Biomechanic of Gait and Treatment of Abnormal Gait Patterns
[…] with good muscle strength limited by contractures.13 7.) Neurogenic Claudication:Pain and neurological deficits with ambulation Pathomechanism: Usually secondary to lumbar spinal stenosis. Will have hyperlordosis with stenosis and vertebral shift if walking/standing.21 Pain and neurologic deficits better with spinal flexion […]
Quality Payment Program/Pay for Performance
[…] (QRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/irf-quality-reporting. Accessed April 19, 2023. Davis, M. When Quality Measures Put Patients with Spinal Cord Injury at Risk. TIRR Memorial Hermann Journal (Online). Spring 2016 Edition. https://memorialhermann.org/services/specialties/tirr/healthcare-professionals/journal/2016/spring-2016/quality-measures-put-sci-patients-at-risk. Accessed April 19, 2023. Fiscal Year 2024 Inpatient […]
Lung Cancer
[…] procedures may be explored. Some options include intercostal nerve blocks, thoracic paravertebral blocks, thoracic sympathetic blocks, epidural injections, interpleural blocks, spinal cord stimulation, and dorsal root ganglion pulse radiofrequency application.8 DILD is described as a spectrum of clinical manifestations, from mild to severe, including asymptomatic infiltrates to acute respiratory distress syndrome. The pathophysiology is related to dose-dependent toxicity or immune-mediated injury. It may develop within days of treatment initiation or may have delayed presentation until months or years later.9,10 Common drugs that are associated with development of drug-induced infiltrative lung disease include anti-inflammatory agents, chemotherapeutic agents, and biologic agents. Some drugs which are commonly used to treat non-small cell lung cancer that are associated with the development of radiation pneumonitis or subsequent interstitial lung disease include paclitaxel, docetaxel, gemcitabine, and etoposide. Cisplatin and gemcitabine have been shown when co-administered with bleomycin to increase the risk of development of DILD.11 Radiation pneumonitis may present with dyspnea two to three months after high-dose external beam radiation in up to 15% of irradiated patients.12 Exudation of fluid into the alveoli causes decreased compliance and gas exchange, with eventual development of restrictive lung disease.. Radiation fibrosis syndrome is characterized by radiation injury sequalae to affected tissues. Complications may include neuromuscular damage, myelopathy, radiculopathy, neuropathy, fatigue, dysphagia, radiation pneumonitis and fibrosis, and radiation dermatitis.13 The pathogenesis of this condition is described to occur in three phases.14 The prefibrotic phase is characterized by endothelial cell dysfunction. Local inflammation increased vascular permeability, and edema result in necrosis of the microvasculature and subsequent local ischemia. In this phase patients are usually asymptomatic. The constitutive organized phase is characterized by active fibrosis with myofibroblasts in a poorly organized extracellular matrix and senescent fibrocytes in an already fibrotic extracellular matrix. The late fibroatrophic phase is characterized by successive remodeling of the extracellular matrix resulting in dense radiated tissue. This stage may develop and progress years to decades following radiation therapy. As a result, affected tissue may become poorly vascularized, friable, and fragile.13 Chemotherapy is associated with a broad range of systemic side effects that can severely impact quality of life. Some common side effects include: Chemotherapy-induced nausea and vomiting Hematologic toxicity (manifesting as anemia and neutropenia) Nephrotoxicity Neurotoxicity (especially with cisplatin and taxanes) Fatigue Anorexia and weight loss The role of the physiatrist is to monitor for signs of symptoms, work with the multidisciplinary oncology care team to alter treatment regimens to minimize significant side effects and prescribe treatments that will maximize a patient’s functionality to preserve quality of life. Essentials of Assessment History History-taking for a patient with lung cancer includes a thorough review of history and systems, including cough, hemoptysis, dyspnea, chest pain, fever, night sweats, weight loss, smoking history, family history, prior malignancy, and environmental exposures.15 Review of symptoms should be expansive and include all organ systems because new symptoms can indicate metastatic disease.16 Some key things to inquire about include new bone pain (associated with bone metastasis), neurological symptoms including headaches, weakness, sensory changes, dizziness, balance problems, seizures (associated with brain metastasis), jaundice (associated with liver metastasis), and lymphadenopathy (associated with regional metastatic spread). The physiatrist participating in the care of a patient with cancer should also inquire about a patient’s functional status including ability to perform activities of daily living (ADLs) and instrumental ADLs (iADLs). It is crucial to inquire about whether the patient ambulates with or without an assistive device and if he has a home health aide. An exhaustive social history including occupation, living situation, prior activity level, and family and community support. Physical examination Examination should begin with vital signs, including orthostatic blood pressure, pulse oximetry and respiratory rate. Inspection should be performed, and signs of chest excursion, asymmetry, cyanosis, finger clubbing, venous distension of neck, facial edema and plethora, muscle atrophy, edema, and scapular winging should be noted. Palpation is a key part of examination especially if there is a complaint of focal pain. A comprehensive neurological exam should be performed including mini-mental state examination which may clue into neurocognitive deficits. Further examination should be done to evaluate the cranial nerves, coordination and propioception, sensation (light touch, vibration, pinprick, and temperature), deep tendon reflexes, tone, and gait. Active and passive range of motion should be done, with special attention paid to deficits and pain. Motor strength is evaluated for localized or generalized weakness. Physical therapy, occupational therapy, and speech therapy should also be consulted when indicated to evaluate the patient for impairments in ADLs, strength, coordination, speech, swallowing, hearing, and cognition.16 Clinical functional assessment: mobility, self-care cognition/behavior/affective state Observing the patient ambulating, transferring, and performing ADLs is the easiest way to characterize functional impairments. There are a number of rehabilitation instruments which are useful in assessing a patient’s clinical status including functional capacity and cardiorespiratory performance. The Functional Reach Test is a simple assessment for measuring dynamic balance. The Timed Up and Go Test is an assessment which involves rising from an armchair, walking three meters, turning, walking back, and sitting. Both of these tests have been shown to predict the likelihood of a fall.17 Clinical assessments of exercise capacity include the shuttle walk test, six-minute walk test, and cardiopulmonary exercise testing.18,19 It has been shown that distances less than 350 meters in the shuttle walk test are associated with increased mortality. Laboratory studies Laboratory studies in the diagnosis and work-up of lung cancer would be performed by the medicine and oncology care team. Preliminary studies may include complete blood count and comprehensive metabolic panel.19 Further assessment may include testing for tumor markers including carcinoembryonic antigen, squamous cell carcinoma antigen, neuron-specific enolase, cytokeratin 19 fragment and pro-gastrin-releasing peptide.20 Imaging A chest x-ray is used for initial evaluation of symptoms of lung cancer,21 followed by further characterization with computed tomography (CT) imaging. The US Preventative Services Task Force recommends annual screening for lung cancer with low-dose CT in adults 55-80 years of age with a smoking history of 30 pack-years who currently smoke or are in remission for 15 years.22,23 For investigating metastases, positron emission tomography (PET) imaging may be utilized. Supplemental assessment tools Signs and symptoms suspicious of new metastasis or cancer recurrence requires investigation by the primary oncology team, and may include imaging.24 PET imaging can distinguish between persistent or recurrent tumor from post-treatment scarring or fibrosis.25 CT imaging can demonstrate osteolytic and osteosclerotic lesions.25 Magnetic resonance imaging (MRI) can demonstrate metastatic lesions to soft tissue, bone marrow cavity, or suspected cord compression secondary to pathologic vertebral compression fractures.26 Skeletal scintigraphy (bone scan) is commonly used to detect skeletal metastasis, with the added benefit that whole body scan can be performed.27 Early predictions of outcomes TNM staging influences treatment and predicts survival. Poor performance status and/or weight loss have been associated with shortened survival. Staging of SCLC usually uses the Veterans Administration Lung Study Group designations of limited (one hemithorax) or extensive (beyond one hemithorax) disease.28 Poorly differentiated tumors and lymphatic invasion are associated with worse prognosis. A tumor’s metabolic activity can be measured using the standardized uptake value (SUV) to assess the tumor uptake of fluorodeoxyglucose (FDG); high SUV was associated with a poor prognosis, and a lower FDG uptake was associated with a better prognosis.29 PET (or PET-CT) may also be useful in predicting response to chemotherapy. Environmental Smoke exposure is the primary risk factor for lung cancer. Other factors include exposure to asbestos, radon, metals (arsenic, chromium and nickel), ionizing radiation and polycyclic aromatic hydrocarbons.30 Dietary factors may reduce the risk of lung cancer, these include antioxidants, cruciferous vegetables and phytoestrogens. Social role and social support system Cancer survivors have specific cancer-related impairments that impact their roles in their families, communities, and workplace.31 This can lead to difficulty in adjusting to newly defined versions of social life. Therefore, a basic psychological evaluation for mood changes is important in evaluating for depression, anxiety, and adjustment disorder. Professional issues Lung cancer survivors are two to three times more likely to be unemployed and have the strongest decline in earnings compared to those affected by other cancers due to an observed higher median duration of sickness.32 Involving a vocational therapist early in treatment may help patients navigate occupational options. Rehabilitation Management and Treatments Available or current treatment guidelines Lung cancer rehabilitation is unique and tailored to a patient’s individual needs. This may include physical therapy, occupational therapy, speech therapy, and pulmonary rehabilitation. Pulmonary rehabilitation is defined by the American Thoracic Society as a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.33 Pulmonary rehabilitation is a comprehensive treatment program focused on improving quality of life, and may in turn be considered a form of palliative care. All prescriptions for pulmonary rehabilitation should be based on outcomes observed from exercise capacity testing. A therapy prescription should be defined in terms of exercise intensity, duration, frequency, type (interval or continuous), mode (e.g., walking, cycling, arm exercise), and progression recommendations. Home oxygen may be indicated if: Arterial oxygen tension (PaO2) is less than or equal to 55 mmHg or a pulse oxygen saturation (SpO2) less than or equal to 88%, or, PaO2 less than or equal to 59 mmHg or a SpO2 less than or equal to 89% and there is evidence of cor pulmonale, right heart failure, or erythrocytosis.34 In addition, if there is dyspnea or ventilatory abnormalities during exercise, supplemental O2 may be given during exercise without evidence of desaturation demonstrated by a decrease in SpO2. At different disease stages In the acute phase of cancer treatment deconditioning, anxiety, and weakness are common contributors to disability. Dyspnea is highly prevalent as well, which may have been present pre-morbidly due to COPD since the vast majority of lung cancer patients have a history of smoking. This compounds the symptoms burden. The majority (>75%) of cancer patients experience cancer-related fatigue, which can occur at any point along the cancer continuum.35 Paraneoplastic phenomena can […]
Phantom Pain
[…] non-painful sensation of the presence of a missing limb. Etiology Phantom limb sensation may be present as a result of spinal cord injury, amputation, or congenital deficiency. Phantom pain is almost exclusively experienced after amputation. It has also been observed after surgical […]
Rehabilitation Approach to Adolescent Pain
[…] Newer technologies are showing promise in management of chronic pain in adults, including modulation therapies such as Transcutaneous Magnetic Stimulation, spinal cord stimulation and deep brain stimulation. Significant research needs to be completed on these therapies before becoming universally accepted. […]
The Early History of Physical Medicine and Rehabilitation in the United States
[…] become board certified in seven diverse subspecialties: brain injury medicine, hospice and palliative care, neuromuscular medicine, pain medicine, pediatric rehabilitation, spinal cord injury medicine, and sports medicine. Expansion into these subspecialty areas represents the state of the field in the late 20th […]
Integrative Approaches to Therapeutic Exercise
[…] Bowen JE, Druin EL. Acupuncture and Trager psychophysical integration in the treatment of wheelchair user’s shoulder pain in individual’s with spinal cord injury. Arch Phys Med Rehabil. 2001;82(8):1038-1046. Witt PL, MacKinnon J. Trager Psychophysical Integration: A Method to Improve Chest Mobility of […]
Brain Metastasis
[…] Medicare. Though brain tumors can be categorized under the diagnosis of “brain injury” and similarly with spinal tumors under “ spinal cord injury”. IRFs may be unable to provide specialized cancer care and often specific oncological treatment must be delayed. From a […]
Essentials of Physiatric Assessment and Management Strategies
[…] evolve to include: Brain Injury Medicine, Sports Medicine, Neuromuscular Medicine, Hospice & Palliative Medicine, Pediatric Rehabilitation Medicine, Pain Medicine, and Spinal Cord Injury Medicine. In order to objectively understand the functional changes attained through methodic treatment interventions, the rehabilitation team will use assessment instruments allowing for a systematic evaluation and comparison of clinical changes in an objective manner. The use of instruments and outcome measures contributes to improved clinical decision making and evidence-based-practice. 2 There are numerous assessment instruments available. In order to select the appropriate instrument, it is important that clinicians determine what is being measured, the population under study, and reliability and validity of the instrument being applied. Most importantly, the physiatrist must comprehend that objective assessment tools should not be placed above clinical care and should only serve to enhance (or improve) therapeutic recommendations. Conceptual Model: The rehabilitation field uses a biopsychosocial model of care; this implies that as specialists, we do not limit our practice to diagnosing and treating a pathology (biomedical model), but we expand into understanding and treating the secondary effects of injury and illness. To successfully address this, the physiatrist will see the whole patient, incorporating motor, cognitive and emotional dimensions to the assessment so that a full picture of goals and barriers can be identified early in the planning of the rehabilitation program. 3 These components, or dimensions, will be incorporated into the assessment tools, which will subsequently assist in this ongoing process of active change as individuals achieve and reset their functional goals. The International Classification of Functioning, Disability and Health (ICF) endorsed by the World Health Organization (WHO) supports assessment tools and presents recommendations on which tools to use and how to use them. The framework is divided into: (1) Functioning and Disability, which is subdivided in body function and body structures, and (2) Contextual Factors. The first one considers the individual and the societal perspective, and his/her ability to perform. The second one considers personal, attitudinal, environmental, physical and social factors. 4 Range of Procedures and Settings: The practice of PM&R includes in-patient and outpatient settings. The setting where the evaluation is taking place will impact the extent and format followed to assess our patients. Traditionally, the inpatient scenario includes an inter-professional team that allows for a comprehensive evaluation and treatment recommendations. The family takes a huge role in this setting, particularly with the purpose of understanding the psychosocial context of the patient as well as the overall residual function and impairment. This setting is highly influenced by third party medical insurers who will dictate costs and the limit/length of stay. 3 The specialty of PM&R makes use of a series of procedures that allows the diagnosis and treatment of patients with functional disability. Electromyography has complemented the physical exam impression by allowing the study of muscles and nerves through electrophysiology principles. This study uses a combination of superficial and intramuscular electrodes to study the nerve and muscle physiologic behavior, allowing the qualification and quantification of pathology, its localization, and the establishment of prognosis. Electrodiagnostic studies are not a substitute for radiologic imaging or physical exam, but a complement to understanding anatomic and clinical findings. Specialized training is required to be able to provide a comprehensive interpretation of the pathology identified by the study. 5 Procedures in PM&R include an array of interventions ranging from peripheral joint and trigger point injections to interventional pain management of spine and deeper joints under fluoroscopy and ultrasound guidance. Although interventional procedures in pain management can be done by other medical subspecialties, the physiatrist’s intervention incorporates not only the expertise of pain management, but the component of function and rehabilitation after the procedure is completed. This creates an impact in wellness and overall quality of life. 6 ,7 Diagnostic ultrasound is another tool that has taken an important role in musculoskeletal medicine. This technology allows for quick, real-time portability, low cost and safe application in the clinical practice, allowing for a functional evaluation, diagnosis and treatment of musculoskeletal complaints and conditions. At the care site, the physiatrist can make immediate decisions about therapeutic interventions, particularly when applied to guided injections.8 Determining Prognosis: Assessment tools allow measuring and comparing clinical outcomes based on expected milestones. Ongoing observations allow for determining if functional progress goes along with the expected prognosis. Specific features of clinical applications of the assessment /treatment procedures: In rehabilitation medicine, a detailed history is initially obtained by the physiatrist, complemented by a comprehensive approach with inter-professional contribution of collaborative disciplines like the speech pathologist, the occupational therapist, the physical therapist, and the rehabilitation nurse, among others. The history includes the present illness, past medical history, and functional limitations. Although this information is obtained from the patient, the caregiver and family play a key role in understanding the contextual dimension. A functional history allows for an understanding of the resulting disability, the remaining capabilities, and the compensatory techniques used by the patient. There are several activities of daily living evaluated; some of these are communication, transfers/mobility, self-care ability, and household chores. Functional limitations in each area may vary; therefore, treatment goals are specific and adapted to improve them.3 Specific diagnostic criteria that justify use of the assessment/treatment procedure:9,10,11 Once a subjective evaluation is completed, the physiatrist will establish a diagnosis and rehabilitation goals. He/she will use objective instruments to quantify the disability and later compare the functional changes obtained after therapeutic interventions. These instruments are called assessment tools, which can be generic or specific. Specific tools can either be disease-specific or region specific. Generic tools are designed to measure and improve quality of life; thus, they are considered broad-ranged and generic and very sensitive to any health change. It can include concepts like physical health, psychological state, and level of independence, social relationships, and the relation to the patient’s environment. They are applicable to different disease and cultural groups. In response to the Affordable Care ACT (ACA) and the reporting requirements identified in the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014, the Inpatient Rehabilitation Facilities (IRF) Quality Reporting Program (QRP) was established in fiscal year (FY) 2014. The Centers for Medicare and Medicaid services (CMS) and their post-acute settings (PACS) which include skilled nursing facilities, long term care hospitals, inpatient rehabilitation facilities, and home health services utilize the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual; specifically, Section GG to evaluate functional abilities and goals. Self-care and mobility are measured using the GG codes on admission and discharge. Assessment tools to be used will be based on the diagnosis established and the specific treatment goals that are aspired to attain and measure. Other scales are used for classification of health conditions, re-assessment and reimbursement purposes. Some examples of assessment tools include: Scale What it assesses? Disability target or function Where it is used? FIM (Functional independence measure)* Functional Status, Self care, mobility, cognition 18 items in a 7-level scale that is used to uniformly to assess the severity of patient disability and medical rehabilitation functional outcomes. IRF RUGS (Resource Utilization Groups)* Level of the patients care requirement; 8 major categories divided in different subcategories Activities of daily living, special care, clinically complex, behavioral, cognitive and function Skilled Nursing Facilities OASIS (Outcome and Assessment Information Set)** Comprehensive assessment related to individuals clinical and functional status, demographic and service needs Can be used for quality improvement for skilled services rendered. Allows for a systematic comparative measurement of home health care outcomes Home health agencies ICD(International classification of Disease)** Classification of diseases and health conditions Disease classification tool that it is also used for quality, epidemiological and reimbursement purposes All agencies ICF (International Classification of Functioning, Disability and Health)* “Provides a standard language and framework for describing health and health related conditions” Overall function and disability including contextual factors such as environmental, personal and societal factors All agencies LCDS(local coverage determination)* Determination of whether a service is covered Coverage criteria is defined within each LCD Long term care hospitals MDS (Minimum Data Set) * Self- care and mobility needs Current needs for self-care of individuals; specific GG codes capture current ability or performance All PACs Arthritis impact measurement scale multidimensional health status index used in arthritis patients It consists of 9 areas of evaluation: mobility, physical activity, dexterity, household activities, activities of daily living, social activities, anxiety, depression, and pain. All users Fibromyalgia Impact Questionnaire assessment and outcome instrument developed to assess health components affected by this condition Items evaluated include physical function, pain and fatigue, among others. All users Oswestry disability questionnaire Measurement of disability and quality of life Measures disability especially in low back pain All users Barthel Index it allows measuring activities of daily living with chronically disabled patients; Ten items, among those, bowel and bladder assessment scores. All users Katz Index of Independence evaluates results of treatment and prognosis in the elderly and in chronic illness This tool includes activities of self-care. *CMS.gov **www.ncbi.nlm.nih.gov>pmc>articles>PMC4529994 Other factors that may influence clinical decision making when applying the assessment/treatment procedures: A comprehensive rehabilitation treatment plan takes […]
Functional Assessment
[…] It is important to note the complexity of the population due to the multiple subspecialties within the field, such as spinal cord injury, brain injury, palliative care, pediatric, pain management, sport medicine, cardiopulmonary rehabilitation. This diversity calls for a complex, detailed approach […]