Douglas Elwood

Length of Stay in Rehabilitation is Associated with Admission Neurologic Deficit and Discharge Destination

This study explores the link between neurologic deficit as measured by the National Institutes of Health Stroke Scale (NIHSS), and its relationship to length of stay (LOS) and discharge destination.

Mobile Health: Exploring Attitudes Among Physical Medicine and Rehabilitation Physicians Toward this Emerging Element of Health Delivery

Health care reform, coupled with recent technologic advances, is driving the rapid adoption of medical technology. Individual medical practitioners and integrated health care delivery systems have been forced to alter their approach to technology and to understand the potential applications within their practice. Among these technologic innovations is mobile health (mHealth), which is the practice of medical or public health supported by mobile electronic devices. mHealth enables the monitoring and delivery of health care and healthrelated information to a broad community in a real-time fashion. The power of mHealth stems from the ability to provide information, education, and resources to both health care providers and patients where and when they need it, thus extending traditional modes of information sharing and dissemination across the spectrum of health delivery. The dynamic nature of the devices and the accompanying software applications (apps) allows users to interact with each other and to access data in an unprecedented manner. For physicians and other members of a multidisciplinary care team, the result could be improved communication and alignment of services, clinical monitoring, multidisciplinary coordination of care, patient education, access to health records, and continuing medical education; for patients, mHealth could provide an additional point of contact with their providers that is interactive and that accompanies them throughout their day in their individual psychosocial milieu, allowing them to access information and become empowered at the point of need. Currently, our physical medicine and rehabilitation (PM&R) department is conducting a prospective study evaluating the impact of tablet computers, specifically the iPad (Apple Inc. Cupertino, CA), on patient care and resident education within a rehabilitation setting. Here we discuss attitudes among PM&R resident and attending physicians toward mHealth to better understand the current use and potential benefits within our field. The rapid movement of technology that is emerging outside of the traditional realm of hospital-driven information technology was initially dominated by personal digital assistant devices and by phones with advanced computer-like capabilities (smartphones) and has recently expanded to encompass tablet computers, including the iPad. There are currently more than 15,000 health-related apps available on iTunes, and at least 3 medical schools have already integrated iPads into the first-year curriculum [1,2]. Recent surveys suggest that 22% of physicians will own an iPad by the end of 2010 and more than 50% will have one by the end of 2011 [3,4]. The rapid adoption of mobile technology by health care practitioners has been matched by the use of mobile devices by patients. In fact, more than 80% of Medicaid patients text regularly, and groups who would otherwise have limited access to Internet services (eg, ethnic minorities) are leading adopters of Smartphones and tablets [5]. Not only can mHealth reach individuals whenever and wherever they carry their mobile device, it has the potential to accompany individuals over long periods of time and to involve underserved communities. Physicians indicate a willingness to have patients monitor their health remotely, with more than 85% of physicians stating they would prefer to have patients take more control of their own care in this way [5]. It is estimated that more than 14% of adult Americans are already using mobile devices to monitor their health [6], with some positive preliminary results reported [5-9].

Assessing Patient Expectations and Concerns in a Physical Medicine and Rehabilitation Unit: A Real-Time Snapshot

To evaluate patient expectations, concerns, and satisfaction during physical medicine and rehabilitation (PM&R) inpatient hospitalization. Patients were also asked to comment on what resources might benefit them during their stay.

Intraspinal Hematoma Following Neuraxial Anesthesia and Low-Molecular-Weight Heparin in Two Patients: Risks and Benefits of Anticoagulation

his article examines one of the potential, and perhaps most drastic, complications of ow-molecular-weight heparin (LMWH): intraspinal hemorrhage leading to paraplegia. The atients discussed here are unique for numerous reasons, and their presentations offer a hance not only to review various anticoagulants but also to highlight the relevance of this opic to physical medicine and rehabilitation (PM&R) physicians. It is especially pertinent iven that both patients developed this complication with the administration of LMHW to revent venous thromboembolism following routine joint replacement surgery, a common rocedure that leads patients to physiatrists. Indeed, orthopedic surgeries of this type in the nited States have been steadily increasing, with a reported 226,000 total hip replacements THRs) and 432,000 total knee replacements (TKRs) in 2004 alone, a jump of over 37% and 3%, respectively, from 2000 [1]. A major complication of these surgeries is deep venous hrombosis (DVT). Understanding appropriate prophylaxis of DVTs while being cognizant f potential warning signs and symptoms of an intraspinal hemorrhage affords PM&R hysicians the best opportunity to ensure their patients’ safety. Before the regular use of anticoagulation in the perioperative period, patients not eceiving prophylaxis after orthopedic surgery experienced DVTs with a frequency of 50% o 80%, with 2% leading to fatal pulmonary embolus [2,3]. Venous stasis and positional/ ompressive techniques during surgery were cited as primary factors for the development of hese blood clots [4]. In general, hospitalized patients are at increased risk of developing VTs due to immobility leading to venous stasis, reaching up to 130-fold greater prevalence han for nonhospitalized individuals [5]. Many patients with joint replacement transition to ehabilitation facilities for continued care before returning home, prolonging their hospital tay and therefore their DVT risk. However, various methods have reduced these numbers ramatically. Initially, anticoagulant agents such as warfarin or unfractionated heparin (UFH) were sed for the prophylaxis and/or treatment of venous thromboembolism. Intermittent neumatic leg compression devices have also been used to prevent clots by reducing stasis nd promoting blood flow in the deep leg veins, reducing plasminogen activator inhibitor-1 nd enhancing fibrinolysis [6]; however, they are not as effective in deeper, more proximal eins [7]. In addition, they are difficult to use for patients undergoing rehabilitation because hey cannot be used continuously without disrupting therapy. Debate regarding which gent to use has heightened since the introduction of low-molecular-weight heparin LMWH) into the United States in 1993. Enoxaparin is a type of LMWH and is derived from UFH by chemical or enzymatic epolymerization and is one third the size of its precursor, differing in pharmacokinetic roperties and anticoagulation effect. It is similar to UFH in its action on antithrombin III to nactivate factor Xa in the coagulation cascade [8,9] (Figures 1 and 2). However, LMWH is onsidered superior to this agent for many reasons. Because of its unique pentasaccharide equence and truncated chain length, LMWH has less ability to deactivate thrombin, educed activity against anti factor IIa compared with factor Xa, and a longer plasma alf-life and bioavailability. These factors allow for less frequent administration to a nce-daily dosage and a more predictable dose response, which eliminates the need for S a

Poster 208: Evaluating the Efficacy of a Hospital-Based Multidisciplinary Amputee Support Group

that their subjective knowledge was not sufficient and most are interested in more end-of-life care training, indicating that there is likely an educational need in this area for providers who care for persons with MS. Providers appear more comfortable with procedural skills related to end-of-life care, such as making a hospice referral or completing a DNR form, than with interpersonal skills. Challenges with the design and analysis of this study reinforce the need for validated survey measures for these outcomes as well as additional surveys to measure provider attitudes, skills and knowledge related to end-of-life care both over time as well as before/after educational interventions.

Poster 49: Gender Differences Across Specialties: A Real-time Snapshot of Patient Expectations

discharge to home with her mother, the patient was at a supervision level for wheelchair propulsion of 75 feet. She required minimal assistance for upper extremity bathing and dressing, moderate assistance for lower extremity bathing and dressing, and moderate assistance for executive functioning tasks. Discussion: Dry beriberi and its neurological sequela of encephalopathy and peripheral neuropathy are typically associated with chronic alcohol use in the United States, but can occur in any thiamine deficient state such as in pregnancy. Neurological symptoms can be reversible if treated early with thiamine supplementation. No accurate statistics are available on the overall incidence of beriberi in the US, and there is no available literature on the functional outcome of such patients. Conclusions: Comprehensive acute rehabilitation is beneficial for patients with nutritional-related encephalopathy and neuropathy, providing them with family training, access to assistive devices, and an opportunity for upgrades in cognition, mobility, and self-care skills.