Michelle S. Gittler

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

Background:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting Outcomes:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Promote Pressure Ulcer Healing in Individuals with Spinal Cord Injury Using an Individualized Cyclic Pressure-Relief Protocol

OBJECTIVE: To evaluate whether an individualized cyclic pressure-relief protocol accelerates wound healing in wheelchair users with established pressure ulcers (PrUs). DESIGN: Randomized controlled study. SETTING: Spinal cord injury clinics. PARTICIPANTS: Forty-four subjects, aged 18-79 years, with a Stage II or Stage III PrU, were randomly assigned to the control (n = 22) or treatment (n = 22) groups. INTERVENTIONS: Subjects in the treatment group used wheelchairs equipped with an individually adjusted automated seat that provided cyclic pressure relief, and those in the control group used a standard wheelchair. All subjects sat in wheelchairs for a minimum of 4 hours per day for 30 days during their PrU treatment. MAIN OUTCOME MEASURES: Wound characteristics were assessed using the Pressure Ulcer Scale for Healing (PUSH) tool and wound dimensions recorded with digital photographs twice a week. Median healing time for a 30% healing relative to initial measurements, the percentage reduction in wound area, and the percentage improvement in PUSH score achieved at the end of the trial were compared between groups. RESULTS: At the end of 30 days, both groups demonstrated a general trend of healing. However, the treatment group was found to take significantly less time to achieve 30% healing for the wound measurement compared with the control group. The percentage improvement of the wound area and PUSH scores were greater in using cyclic seating (45.0 ± 21.0, P < .003; 29.9 ± 24. 6, P < .003) compared with standard seating (10.2 ± 34.9, 5.8 ± 9.2). CONCLUSIONS: The authors findings show that cyclically relieving pressure in the area of a wound for seated individuals can greatly aid wound healing. The current study provides evidence that the individualized cyclic pressure-relief protocol helps promote pressure wound healing in a clinical setting. The authors concluded that the individualized cyclic pressure relief may have substantial benefits in accelerating the healing process in wheelchair users with existing PrUs, while maintaining the mobility of individuals with SCI during the PrU treatment.

Catecholamine-induced hypertension in lumbosacral paraplegia: Five case reports

Hypertension in the patient with SCI is relatively rare and generally restricted to patients with high-level injuries where autonomic dysreflexia can occur. Resting blood pressure in individuals with SCI has been described as lower than that in the normal population. This report describes five previously normotensive teenagers with subsequent paraplegia as a result of gunshot wounds who presented with hypertension secondary to idiopathic elevation of plasma or urinary catecholamine levels. A clonidine suppression test was used as a neuroprobe to inhibit centrally mediated sympathetic outflow, excluding the probability of an extra-axial autonomous catecholamine-secreting tumor as the possible source of hypertension. Positive suppression was achieved in four patients (41%, 37.2%, 4.8%, and 37.2% decreases). One patient had values corresponding to orthostatic changes (an increase of 63%) because of poor compliance with the test. This patient was lost to follow-up; in the remaining four, hypertension resolved at 12, 8, 9, and 6 weeks postinjury. The increased circulating catecholamine level appears to be promoted by a centrally mediated response to the SCI. Elevated blood pressure probably results from an upgraded receptor regulation or an increased receptor sensitivity on the affected cells in the absence of restraining spinal reflexes. The pathophysiology of such hypertension seems to be secondary to autonomic dysfunction and, although it may be transient, it should be treated promptly and reevaluated periodically until stabilization is achieved.

Development of a Measure of Skin Care Belief Scales for Persons With Spinal Cord Injury

OBJECTIVESnTo develop and validate a measure of skin care beliefs and to describe the skin care behaviors of persons with spinal cord injury (SCI).nnnDESIGNnA mixed-methods design was used to develop the Skin Care Beliefs Scales (SCBS). The health belief model framed the hypotheses. Phase 1 included item development, content validity testing, and pilot testing. Phase 2 included testing the scale structure (principal components analysis), internal consistency reliability, test-retest reliability, and relationships between the belief scales and care behaviors.nnnSETTINGnTwo acute rehabilitation hospitals and Internet websites.nnnPARTICIPANTSnPatients with SCI (N=462; qualitative/pilot n=56; psychometric study n=406) participated.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnThe pilot and phase 2 studies, respectively, used 146-item and 114-item versions of the SCBS. A skin care activity log was used to record skin care behaviors.nnnRESULTSnContent validity indicated that the items were relevant and clear. The analysis resulted in 11 independent scales reflecting 3 general beliefs (susceptibility, severity, self-efficacy) and barrier and benefit behavior-specific scales for skin checks, wheelchair pressure reliefs, and turning and sitting times. With the exception of skin check barriers (α=.65), Cronbach alphas of the scale ranged from .74 to .94. Test-retest intraclass correlations were fair to excellent (range, .42-.75). Construct validity was supported. Hierarchical linear regression indicated that turning benefits, barriers, susceptibility, and self-efficacy were significant predictors of turning time. Benefits or barriers were correlated significantly with skin check and pressure relief adherence (ρ range, -.17 to -.33). Self-efficacy was correlated with wheelchair pressure relief (ρ=.18). Skin care behavior adherence varied widely (eg, 0%-100%).nnnCONCLUSIONSnThe scales showed acceptable reliability and validity. Further testing with larger samples is desirable.

Burn from car seat heater in a man with paraplegia: case report

Abstract Objective/background Heated car seats are a common feature in newer automobiles. They are increasingly being recognized as potential hazards as there have been multiple reports of significant burns to its users. The potential for harm is considerably increased in those with impaired sensation with the possibility of a devastating injury. Methods Case report and literature review. Results A 26-year-old male with a T8 ASIA A paraplegia presented to the outpatient clinic for management of a hip burn. Two weeks prior to his visit he was driving a 2004 Jeep Cherokee for approximately 30 minutes. He was unaware that the drivers side seat warmer was set on high. He denied that his seat belt was in direct contact with the skin of his right hip. He presented to an acute care hospital that evening with a hip burn where he was prescribed silver sulfadiazine cream and instructed to apply it until his scheduled follow-up clinic visit. In clinic, the hip wound was unstageable with approximately 95% eschar. A dressing of bismuth tribromophenate in petrolatum was applied to the wound and he was instructed to change the dressing daily. This was later changed to an antimicrobial alginate dressing. The ulcer eventually healed. Conclusions This case illustrates the significant risk of car seat heaters in individuals with spinal cord injuries or neurological impairment who have decreased sensation. Additionally, it highlights an atypical area of potential for burn. Furthermore, it emphasizes the need for a heightened awareness for this unique and dangerous situation.

Does the Physical Medicine and Rehabilitation Self-Assessment Examination for Residents Predict the Chances of Passing the Part 1 Board Certification Examination?

Each year, residents in accredited United States Physical Medicine and Rehabilitation (PMR) residency programs can take the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Self‐Assessment Examination for Residents (SAE‐R). This 150‐question, multiple‐choice examination is intended for self‐assessment of physiatric knowledge, but its predictive value for performance on the part 1 American Board of Physical Medicine and Rehabilitation Certification Examination (ABPMR‐CE) is unknown.

Undocumented Patients and Rehabilitation Services

Limited options for undocumented patients can create ethical dilemmas and moral distress for health care providers working in rehabilitation. Compared with other low-income patients, patients who are undocumented have less access to financial, social, and medical services. For example, uninsured patients who are citizens or permanent residents may be eligible for public aid, charity care, or have access to philanthropic resources. For most undocumented patients, this is not the case, although some states and local communities have made provisions. Furthermore, the U.S. safetynet health care system is geared towards emergency and acute inpatient services. The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, requires that any patient who comes to an emergency department must be screened and, if needed, stabilized. They cannot be turned away from the emergency department based on inability to pay. There is no such requirement for rehabilitation providers, although patients with various conditions and injuries initially treated in emergency departments and acute care hospitals could often benefit from rehabilitation. As a clinical medical ethics fellow from 2000 to 2002, I attended case conferences in which we discussed and analyzed the details of casesdmedical indications, patient preferences, quality of life and contextual factors [1]. We debated the complexities, options, and recommendations. Often, when issues of social justice were brought up, a faculty member cautioned that resource allocation or justice issues should not be adjudicated at the bedside. I understood the cautiondclinicians and clinical ethicists should work with the facts that they can gather and know and make decisions based on the best set of options practically available to them. Yet, as a bicultural daughter of immigrants, keenly aware of social justice issues from my training in clinical/ community psychology and affinity with disability rights,

Poster 29 The Over Utilization of PPIs in an Acute Rehabilitation Hospital and How to Fix it

gain, hirsutism, and progressive proximal muscle weakness. Electromyography and nerve conduction studies prior to admission were normal e consistent with glucocorticoid-induced myopathy. Laboratory work-up revealed low adrenocorticotropic hormone levels andmarkedly elevated 24-hour cortisol. Biopsy of a left adrenal mass seen on MRI confirmed the diagnosis of adrenocortical carcinoma.Mifeprostinonewas initiated,with satisfactory control of endogenous steroid production. Setting: Inpatient Rehabilitation Hospital/Academic Rehabilitation Hospital. Results: The patient was transferred to an inpatient rehabilitation hospital for continued medical treatment and rehabilitation with a focus on strength and endurance. On admission, motor strength was 3/ 5 in bilateral hip flexors, 4/5 in other proximal muscles with relative sparing of distal muscles. She was dependent to maximal assist with all mobility and ADLs except wheelchair use. On discharge she required minimum to moderate assistance; however, she remained non-ambulatory and did not have significant return of strength despite continued control of her DM and cortisol levels. Discussion: Glucocorticoid-induced myopathy is a well-known complication of Cushing Syndrome resulting from iatrogenic steroid exposure. However, its incidence and relation to endogenous cortisol production has not been reported. While the mechanisms underlying myopathy are likely the same, details regarding the associated severity, prognosis, and outcome remain unclear. This patient’s lack of early recovery, despite eliminating endogenous cortisol production, possibly prognosticates a course with minimal strength return. This is in contrast to iatrogenic steroid-induced myopathy. Conclusions: Iatrogenic steroid-induced myopathy is not uncommonly seen in both inpatient and outpatient physiatry. We present a case of glucocorticoid-induced myopathy from endogenous steroid production, which previously has not been reported. It is important for physiatrists to be aware of this syndrome to promote early diagnosis and intervention, and to set appropriate rehabilitation goals. Level of Evidence: Level V

The Value of Maintaining Primary Board Certification in Physical Medicine and Rehabilitation

D. B. is a 49-year-old physiatrist. He is board certified in physical medicine and rehabilitation (PMR however, because his practice is entirely focused on SCI medicine, he is wondering if he should continue to maintain his primary board certification in PM&R in addition to his SCI certification. James Crew, MD, will argue that maintaining subspecialty certification in SCI is sufficient, and Michelle Gittler, MD, will argue that maintaining primary board certification is essential for D. B. Please note: These views do not represent the views of the American Academy of Physical Medicine and Rehabilitation or the ABPMR, and this discussion is intended for educational purposes.

Unilateral Krukenberg Procedure in a Quadruple Amputee; Independence after Rehabilitation: A Case Report

Disclosures: R. G. Durgam, No Disclosures: I Have Nothing To Disclose. Case Description: We report a case of a previously healthy 38-year-old woman, 11 days post-partum, who presented to our medical center with acute onset of chest pain and acute STelevations on EKG. Subsequently, angiogram performed revealed left main coronary artery dissection. She underwent double vessel bypass graft for therapeutic intervention. Herein, we will focus on the presentation of this rare condition and discuss the role of hormones on connective tissue and its further implications into musculoskeletal conditions. Setting: Tertiary care center Results or Clinical Course: After our patient underwent cardiac intervention and was medically optimized, she was later transferred to an acute inpatient rehabilitation unit to maximize function. Once she met all of her rehabilitation goals, she was eventually discharged home with close follow up. Discussion: Spontaneous coronary artery dissection (SCAD) is an extremely rare, at times fatal, cause of acute coronary syndrome. It most commonly presents in young women who are perior post partum. Though the precise etiology of post partum coronary artery dissection has yet to be identified, hemodynamic changes aside, one of the proposed theories is the effect hormonal variations have on connective tissue. Past studies have shown that there are known estrogen receptors present on structures ranging from the tunica media of the aorta to the anterior cruciate ligament (ACL) of the knee. These studies have shown that lower estrogen level conditions or a rapid decline in estrogen levels predispose to connective tissue laxity. This can lead to increased incidences of ACL tears, or in this case, coronary artery dissection. Further evidence to support this correlation is the association of SCAD in women who are menstruating and in those who use oral contraceptives pills. Conclusions: SCAD is a life-threatening condition that requires immediate medical attention. It should be considered in young women who present with acute onset of chest pain. Women’s rehabilitation is an expanding sub-specialty and further investigations into the role of hormonal changes on connective tissue could provide meaningful insight to certain female-predominant conditions.