Joel A. DeLisa

Continuous passive motion after total knee arthroplasty: a prospective study.

ObjectiveContinuous passive motion (CPM) has been shown to increase significantly the amount of knee flexion for patients with total knee arthroplasty in the acute care hospital. Whether there is any additional benefit to using CPM for these patients who are transferred to a rehabilitation hospital is not known. There have been no prospective, randomized, controlled studies in this area. DesignFifty-one such patients on an inpatient rehabilitation service were randomly assigned to two groups. Group 1 (n = 23) received CPM for 5 consecutive hours per day plus physical therapy, whereas group 2 (n = 28) received only physical therapy. Knee flexion was measured by a blinded physical therapist on admission, on the third and seventh days of hospitalization, and at the time of discharge. ResultsThe results indicated no significant difference in passive range of motion between group 1 and group 2. Patients in group 1 achieved an average increase in passive range of motion of 16 degrees, whereas those in group 2 achieved an average of 19 degrees (P = 0.33). ConclusionAlthough power analysis indicated the need for differences in results for 32 patients per group to achieve significance, the difference between the two groups suggested neither statistical nor clinical significance. We concluded that the use of CPM in the rehabilitation hospital is likely of no added benefit to patients admitted after single total-knee replacement.

Alteration of immune system function in tetraplegics. A pilot study

ABSTRACT Over the past 20 yr, evidence has accumulated that implicates the autonomic nervous system as a central modulator of immune function. We hypothesized that injury to the cervical spinal cord would affect immune function by dysregulation of the sympathetic outflow tract. To test this hypothesis, peripheral blood lymphocytes were obtained from five individuals with complete cervical spinal cord injury (SCI) and from five age- and sex-matched neurologically intact controls. Immunologic parameters studied included cell counts by flow cytometry, lymphocyte proliferation response to three mitogens and a natural killer cell cytotoxicity assay. In addition the Ilfeld Psychiatric Symptom Index was completed by all subjects and controls. Repeated measures analysis of variance revealed an impaired lymphocyte proliferation response in the SCI group. Our results suggest that individuals who have sustained complete cervical SCI have alteration in immune function as compared with neurologically intact controls. This may contribute to infections after spinal cord injury. The mechanism may involve dysregulation of the sympathetic arm of the autonomic nervous system.

Factors used by physical medicine and rehabilitation residency training directors to select their residents.

A 17-item questionnaire was designed to assess the relative importance of various factors to physical medicine and rehabilitation (PM&R) training directors when ranking PM&R resident applicants during the National Resident Match. The questionnaire was sent to all PM&R residency training directors. The recipients were asked to grade most selection factors based on a numerical scale: 1, unimportant; 2, some importance; 3, important; 4, very important; 5, critical. The specific factors addressed in the questionnaire were: academic criteria, letters of recommendation, individual applicant characteristics and aspects of the interview process. Twelve yes-or-no questions were also designed to determine the weight that residency training directors place on certain academic criteria. A response rate of 88% (66/75) was obtained. The most important academic criteria were grades in a PM&R clerkship in their facility (4.1 ± 0.8), followed by grades in a PM&R clerkship in another facility (3.6 ± 0.9). The most important letters of recommendation were from a PM&R faculty member in the respondents department (4.0 ± 0.8), followed by the deans letter (3.7 ± 1.0) and the PM&R chairmans letter (3.7 ± 1.0). The three most important applicant characteristics evaluated during the interview were compatibility with the program (4.4 ± 0.8), the ability to articulate thoughts (4.2 ± 0.8) and the ability to work with the team (4.2 ± 0.8). Most program directors used multiple criteria to complete their rank list, but the most important were based upon the interview (4.5 ± 0.9), letters of recommendation (3.7 ± 0.9), medical school transcript (3.6 ± 0.8) and the deans letter (3.6 ± 1.1). Knowledge of the specialty, personal statements and research interest were the least important candidate criteria. The majority of respondents believed that clinical and preclinical honor grades were more important than honor status on the United States Medical Licensing Examination steps 1 and 2.

Issues and challenges for physiatry in the coming decade

I T IS AN HONOR and a privilege to be asked to present the 31st annual Walter Jacob Zeiter Lecture of the American Academy of Physical Medicine and Rehabilitation (AAPMR). Dr. Zeiter was an educator, medical statesman, business and administrative manager, as well as an organizational leader. He completed his residency in physical medicine under Dr. John Coulter at Northwestern University in 1937. Two years later he became the Executive Director of the American Congress of Physical Medicine and served in this capacity until 1960. In that role he also assisted in the administration of the AAPMR. This innovative, efficient physician administrator performed all of this work for 21 years without compensation. His dedication and commitment to our specialty are what we should all emulate. He also had a strong commitment to graduate medical education. He was a founding member of the American Board of Physical Medicine and Rehabilitation (ABPMR) in 1947 and was its second chairman, serving in that capacity from 1949 to 1953. He was also the representative of the American Medical Association on the Residency Review Committee (RRC) for Physical Medicine and Rehabilitation from 1963 to 1969. He received the Gold Key Award from the American Congress of Rehabilitation Medicine in 195 1 and gave ACRM’s 4th John S. Coulter Memorial Lecture in 1954, which he titled “The History of the American Congress of Physical Medicine and Rehabilitation.” 1 The first Zeiter Lecture was given in 1968. It is unusual for a lecture to be named after a living individual. However, Dr. Zeiter’s exceptional credentials and his leadership in nurturing this developing specialty warranted this honor. The Academy decreed that the Zeiter Lecture should relate to the history of physical medicine and rehabilitation. The first lecture was given by Frank Krusen and was titled “Historical Development in Physical Medicine and Rehabilitation During the Last 40 Years.“2 The subsequent 30 lecture titles and speakers are listed in table 1 .2-31 Although it is difficult to categorize these talks, I note 15 lectures on history, 9 on disease management, 5 on health policy, and 1 on research. Dr. Zeiter was instrumental in the development of our specialty. His organizational talents and diplomacy helped us collaborate to achieve solutions to problems facing the specialty. It is with this in mind that I have titled my lecture “Issues and Challenges for Physiatry in the Coming Decade.” Our history helps to define most of these issues.

Functional electrical stimulation bicycle ergometry: patient perceptions.

Forty-seven patients who had participated in a clinical electrical stimulation ergometry program were administered a questionnaire to determine their perceptions of the therapy. Improved endurance was reported by 62% of paraplegics and 65% of quadriplegics. Sixty-two percent of paraplegics and 56% of quadriplegics reported improved self-image, while 54% of paraplegics and 77% of quadriplegics perceived their appearance was better. Thirty-nine percent of paraplegics and 24% of quadriplegics noted decreased lower extremity edema with training. Six out of nine patients with a previous history of neurogenic pain noted an increase in pain, which caused them to leave the program.

Mandatory clerkship in physical medicine and rehabilitation: Effect on medical students' knowledge of physiatry

OBJECTIVE To study the effect of a 2-week clerkship on the perceptions and knowledge of physical medicine and rehabilitation (PM&R) among fourth-year medical students. DESIGN Survey of fourth-year medical students before and after completion of a mandatory clerkship. RESULTS Knowledge of PM&R by fourth-year medical students is marginal, but a clerkship increases the awareness of the practice of physiatry. CONCLUSIONS Mandatory clerkships can help expose future physicians to the benefits of physiatric services and should be pursued by academic PM&R departments.

One program's experience of OSCE vs. written board certification results : A pilot study

The objective structured clinical examination (OSCE) has been the focus of a lot debate with respect to reliability and validity. Much of the controversy surrounding these components lies in a lack of comparison with a “gold standard.” Further work is needed to improve the evaluation of clinical skills to the point that a gold standard can truly be said to exist.

Measuring professionalism in a physiatry residency training program.

DeLisa JA, Foye PM, Jain SS, Kirshblum S, Christodoulou C: Measuring professionalism in a physiatry residency training program. Am J Phys Med Rehabil 2001;80:225–229.A 12-item questionnaire modeled after the one prepared by the American Board of Internal Medicine dealing with professionalism was distributed to 122 physiatry residents representing six training programs, of whom 59% (72) responded. The mean item score on the survey was 7.7 (SD = 1.0) on a scale from 1 to 10, where 10 represents the highest level of professionalism. The internal reliability of the questionnaire was found to be satisfactory (Cronbach’s &agr; = 0.75). A factor analysis of the questionnaire items resulted in three factors explaining 64% of the variance. These factors were: excellence, honor/integrity, and altruism/respect; Eigen values were 3.35, 2.37, and 1.31, respectively. These factors are similar to those obtained in the American Board of Internal Medicine survey. This similarity is a positive feature in ongoing efforts to develop a reliable tool for measuring professionalism in physiatry residency training.

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.

Physiatry as a primary care specialty

The ongoing changes in health care seek to create an affordable, accessible, and high-quality health care delivery system for all Americans. In response to this, Physical Medicine and Rehabilitation (PM&R) is re-examining its role in the provision of health care to the disabled, particularly the severely affected. We surveyed 100 physiatrists and 100 PM&R residents across the country regarding their opinions on the competence, qualifications, and desire of physiatrists to provide primary care for the disabled. Fifty-five physiatrists and 51 residents responded (55% overall). Thirty-nine percent of all respondents agreed that PM&R should be designated as a primary care specialty, and 53% believed that physiatrists should provide primary care to the severely disabled (e.g., spinal cord and head injury). Overall, 53% felt that physiatrists are competent in general medical care, but 38% are convinced that the current 4-yr PM&R residency training sufficiently prepares physiatrists to assume the role of a primary care provider. Of the patient populations considered, the respondents thought that physiatrists should manage the care of spinal cord injury (60%) and head injury (51%), but only 40% were willing to assume primary care responsibilities.