result, many of these patients may require rehabilitation services. Surgery, chemotherapy, and radiation therapy have been longstanding, primary treatment modalities in the management of brain tumors, though these treatments continue to evolve given new developments in research and technology. A better understanding of the diagnostic workup and current treatment standards helps the physiatrist and rehabilitation team identify rehabilitation services needed, recognize potential side-effects from anticipated or concurrent treatments, and coordinate care with referral sources. The purpose of this article is to review these new advances in diagnosis and treatment of patients with brain tumors, as well as discuss the rehabilitation implications for this population, including factors such as rehabilitation approach, timing of concomitant treatment, cost management, and coordination of care.

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.

How 'preventable' are lower extremity amputations? A qualitative study of patient perceptions of precipitating factors.

PURPOSE: Clinicians commonly believe that lower extremity amputations are potentially preventable with coordinated care and motivated patient self-management. We used in-depth interviews with recent amputees to assess how patients viewed their initial amputation risk and causes. METHOD: We interviewed 22 patients at a rehabilitation hospital 2-6 weeks after an incident amputation. We focused on patients' representations of amputation cause and methods of coping with prior foot and leg symptoms. RESULTS: Patients reported unexpected onset and rapid progression of ulceration, infection, progressive vascular disease, foot trauma and complications of comorbid illness as precipitating events. Fateful delays of care were common. Many had long histories of painful prior treatments. A fatalistic approach to self-management, difficulties with access and communication with providers and poor understanding of medical conditions were common themes. Few patients seemed aware of the role of smoking as an amputation risk factor. CONCLUSIONS: Most patients felt out of control and had a poor understanding of the events leading to their initial amputations. Prevention of subsequent amputations will require rehabilitation programs to address low health literacy and psychosocial obstacles to self-management.

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.

Limb deficiency and prosthetic management. 1. Decision making in prosthetic prescription and management.

UNLABELLED: This self-directed learning module highlights decision making in prosthetic management in pediatric and adult patients. This chapter reviews classification of congenital limb deficiency and management of congenital pediatric upper-extremity amputees. Differences in management of amputees of various ages from infancy to old age is discussed. Case examples are used to formulate prosthetic prescriptions for transradial limb deficiency as well as knee disarticulation and transtibial level amputations. Common prosthetic gait deviations and anticipated functional levels are evaluated. OVERALL ARTICLE OBJECTIVE: To discuss prosthetic prescription and management in congenital limb deficiency and acquired amputations for patients of various ages.

Limb deficiency and prosthetic management. 2. Aging with limb loss.

UNLABELLED: This self-directed learning module highlights the issues faced by people aging with limb loss. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the impact that limb loss has on health and physical function throughout the life span. Case examples are used to illustrate what effect limb loss in childhood or young adulthood has on the incidence and management of new impairments or disease processes commonly associated with aging. OVERALL ARTICLE OBJECTIVE: To discuss the impact of early-life limb loss on the incidence and management of physiologic and functional changes associated with aging.

Limb deficiency and prosthetic management. 3. Complex limb deficiency.

UNLABELLED: This self-directed learning module highlights rehabilitation and prosthetic issues associated with complex limb deficiencies. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses rehabilitation and prosthetic management of patients with amputations for complex limb deficiencies secondary to trauma. Mechanisms of injury, prosthetic issues, prosthetic components, and potential problems in prosthetic fitting will be discussed. OVERALL ARTICLE OBJECTIVE: To evaluate common problems associated with complex limb deficiency.

Advances in amputee care.

UNLABELLED: This self-directed learning module highlights the recent innovations in amputee care. It is part of the study guide on limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review article describes the key elements of a successful comprehensive amputee program, the basic surgical considerations for upper- and lower-extremity amputation, and some of the more recent advances in prosthetic components. Further, an update is given on issues such as hand transplantation and the integration of robotics and artificial muscles for people with limb loss. OVERALL ARTICLE OBJECTIVE: (a) To discuss current issues and advances in the care of patients with amputation, (b) to describe the key elements in designing a comprehensive amputee care program, and (c) to discuss surgical considerations of limb preservation and amputation levels.

Limb deficiency and prosthetic management. 4. Comorbidities associated with limb loss.

UNLABELLED: This self-directed learning module highlights common comorbidities found in people with amputations and their impact on functional outcome. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on prosthetic considerations, functional outcome, and potential complications for a woman with the comorbidities of stroke and diabetes who experiences a dysvascular amputation. Formulation of the differential diagnosis, management of limb pain, and evaluation of the potential psychosocial issues arising after amputation are also discussed. OVERALL ARTICLE OBJECTIVE: To analyze common comorbidities of people with amputations and to delineate their impact on functional outcome.

Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation.

OBJECTIVE: To determine the prevalence of venous thromboembolic disease (VTED) and impact on functional outcome in patients with major lower-extremity (LE) amputation admitted to an inpatient rehabilitation unit. DESIGN: Retrospective medical records review. SETTING: Acute inpatient rehabilitation unit in a tertiary, urban academic medical center. PARTICIPANTS: Fifty consecutive patients admitted to an acute inpatient rehabilitation unit after a major LE amputation. Participants were screened at rehabilitation admission for LE deep vein thrombosis using duplex ultrasonography. INTERVENTIONS: Not applicable. Main outcome measures VTED incidence, FIM instrument, total rehabilitation charges, and length of stay (LOS). RESULTS: Six of 50 patients (12%) had evidence of VTED. The VTED cohort had significantly lower admission and discharge FIM scores than the no-VTED cohort (admission FIM score, 57.2 vs 76.0; discharge FIM score, 66.0 vs 90.1, respectively; P< or =.02). Subjects with VTED had a longer rehabilitation LOS (22.8d vs 13.9d, respectively; P=.02) and higher total rehabilitation charges (28,314 US dollars vs 17,724 US dollars, respectively; P<.05). CONCLUSIONS: In this study, VTED prevalence after LE amputation in a rehabilitation setting was 12%. Subjects with VTED had lower admission and discharge functional status, longer LOS, and higher hospital charges. The utility of screening duplex ultrasound examinations at rehabilitation admission remains unclear.