Jennifer M. Zumsteg

Quality of Care Indicators for the Structure and Organization of Inpatient Rehabilitation Care of Children With Traumatic Brain Injury

OBJECTIVES To develop evidence-based and expert-driven quality indicators for measuring variations in the structure and organization of acute inpatient rehabilitation for children after traumatic brain injury (TBI) and to survey centers across the United States to determine the degree of variation in care. DESIGN Quality indicators were developed using the RAND/UCLA modified Delphi method. Adherence to these indicators was determined from a survey of rehabilitation facilities. SETTING Inpatient rehabilitation units in the United States. PARTICIPANTS A sample of rehabilitation programs identified using data from the National Association of Childrens Hospitals and Related Institutions, Uniform Data System for Medical Rehabilitation, and the Commission on Accreditation of Rehabilitation Facilities yielded 74 inpatient units treating children with TBI. Survey respondents comprised 31 pediatric and 28 all age units. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Variations in structure and organization of care among institutions providing acute inpatient rehabilitation for children with TBI. RESULTS Twelve indicators were developed. Pediatric inpatient rehabilitation units and units with higher volumes of children with TBI were more likely to have: a census of at least 1 child admitted with a TBI for at least 90% of the time; adequate specialized equipment; a classroom; a pediatric subspecialty trained medical director; and more than 75% of therapists with pediatric training. CONCLUSIONS There were clinically and statistically significant variations in the structure and organization of acute pediatric rehabilitation based on the pediatric focus of the unit and volume of children with TBI.

Lifestyle Changes in the Prevention of Mobility Disability

The prevention of functional decline with aging is essential for maintaining independent mobility for daily living and community access. The onset of mobility disability may be progressive or catastrophic in nature. Self-reported and performance-based clinical measures can be valuable for identifying the onset of mobility disability. Identification of modifiable lifestyle factors and preclinical predictors of mobility disability can be utilized in preventive care. Modifiable lifestyle factors related to mobility disability include physical activity (PA) level, smoking, nutrition, and body mass index (BMI). Age-related comorbid conditions including cardiovascular health, sarcopenia, metabolic dysregulation, cognitive impairment, and multi-morbidity influence the trajectory of decline toward mobility disability. This clinical review summarizes current knowledge about the onset and prevention of mobility disability, reviews intervention studies related to decreasing the risk for mobility disability, and provides suggestions for clinicians related to predicting and preventing mobility disability in older adults. Special attention is given to useful clinical measures, modifiable lifestyle factors, and delivering care in the context of age-related comorbid conditions in older adults.

Publishing Clinical Cases: Who Owns the Story? Is the Patient's Consent Needed?

Patient stories are the bread and butter of clinical teaching. Whether the format is the “Clinical Problem-Solving” series in the New England Journal of Medicine, “Grand Rounds” in JAMA, or “Case Presentations” in PM&R, almost every medical journal has a category that highlights the patient’s story. Invariably, the story is told from the perspective of a clinician for the edification of clinicians. The role of the patient, however, is much more variable. No doubt, the patient is the plot device and the object of inquiry. What is less certain is whether the patient contributes to the narrative shaping, provides consent for the telling, or participates in altering details to protect privacy. (A notable exception is the “Clinical Crossroads” series in JAMA, which not only includes a case presentation and expert discussant but also must incorporate the patient’s voice) [1]. Despite the prominence of the patient story in clinical teaching, surprisingly little consensus exists about publication standards for patient consent when a case study or story is presented. There have been some notable attempts to address this issue, such as the International Committee of Medical Editors (a consortium of member international biomedical journals), which first published standards for managing patient privacy in their Uniform Requirements for Manuscripts in 1995 and updated their recommendations in April 2010 [2,3]. However, not all biomedical journals have adopted these standards, nor are all journals “biomedical.” Several areas of uncertainty remain. Specifically, journals have varying standards about when to seek the patient’s consent, how one should alter details of the story to protect a patient or family member’s identity, and when details cannot be altered without fundamentally altering the essential “truth” of the story. Even if we agree that patient consent and participation are desirable, when is it permissible to proceed without consent? For example, when contact with the patient has been lost? When difficult interpersonal dynamics, such as unresolved anger, ongoing litigation, or cognitive or psychic illness exist? I am pleased that this issue was brought forward by Dr Jennifer Zumsteg, who took me up on my standing offer to send me an e-mail with responses or ideas for columns. Dr Zumsteg is an acting instructor/senior fellow in the Department of Rehabilitation Medicine at the University of Washington in Seattle. She summarized her concerns as follows:

Poster 20 Cerebellar Cognitive Affective Syndrome: A Case Report

Disclosures: E. W. Latzka: I Have No Relevant Financial Relationships To Disclose. Case Description: A 71-year-old man presented reporting 48 hours of dizziness, dysarthria, dysphagia, and ataxia. Clinical examination and imaging were consistent with a bilateral cerebellar ischemic stroke. The patient’s 3-week acute care course included management with bilateral posterior fossa decompressive craniotomy, external ventricular drain placement, and a nasogastric tube for enteral nutrition secondary to severe oropharyngeal dysphagia. Setting: Tertiary care stroke center, acute inpatient rehabilitation. Results or Clinical Course: Physiatry examination and rehabilitation team findings included slight slowing and decreased accuracy in finger to nose coordination on the right, but otherwise normal coordination. Cognitive assessment revealed impairments in naming, orientation, direction following, attention, visuospatial skills, and memory. The patient had significant functional recovery during his 2-week admission to acute inpatient rehabilitation with resolved dysarthria, improved ataxia and mobility, and improved oropharyngeal dysphagia. He continued to demonstrate moderate impairments in cognition and communication including the domains of reasoning, problem solving, word retrieval, auditory processing, visuospatial tasks, attention, executive function and memory. Discussion: The cerebellum is well known for its role in coordination, spanning a wide range of motor control functions including gait, swallowing, visual tracking, and vocalizing, but its role in cognition and affective regulation is less well appreciated. The impairments seen in Cerebellar Cognitive Affective Syndrome (CCAS) commonly include executive function, language, visual-spatial attention, and mood/personality. Clinical evaluation after cerebellar stroke that is limited to coordination tasks is unlikely to appreciate deficits in cognitive and affective domains that are excellent targets for rehabilitation interventions. Conclusion: Clinical evaluation of patients after cerebellar strokes should include a thorough evaluation of cognition and mood, as these may be impaired along with well-recognized deficits such as ataxia, dysarthria, and dysphagia. The understanding of the role of the cerebellum in neuropsychologic function continues to evolve and is an area of interest for continuing medical education for physiatrists.

Poster 207: End-of-Life Care for Persons with Multiple Sclerosis

ter. Participants: 8 physicians (5 residents, 3 attending physicians). Interventions: Each participant measured a zoomed static image of a median nerve on a GE LogiqE ultrasound compact system, to determine cross sectional area using both the ellipse and the tracing method. Participants were blinded to the other participants’ measurements. Main Outcome Measures: Cross sectional area of the median nerve. Results: Utilizing both methods, one using an adjustable ellipse and the other using a freehand tracing of the median nerve, the results were as follows: Mean (mm) 7.96 vs. 7.14; Median (mm) 7.91 vs. 7.23; and standard deviation of 0.70 vs 0.50 respectively. Conclusions: In terms of reproducibility, this preliminary study demonstrates that using a freehand tracing method produces a more consistent measurement among ultrasound machine users. However, further study is needed to determine which method is more accurate.