Elizabeth A. Moberg-Wolff

Journal clubs. Prevalence, format, and efficacy in PM&R.

Journal clubs can play an integral part in graduate medical education. They promote critical thinking, dissemination of information, and research and impact clinical practice. Little has been written, however, about how to organize a journal club or improve its efficacy. Although numerous articles discuss how journal clubs can be used to evaluate medical literature, only a few have examined what physicians are actually doing. We surveyed all accredited PM&R program chief residents to ascertain the prevalence, format, and efficacy of PM&R residency journal clubs. All programs that responded (89%) reported having a journal club, with most stating its purpose was to disseminate information from the current literature. Review of classic articles and specialty topics (e.g., electromyography, sports medicine) was fairly uncommon. Eighty-four percent of journal clubs were department-sponsored, and most met monthly for 1 hr during the workday. Typically, four or more articles were presented under the guidance of the chief or other resident. Impacting clinical practice and teaching critical analysis were other important goals of the journal clubs, yet most (76%) lacked an organized method for critical review. This, in addition to poor faculty attendance, was a chief concern of those surveyed. Surprisingly, journal club participation was not felt to significantly alter the amount of reading residents did. Although most felt their journal clubs were successful, improving faculty participation, strengthening critical analysis skills, identifying and incorporating classic articles, improving clinical relevance, and providing a mechanism for feedback may further improve journal club efficacy and participant satisfaction.

Potential Clinical Impact of Compounded Versus Noncompounded Intrathecal Baclofen

OBJECTIVE To assess the differences between commercial and pharmacy-compounded preparations of baclofen for intrathecal administration. DESIGN Random sample. SETTING Pharmacies in the United States advertising compounded intrathecal baclofen preparation. PARTICIPANTS Not applicable. INTERVENTIONS Intrathecal baclofen (ITB) samples were collected from 1 Food and Drug Administration-approved commercial source and 6 compounding pharmacies. An independent analysis of drug concentration and density was conducted. Information regarding ordering process, manufacturing, packaging, storage, and expiration was collected. MAIN OUTCOME MEASURE Comparison of concentration and density variations. RESULTS Twenty-nine ITB samples in concentrations of 2000, 3000, 4000, 5000, and 6000 microg/mL were analyzed. Over 40% of compounded samples were more than 5% above or below labeled concentration. Twenty-two percent of compounded samples were more than 10% above or below labeled concentration. The only samples with no concentration deviation and consistent drug density were the commercially available, noncompounded products. CONCLUSIONS Compounding pharmacies have variable practices in the provision of ITB. A high incidence of concentration inaccuracy existed. The use of compounded ITB may result in unintended dose alterations. Variable clinical efficacy, or life-threatening overdose or withdrawal may occur in patients who are sensitive to slight dose fluctuations. Given the variability of these compounded ITB samples, informed consent to use these products and understanding of potential side effects should be reviewed with patients.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities.

This self‐directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learners knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Pediatric Rehabilitation: 5. Transitioning Teens With Disabilities Into Adulthood

This self‐directed learning module focuses on preparing adolescent patients with special health care needs for adulthood by promoting their independence in their own self‐care; helping them to navigate issues of sexuality, marriage, and parenting; preparing the patient and family to make guardianship decisions during the transition between childhood and adulthood; and planning for higher education or vocation. Emphasis will be on the role of the physiatrist in providing this guidance and its importance in improving the patients quality of life. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to refine the learners knowledge of preparing adolescent patients with special health care needs for adulthood to improve their quality of life.

An aggressive approach to limb dystonia : A case report

A 15-year-old boy presented with a severe fluctuating foot and ankle dystonia resulting from a basal ganglia insult at the age of 4. This followed an embolic event related to an undiagnosed prolapsed mitral valve. Functionally, the patient was ambulatory with rocker bottom crutches and an ankle-foot orthosis, but there were periods of up to a year when pain and increased dystonic deformity required him to use a wheelchair. A new orthotic was made nearly every month because the orthotist could find no material that would withstand his tone without breaking, yet he could not ambulate without one. Multiple interventions, including biofeedback, contrast baths, stretching and strengthening, oral lioresal (Baclofen), diazepam (Valium), benztropine mesylate (Cogentin), carbidopa-levodopa (Sinemet), carbamazepine (Tegretol), and injections of botulism toxin (BOTOX) were tried, all with minimal effects. Amputation was recommended, based on anatomic and functional considerations. The patient and his family adjusted well to this decision, although not all orthopedists and therapists adjusted easily to the choice. The patient is now functionally independent with a prosthesis and has a normal teenage lifestyle for the first time.

Pediatric Rehabilitation: 3. Facilitating Family-Centered Treatment Decisions

This self‐directed learning module focuses on the role of accurate diagnosis, psychological support, and family integration of children who have chronic impairments such as pain, spasticity, or cognitive disability. It is part of the study guide on pediatric rehabiliation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The role of therapeutic, medical (traditional and nontraditional) and psychological interventions that improve family and individual function are emphasized. The goal of this article is to refine a learners knowledge of the impact family‐centered care can have on the medical, psychological, financial, and functional capabilities of families to improve treatment decisions in the context of children with disability.

Pediatric rehabilitation: 4. Prescribing assistive technology to promote community integration.

This self‐directed learning module highlights the equipment and assistive technology needs of children and youth with disabilities. This article specifically focuses on preparing families and patients for equipment transitions that occur over the course of childhood and adolescence including progressing from stroller to wheelchair to powerchair, as well as job training and use of augmentative communication. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to modify the learners current practice techniques to ensure that assistive technology is used to promote community integration from early childhood through transition and into adulthood.

Poster 296: Blood Pressure and Obesity in Ambulatory Children and Adolescents With Cerebral Palsy

pain generators over time can make obtaining the correct etiology, such as spinal stenosis, primary hip pathology, or sacral fractures, a significant challenge. Conclusions: When evaluating the chief complaint of low back pain and extremity pain in the elderly stenotic patient, one must explore all diagnostic entities and continuously remember the vast differential diagnosis. If treatment is unsuccessful, reassessment and consideration of alternative diagnoses is essential.

Pediatric Rehabilitation: 2. Environmental Factors Affecting Participation

This self‐directed learning module highlights the environmental factors that influence the participation of children and youth with disabilities in life situations, including activities of self‐care, mobility, socialization, education, recreation, and community life. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. This module emphasizes the participation of children with disabilities in adapted sports and reviews mobility devices to promote function, in the context of the International Classification of Functioning and in reference to the Americans with Disabilities Act. It provides the physiatrist with strategies to promote community participation, functional independence and healthcare transitions for children with disabilities as they approach adulthood. The goal of this article is to improve the learners treatment strategies to maximize the participation of children and youth with disabilities in all settings, particularly schools and communities.

Physical and Social Participation Factors Impacting Quality of Life in Ambulatory Children and Adolescents With Cerebral Palsy

Disclosures: E. A. Hurvitz, None. Objective: To describe medical, functional and psychosocial outcomes and satisfaction of adults with cerebral palsy (CP) who had a rhizotomy as a child. Design: Retrospective cohort. Setting: Academic medical center. Participants: Adults and adolescents (16 years or older) with a diagnosis of CP who had a selective dorsal rhizotomy as a child or young adolescent. Interventions: Surveys administered in person or on the phone. Main Outcome Measures: Subjects were administered the Satisfaction with Life Scale (SWLS), Gross Motor Functional Classification Scale (GMFCS) and Manual Abilities Classification System. Subjects were asked about general health, and if they felt that the rhizotomy had affected their QOL. They were also asked if they would recommend the rhizotomy to others. Results: There were 31 subjects ages 16-39 years (mean 24.1 years; SD 5.2), mean age at rhizotomy 6.6 years (SD 4.0), mean follow up of 17.5 years (SD 3.0), and 53% men. About half the informants were self and half were parent or caregiver. The GMFCS levels were I, 6%; II, 16%; III, 26%; IV, 36%; V, 16%. Forty-eight percent thought they were in excellent or very good health, whereas 42% reported good health. Seven baclofen pumps had been placed some time after rhizotomy, but 2 were removed. Thirty-nine percent noted chronic pain, most commonly in the back and legs. The mean score on the SWLS was 26.0. Higher perception of health correlated with higher SWLS scores. There was also a trend (P .06) toward lower SWLS scores in those who reported pain. Sixty-four percent reported that the rhizotomy had improved their QOL, whereas 10% thought it decreased their QOL. Seventy-one percent would recommend the rhizotomy to others. A perception of improved QOL predicted a positive recommendation (P .01). Conclusions: Adults and adolescents were generally satisfied with childhood rhizotomy outcomes and would recommend it, especially if they had a perception of improved quality of life. These adults were generally healthy, although they had significant pain, common in adults with CP. The relationship between back pain and rhizotomy, which involves a laminectomy, needs more investigation.