Bruce M. Gans

Language profiles in nonspeaking individuals of normal intelligence with severe cerebral palsy

Evidence is presented that verbal intelligence may be relatively superior to nonverbal intelligence in many nonspeaking individuals of normal intelligence with severe cerebral palsy and that unqualified generalizations about language abilities in this patient population should be avoided. Standardized tests of different levels of processing oral language (phonemic analysis, vocabulary knowledge, sentence syntax, discourse comprehension), of processing written language (word decoding out of sentence context and sentence and paragraph comprehension), and of producing written language (spelling single dictated words) were administered to a nonspeaking adult, adolescent, and child of normal intelligence with severe cerebral palsy. Intraindividual differences and common patterns across language profiles were examined. Not all subjects showed the same pattern within their language profiles, but all showed relatively better receptive oral language at the discourse level than any other level and were relatively b...

Description and interobserver reliability of the Tufts Assessment of Motor Performance.

This paper describes the conceptual basis for the development of a new clinical evaluation instrument, the Tufts Assessment of Motor Performance (TAMP). The TAMP is a 32-item, diagnosis-independent, criterion-referenced test that samples physical performance items in the areas of mobility, activities of daily living and physical aspects of communication. The administrative and scoring criteria of the TAMP are presented, and the multiple measurement dimensions are described. The documentation of patient status and progress, as described in the functional and performance profiles, is outlined. The paper also reports initial interobserver reliability on the intraitem tasks and the summary indexes of the two profiles. Forty individuals (20 adults and 20 children) with neurologic and musculoskeletal disorders comprised the reliability sample. Kappa and intraclass correlations were used to estimate the reliability of three independent raters on individual tasks and aggregate scores, respectively. Task reliability for the assistance and approach measurement dimensions were generally higher than for the more qualitative pattern and proficiency dimensions. Yet over 90% of all the tasks had acceptable reliability, while all the summary indexes had high interobserver reliability. Determination of interobserver reliability data is the initial phase of defining the most appropriate and technically valuable items, and will serve as a basis for item revision and reduction to enhance the clinical utility of the test.

Patient Protection and Affordable Care Act: Potential Effects on Physical Medicine and Rehabilitation

The objective was to review pertinent areas of the Patient Protection and Affordable Care Act (PPACA) to determine the PPACAs impact on physical medicine and rehabilitation (PM&R). The law, and related newspaper and magazine articles, was reviewed. The ways in which provisions in the PPACA are being implemented by the Centers for Medicare and Medicaid Services and other government organizations were investigated. Additionally, recent court rulings on the PPACA were analyzed to assess the laws chances of successful implementation. The PPACA contains a variety of reforms that, if implemented, will significantly impact the field of PM&R. Many PPACA reforms change how rehabilitative care is delivered by integrating different levels of care and creating uniform quality metrics to assess quality and efficiency. These quality metrics will ultimately be tied to new, performance-based payment systems. While the law contains ambitious initiatives that may, if unsuccessful or incorrectly implemented, negatively impact PM&R, it also has the potential to greatly improve the quality and efficiency of rehabilitative care. A proactive approach to the changes the PPACA will bring about is essential for the health of the field.

Assessing word processing capability of the nonvocal, nonwriting

Issues in clinical assessment of nonvocal, nonwriting individuals (school-aged or adult) for prognosis for learning to read and spell and thus for using computers for linguistic communication are discussed. Specific tests of visual skills (for whole word or word-like patterns and for embedded symbol or symbol sequence) and of linguistic skills (for phonemic analysis and vocabulary knowledge) are recommended because they were shown to have concurrent validity for achievement in word decoding and encoding for a nondisabled sample of beginning readers before and after a year of formal reading instruction; these tests can be administered in the same way to nonvocal, nonwriting individuals as to nondisabled individuals on whom the tests were normed. Tests are also recommended for monitoring text comprehension, once reading instruction is implemented that is adapted to the response capabilities of the nonvocal, nonwriting individual. Professionals in the field of augmentative and alternative communication are u...

Physical medicine and rehabilitation workforce study: The supply of and demand for physiatrists☆☆☆

OBJECTIVE Analysis, results, and implications of a supply and demand workforce model for physical medicine and rehabilitation. Explicit issues addressed include: (1) the supply implications of maintaining current (1994-1995) output of physiatrists from residency programs; (2) the implications of continued growth in managed care on the demand for the services of physiatrists; (3) likely future supply and demand conditions; and (4) strategies to adapt to future conditions. DESIGN A workforce model of the supply and demand for physiatrists was developed. Parameters of the model are estimated using econometric models and by applying the judgments of a consensus panel. The model evaluated several different scenarios regarding managed care growth, competition from other providers and other factors. RESULTS Based on the analysis, physiatrists will continue to be in excess demand through the year 2000. More aggressive growth in managed care can affect this result. CONCLUSIONS Based on an overall assessment of supply and demand conditions, and under the assumption that the supply of new entrants each year remains in the range of 1994-1995 levels, demand for physiatrists will continue to exceed supply, on average, through the year 2000. Excess supply has, and will, emerge in selected geographic areas. If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.

Functional Assessment in Young Children with Neurological Impairments

The assessment of basic functional skills is an important domain in the comprehensive educational assessment of young children with neurological impairments. Most children with neurological impairments have significant limitations in physical function that can impede their educational progress. For young children with physical impairments, special educators are primarily concerned with the evaluation of basic functional skills such as mobility and self-care. Educational plans for children with neurological impairments often incorporate functional activity training; thus, functional assessment can serve as an effective means for program planning and documenting progress. The purposes of this paper are to: (a) review the status of functional assessment in young children, (b) examine the conceptual issues in the selection of functional assessment measures in special education, and (c) describe functional assessment approaches developed in the field of pediatric rehabilitation.

Impact of the "60% rule" on inpatient medical rehabilitation.

Gans BM: Impact of the “60% rule” on inpatient medical rehabilitation. Am J Phys Med Rehabil 2008;87:255–257.

Practicing Physical Medicine and Rehabilitation in an Ethical Manner

B P s J g r K D ost medical students accumulate substantial debt and earn little to no income. Residency nd fellowship training programs offer relatively modest stipends, usually not amounting to hat most trainees need both to live on and also to repay their accumulated debt. Therefore, hen trainees finally complete the period of deferred-income appreciation, it is no surprise hat they begin paying much more attention to the economic aspects of practice. After all, his is the time when they should finally be able to earn a “decent” income, either by eceiving a salary from an institution or established practice, getting fee-for-service payents from patients, or some combination of these earning mechanisms. Given the conomic pressures that young physicians face, it is natural for them to begin considering he economic consequences of their career and professional choices as they enter the active orkforce. They quickly become much more sensitized to the fact that how one practices nd the decisions one makes clinically will have economic consequences, not only for atients and the institutions that serve them, but also for themselves. Yet, I have rarely met a physician who was drawn to medicine (or physiatry more pecifically) primarily for the earning potential as opposed to the emotional and intellectual atisfactions associated with the specialty. In this regard, I believe that many younger ndividuals make the conscious decision that they will be giving up a more highly compenated career choice in favor of a more modestly rewarding one when they choose to enter the eld of physical medicine and rehabilitation (PM&R). The reasons that physicians cite to xplain their choice of PM&R as a specialty frequently relate to personal experiences with a riend or family member with a serious disabling condition, a preference for the establishent of long-term relationships with patients, a desire for a more balanced lifestyle without xtensive call schedules intruding on personal time, and an interest in patients as people ather than organs with diseases. It is the latter reason that distinguishes PM&R from most ther medical specialties and justifies the real privilege of becoming certified in this specialty y the American Board of PM&R. The setting that one chooses for his or her career also reflects personal values and style. eople who prefer doing things themselves without delegating or relying on others tend to ravitate towards independent practices that are not burdened with organizational bureauracy. Individuals who gain more satisfaction from immediate responses to their medical ecision making are likely to prefer musculoskeletal practices in which diagnosis, treatent, and response frequently follow a more rapid pace than the changes one sees in n-patient rehabilitation. But regardless of the practice setting, physicians have fiduciary bligations to multiple parties: the patient, the institution or group in which they practice, he third party paying the bill, society as a whole, and themselves. Frequently, tension may exist between what is in the best interests (or agendas) of these arious parties and these stresses may result in ethical challenges. Because physiatrists deal ith patient problems in the domains of Activity and Participation, as well as Disease and mpairment (to use the World Health Organization conceptual framework), we are uniquely ikely to be confronted by struggles our patients are having with insurance companies, overnment agencies, and public institutions that involve the use of financial resources. The ature of PM&R often leads the physiatrist to struggle with decisions that juxtapose business nd clinical choices, leading to ethical dilemmas. For example, in my personal practice, I have been asked by patients to prescribe drugs, evices, equipment, supplies, or some special treatment that were not of my own initiative. D C

Avoiding Harm and Achieving Good in Rehabilitation Hospitals and Units.

Preventing harm and delivering safe, high-quality care are focuses of the health care delivery system reforms that are sweeping both the public and private sectors. Payment reforms are generally the approaches being taken to improve the care delivery enterprise. They also are intended to maximize th

Poster 3: Reasons for Medical Necessity Based Denials of Coverage by Medicare for Inpatient Rehabilitation Hospital and Unit (IRH/U) Admissions: Expert Assessment of the Clinical Reasons Cited and Their Appropriateness

Disclosures: B. M. Gans, Kessler Institute for Rehabilitation, Employment; Select Medical Corporation, Employment; Five Star Quality Care, Inc, Consulting fees or other remuneration; Hospitality Properties Trust, Consulting fees or other remuneration; Chair, AMRPA Board of Directors, Non-remunerative positions of influence President Foundation for PM&R, Non-remunerative positions of influence; Director, ThinkFirst Foundation, Non-remunerative positions of influence Director, APEC, Non-remunerative positions of influence Professor, UMDNJ-NJMS, Other. Objective: To examine a sample of IRH/U admissions for which coverage was retroactively denied by Medicare to determine what factors contributed to the denials, and to compare the determinations with professional standards and expert medical opinion. Design: Reviews of medical records by expert physiatrists in a group setting. Setting: 24 medical records from a variety of IRH/U in the United States. Each case was denied for coverage both by a Fiscal Intermediary (FI) and also on appeal to the Qualified Independent Contractor (QIC). All cases were then appealed to an ALJ. Participants: Eight expert physiatrists highly experienced as medical directors of inpatient rehabilitation hospitals or units. Interventions: Not applicable. Main Outcome Measures: Survey score sheets using primarily dichotomous response options. For each item of each case, the presence of a specific factor being cited as a reason for denial was determined if at least 6 of the 8 independent reviewers identified it as so. Similarly, concurrence or disagreement with the judgment of the Medicare Contractor was determined. Results: Of the 24 cases reviewed, 14 claims were paid because of the judgments of the ALJ, 2 were paid in part, and 8 continued to be denied for coverage. The majority of cases involved patients with orthopedic diagnoses (87%). Need for either close medical supervision or intense therapy services were the 2 reasons most commonly cited by the FI, QIC and ALJ for denial of coverage. Diagnosis was not explicitly cited as a reason for denial. The experts achieved consensus in 21 of 24 cases that the decisions of the FIs and QICs to deny payment did not meet the Academy’s Standards. Experts disagreed with the ALJs in 5 of 8 cases ruled unfavorably. Conclusions: This study showed how varied the expert opinions of experienced physiatrists may be regarding the application of expert judgment or the Academy’s Standards. It also showed how inconsistent the determinations by FIs, QICs, or ALJs may be with either expert judgment or the Academy’s standards. Other means of achieving resolution to the ongoing conflicts between physicians, Medicare contractors and IRH/U will need to be developed.