Judith B. Kosasih

Motorcycle Helmets and Spinal Injuries: Dispelling the Myth

STUDY OBJECTIVE To determine the relationship between spinal injuries and helmet use in motorcycle trauma. DESIGN Retrospective case series. SETTING Twenty-eight hospitals in four midwestern states--Illinois, Iowa, Nebraska and Wisconsin--representing urban, suburban, and rural settings. PATIENTS AND OTHER PARTICIPANTS Consecutive sample of motorcyclists treated at the participating centers. INTERVENTIONS None. MAIN OUTCOME MEASURES The major variables evaluated were helmet use, ethanol use, and significant head or spinal injuries. RESULTS 1,153 cases were analyzed. Helmet use was not significantly associated with spinal injuries (odds ratio, 1.12; 95% confidence intervals, 0.79, 1.58) whereas head injury was markedly decreased with helmet use (odds ratio, 0.35; 95% confidence intervals, 0.23, 0.53). Ethanol use was a significant variable in both head (odds ratio, 3.89) and spinal (odds ratio, 2.41) injuries. CONCLUSION In contrast to a significant protective relationship identified for head injuries, helmet use was not associated with an increased or decreased occurrence rate of spinal injuries in motorcycle trauma.

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.

Nursing home rehabilitation after acute rehabilitation: Predictors and outcomes☆☆☆

OBJECTIVE To determine the predictive factors and functional outcomes of patients who were discharged from an acute rehabilitation unit to a nursing home care unit (NHCU) at a Veterans Affairs (VA) hospital. DESIGN Cohort descriptive study. SETTING An academically affiliated urban VA Medical Center. PATIENTS All patients (n = 81, median age 68 years) admitted to a VA rehabilitation unit over a 1-year period. OUTCOME MEASURES Discharge locations, predictors for NHCU transfer, and functional status as determined by Functional Independence Measure (FIM) scores. RESULTS Patients discharged to the NHCU (17%) were compared with those discharged to the community (80%). Multiple logistic regression analysis showed that acute rehabilitation length of stay (LOS), admission, and discharge FIM scores were the only independent variables that predicted discharge to the VA NHCU. Although overall FIM gains in both groups during acute rehabilitation were similar, the NHCU group had significantly lower admission FIM scores and lower LOS efficiency because of longer acute rehabilitation LOS. Postacute NHCU rehabilitation resulted in significant gains in FIM scores at a slower rate. Sixty-four percent of these nursing home patients eventually returned to the community. CONCLUSION Nursing home rehabilitation can result in favorable functional and community outcomes for selected patients.

Feasibility Study of TheraDrive: A Low-Cost Game-Based Environment for the Delivery of Upper Arm Stroke Therapy

Rising healthcare costs combined with an increase in the number of people living with disabilities due to stroke have created a need for affordable stroke therapy that can be administered in both home and clinical environments. Studies show that robot and computer-assisted devices are promising tools for rehabilitating persons with impairment and disabilities due to stroke. Studies also have shown that highly motivating therapy produces neuromotor relearning that aids the rehabilitative process. Combining these concepts, this paper discusses TheraDrive, a simple, but novel robotic system for more motivating stroke therapy. We conducted two feasibility studies. The paper discusses these studies. Findings demonstrate the ability of the system to grade therapy and the sensitivity of its metrics to the level of motor function in the impaired arm. In addition, findings confirm the ability of the system to administer fun therapy leading to improved motor performance on steering tasks. However, further work is needed to improve the systems ability to increase motor function in the impaired arm

Robotic Systems that Rehabilitate as well as Motivate: Three Strategies for Motivating Impaired Arm Use

Despite motor reduction due to rehabilitation training, whether robot-mediated or otherwise, many stroke patients with hemiplegia have learn non-use and lack motivation to use their impaired arm in real life. Therefore, other factors besides motor impairment and strength levels are critical to recovery of function on real activities. This paper discusses barriers to impaired arm use in the real world and presents a definition of motivation that is relevant to robot-assisted therapy. Three case studies highlighting three strategies to create robotic systems that are more motivating are discussed. The strategies are 1: embed therapy within a framework that provides patients with monitoring and interaction with therapists, 2: embed therapy into fun, video game like activities, and 3: embed therapy within patient-centered real-life functional activities

Task-oriented and Purposeful Robot-Assisted Therapy

Robot-assisted therapy devices are available for rehabilitation of persons after stroke, which is the leading cause of disability among adults in the United States (AHA 2006, Volpe et al. 2002). Improving upper extremity function after stroke is critical for performance of one’s life-role and the completion of unilateral and bilateral activities of daily living (ADLs). Carryover to real-life activities after rehabilitation training cannot be assumed (Sterr et al. 2000; Maclean et al. 2000; Ma and Trombly 2002; Trombly and Ma 2002; Prange et al. 2006). For example, the existence of learned non-use behavior indicates that motor gains after rehabilitation therapies may not transfer to long-term functioning on ADLs (Taub et al. 1994; Taub et al. 1999; Sterr et al. 2000). This behavior is present when persons with hemiparesis due to strokes demonstrate significant differences between residual movement capabilities and spontaneous use of the impaired arm in real world. There is a need to address barriers to the carryover of motor gains during training to stroke function in real life. This chapter reviews examples of current upper arm robot-assisted therapy environments and present findings from case study experiments with a new task-oriented, robot therapy system focused on improving carryover of motor improvements to functional activities of daily living. We draw attention to influence of function on arm movements during robot training and explore how future environments can be more functional and engaging. Robot-assisted therapy devices are now being used more frequently in the rehabilitation of persons with physical disabilities due to neurological trauma caused by stroke and spinal cord injury. These therapy robots provide semi- or fully-autonomous training and permit patients using them to engage in repeated and intense practice of goal-directed tasks (Volpe et al 2002; Prange et al 2006; Burgar et al. 2000; Loureiro et al. 2003; Patton et al. 2006; Krebs et al. 2003; MacClellan et al. 2005, Kahn et al. 2006). Typically, the automation of therapeutic exercises involves generating trajectories that guide reaching movements and the application of forces directly or indirectly to the impaired arm to assist, resist, and/or passively support it during the reaching exercise. For example, the MIT-MANUS (Krebs et

Implementing a global integrative rehabilitation medicine rotation: a physical medicine and rehabilitation residency program's experience.

ABSTRACTAn innovative international rotation in integrative rehabilitation medicine was implemented as part of the physical medicine and rehabilitation residency program at the Medical College of Wisconsin. Rotation objectives were to introduce medical knowledge of integrative medicine treatments into physical medicine and rehabilitation practice and to initiate collaboration with international academic partners. Residents were approved based on their academic record, completion of prerequisites, and personal statement. During a 4-wk rotation located in Italy, residents developed an integrative treatment strategy for each patient using conventional medical care and other therapeutic options, including acupuncture, biofeedback, aquatic therapy, yoga, and others. Postrotation assessment included evaluations by Italian team and patients, residents’ evidence-based presentations, and postrotation self-reflection. Participating residents reported high achievement in clinical performance, improved application of integrative medicine, broader appreciation of cultural diversity in patient care, and increased personal and professional development. This reciprocal program model serves as an example for other programs interested in implementing similar international rotations.

The Veterans Health Administration’s traumatic brain injury clinical reminder screen and evaluation: Practice patterns

The goals of this study were to describe clinical practice patterns associated with the Veterans Health Administrations (VHAs) Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and determine whether practice patterns vary by patient, provider, or facility characteristics. Veterans (N = 614) who had initial healthcare visits between 2008, and 2011 and who had previously completed the VHAs traumatic brain injury (TBI) screen and subsequent CTBIE were drawn from a national database. Participants were primarily male (95%) with a mean age of 29.8 yr (standard deviation = 8). Chart reviews were conducted on a random sample of charts with completed CTBIEs from 21 sites. Using a cross-sectional design, patient- and facility-specific variables were investigated as potential predictors of practice variation. During the study period, 79% of patients in this national sample were screened within 1 d of their initial healthcare visit and 65% were evaluated via CTBIE within 30 d of screening. Provider and participant characteristics were generally not associated with timeliness. The CTBIE was completed by individuals versus teams at comparable rates. Much of what occurred during the evaluation, beyond TBI-specific procedures, were medical assessments, such as review of medications and other substances.

Re: Alternative medicines: Yes; Alternatives to medicine: No

It is important to highlight three main points in our response. Our manuscript, BImplementing a Global Integrative Rehabilitation Medicine Rotation: A Physical Medicine and Rehabilitation Residency Program’s Experience[ describes first and foremost a global health resident experience and faculty teaching collaboration, with clearly defined resident learning goals and objectives based on ACGME competencies. Second, it describes resident exposure to integrative medicine, within an established successful group practice. Finally, the manuscript is descriptive, not a research article addressing the efficacy or safety of complementary and alternative medicine and, therefore, cannot be viewed in such a manner. A clear definition of integrative medicine and its tenets has been previously described and form an important component of Bpatient-centered care.[ The Veterans Health Administration is applying these concepts while embarking on a transformation of health care, to drive the current model that is primarily Bfind it, fix it[ disease care to a personalized, proactive approach that is driven by the individual needs of the Veteran. An in-depth study of each and all of these complementary and alternative medicine practices is not possible during a 4-week rotation and is not a rotation learning goal. Careful selections of the techniques and teachers who deliver them within the integrative group, as well as ongoing formation by means of in-service journal clubs, discussion groups, and cross-participation among the practices, are the cornerstones of our integrative medicine experience. The focus of both the outpatient and inpatient experiences is to create clarity of thought in prescribing comprehensive medical treatment, for an effective, precise prescription of pharmacologic agents, allopathic treatments, modalities, or exercise based on individualized patient assessment and goals. The integrative approach is a philosophy, not a series of techniques to be memorized and applied as mere protocol, reflecting the concept that Bthe whole is greater than the sum of its parts.[ We agree that the conventional standards of evidencebased medicine need to be applied equivalently to all areas of medical care, including complementary and alternative medicine. Further research addressing patient safety, efficacy, and cost effectiveness is needed and desired. Ongoing resident education must teach and practice critical review of the scientific literature, including the application of complementary and alternative medicine techniques.