Susan M. McDowell

Pilot study of a 360-degree assessment instrument for physical medicine & rehabilitation residency programs.

Musick DW, McDowell SM, Clark N, Salcido R: Pilot study of a 360-degree assessment instrument for physical medicine and rehabilitation residency programs. Am J Phys Med Rehabil 2003;82:394-402. Objective To perform a pilot test on a new format for multidisciplinary assessment of resident physicians’ professionalism and clinical performance in acute inpatient rehabilitation settings. Design In this pilot study, a 26-item ratings instrument was developed for use by therapists, nurses, social workers, case managers, and psychologists to rate inpatient residents. Results A total of 421 ratings forms were returned over four academic years. Alpha reliability coefficient for instrumentation sample was 0.99. &khgr;2 and analysis of variance procedures examined item mean differences. Significant differences (P ≤ 0.05) were found based on resident sex (17 items) and rotation setting (20 items). No significant differences were found based on rater profession; mean ratings by profession ranged from 6.67 (physical therapists) to 7.46 (case managers). Conclusions Psychometric properties of this new ratings format are encouraging. The tool was a useful way to provide formative feedback to residents regarding professionalism and performance. Residency program directors can use this approach to fulfill Accreditation Council for Graduate Medical Education mandates to use a variety of assessment methods regarding resident education. However, potential sex bias and other issues affecting performance ratings should be considered in interpreting results and warrant further study.

Restraint Use in Inpatient Rehabilitation: Incidence, Predictors, and Implications

The use of mechanical restraints in rehabilitation facilities focuses attention on the conflict between patient safety and independent physical function. To evaluate restraint use, we reviewed records of 323 inpatient rehabilitation admissions. Restraint orders were written for 78.3% of admissions, but used in only 32.2% of cases (mean duration of use was 16 days). Posey vests were most commonly used (78.2%). Reasons for restraint were previous fall (26.8%), impulsivity (23.7%), and inappropriate self-transfers (19.6%). Male sex, decreased mental status, low admission functional independence measure (FIM) score, stroke, or traumatic brain injury were closely associated with restraint use. Falls occurred in 25% of restrained and 10.1% of unrestrained patients. Conclusions are as follows: (1) although physician orders are required to apply restraints, nursing staff initiate, monitor, and discontinue restraint use independently; (2) traumatic brain injury or stroke, decreased admission mental status, lower FIM scores, and male sex are indicators of restraint use; (3) age is not associated with restraint use; and (4) restraints may not prevent falls.

An exploratory examination of an academic PM&R inpatient consultation service

Purpose : This study sought to examine an inpatient consultation service delivery system at an academic teaching hospital. Method : Descriptive; retrospective; exploratory. Data from a 33 month period were analysed. Demographic profiles of patients receiving consultation were examined. A comparison was also made between alternate methods of delivering physiatric consultation. Results : Only 80% of patients admitted to a teaching hospital during the study period received consultation. Referrals increased by 75% with the institution of a full-time consultation practice model. Conclusions : The utilization of an inpatient consultation service appears to be dependent upon the service delivery format. Further studies are needed to understand referral patterns and specific challenges to consultation services in an academic setting. Future research should focus on comparing clinical outcomes for patients in diagnostic categories who do and do not receive physiatric consultation.

Neuroleptic Malignant Syndrome Associated With the Use of Carbidopa/Levodopa for Dystonia in Persons With Cerebral Palsy

Cerebral palsy (CP) is a disorder of movement and posture resulting from a nonprogressive injury to the immature brain that is marked by changes in muscle tone at rest and with activity [1]. The diagnosis is usually made during childhood. Affected children have delayed motor development that usually is substantiated by magnetic resonance imaging findings [1]. Hypotonia may be present in the early stages of CP, but upper motor neuron findings ultimately predominate, with increased tone and hyperreflexia and impaired motor control, balance, and coordination. These changes often lead to secondary contractures and deformities. Various movement disorders are found in patients with CP, including spasticity, dystonia, choreoathetosis, and ataxia. Dystonia is usually treated medically with agents that stimulate dopaminergic activity. The combination drug consisting of levodopa and carbidopa uses levodopa as a precursor to dopamine that is able to cross the blood-brain barrier for conversion to dopamine in the central nervous system [2]. Trihexyphenidyl and benztropine are anticholinergic medications used to treat dystonia by antagonizing remaining cholinergic receptors. All these medications are used to re-establish a balance between injured dopamine and acetylcholine pathways, which are hypothesized to coexist in the substantia nigra of the basal ganglia [3]. Neuroleptic malignant syndrome (NMS), a disorder thought to be caused by dopamine receptor blockade, causes fever, rigidity, and altered mental status [4,5]. Normally this disorder is caused by antipsychotic medications or abrupt withdrawal of dopamine agonists [6].

Electrical Stimulation: A Societal Perspective

Societal perspective on functional electrical stimulation is colored by media influence, popular thought, and political climate as much as by the science that supports it. The purpose of this article is to examine how these influences facilitate or inhibit the application of electrical stimulation in todays world and to describe the challenges facing the use of electrical stimulation in the future. Emphasis will be placed on perceived need, cost, and available resources and how these factors must be addressed to utilize functional electrical stimulation successfully in society.