PM&R最新文献

Background: Epidural steroid injections are common procedures in physical medicine and rehabilitation practice. However, their environmental impact has not been characterized.

Objective: The primary aim is to estimate and compare the carbon footprint of two standard injection kits used to perform epidural steroid injections at a single academic institution. Secondary objectives were (1) to create a step-by-step guide for estimating the carbon footprint of materials and (2) to survey physicians on practice patterns and identify areas for improvement.

Design: Pilot study.

Setting: Academic medical center.

Participants: N/A.

Interventions: N/A.

Outcome measures: Carbon emissions measured in CO₂ equivalents (CO₂ eq).

Methods: Using guidance from the Greenhouse Gas Protocol, the carbon footprint of the two kits was estimated by taking the sum of carbon emissions resulting from the production of the kit materials and the carbon emissions resulting from the waste disposal of the kit materials.

Results: The carbon footprint of the transforaminal epidural steroid injection (TFESI) kit was estimated at 1.328 kg CO₂ eq. The carbon footprint of the interlaminar epidural steroid injection (ILESI) kit was estimated at 2.534 kg CO₂ eq. For both kits, the carbon emissions resulting from the production of the kits were greater than the emissions resulting from disposal. The survey of interventionalists performing TFESI revealed all respondents required materials in addition to those provided in the standard epidural kit. Despite this, kit materials were typically wasted in 62% of respondents.

Conclusion: Creating a methodology for quantifying carbon emissions is the first step to reducing carbon emissions. Once emissions are measured, the health care industry can determine the most effective strategies for reducing its impact. Our analysis has shown that it is feasible to perform emissions calculations and delineates a clear method with publicly available resources. Solutions to reduce epidural injection carbon footprint waste may include improved kit customization.

Climate change has deleterious effects on stroke recovery, disproportionately affecting populations with increased stroke incidence. These effects start prior to the acute care hospitalization, precipitated by environmental etiologies and are sustained throughout the life course of stroke survivors. Health care practitioners play a critical role in identifying these concerns and mitigating their impact through effective strategies at the patient level, interventions at the community level, and advocacy at the state and federal level. As the experts on improvement in function, quality of life, and the mitigation of disability, physiatrists have the opportunity to lead efforts in this space for stroke survivors and their caregivers.

Background: The critical need for assistive technology (AT) for children with brain injury is recognized. Despite its importance, there is scant literature on how delays and denials in the provision of AT affect recovery and rehabilitation.

Objective: To examine the complex ecosystem of AT usage and barriers to access, drawing upon the perspectives of clinicians, vendors, and parents in an exploratory qualitative study.

Design: This is a companion study to a quantitative retrospective medical chart review using grounded theory methods. Two focus groups with clinical staff, one focus group with vendors, and six interviews with parents of children with brain injury were conducted. The narrative data were combined to maximize the triangulation of themes.

Setting: Pediatric rehabilitation hospital.

Participants: Multidisciplinary rehabilitation clinicians, vendors who provide AT, and parents of children with brain injury.

Results: Primary themes included coordinating with insurance, vendors, and funding; fostering age-appropriate independence; family's familiarity with AT; understanding the dynamic nature of development and recovery; impact on family relationships; costs/financial considerations; accepting role of AT; discovering new AT; accepting child's reality; and advocating for AT access.

Conclusion: The ethical implications of delays in access to AT, particularly in children with maturing and recovering brains, are far reaching and bring to the forefront concerns about the potential impact of disability stigma, social justice, and access to devices and information and the importance of maximizing self-determination and enabling independence and autonomy. Delays in access to AT preclude both a child's rights and capabilities, adversely affecting their recovery and maturation and limiting their integration into society under disability law.

Background: Health care outcomes for people with disability may be disproportionately affected by climate change through multiple interlinked factors, which are not well understood.

Objective: With use of scoping review methodology, this study aimed to model this intersectionality using socioecological (SE) levels to connect person-level rehabilitation diagnoses with systems/policy-level climate change and use this model to identify multilevel factors, rehabilitation outcomes, and responsive strategies from literature.

Methods: A scoping review of literature was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews methodology from three databases (PubMed Medline, Ovid Medline, CINAHL) using combinations of keywords (climate change), (rehabilitation), (disability), and (race). Logic and SE models were combined to model this intersectionality and create review forms that were used to abstract data. Common themes were collated (results), and additional experiential insight was added to provide contextual relevance (discussion).

Results: Of 32 deduplicated articles, 11 met inclusion criteria for qualitative analysis. Rehabilitation outcomes included physical, economic, mental, cognitive, and mortality (person level); rehabilitation services disruption, medical supply delay, emergency capacity overwhelmed (organizational level); and disabled environment (community level). Responsive strategies included education, backup supplies, planning, social support/utility registration (person level); competency assessment/training, physical medicine and rehabilitation physicians (PM&R) assisting patient in planning, providing pre-/postevent services, and establishing cross-coverage (interpersonal level); telerehabilitation, energy/resources conservation, PM&R inclusion in disaster mitigation planning (organization level); building accessible/resilient infrastructure, evidence-based practice guidelines through professional organizations (community level); and research funding, utility companies prioritizing power, and patients/providers included in planning (system/policy level).

Discussion: Climate change impact on rehabilitation diagnoses such as spinal cord injury and limb loss, as well as intersectionality with rehabilitation outcomes and identified responsive strategies, has been comprehensively modeled using SE levels. Race is not a commonly identified factor.

Conclusion: PM&R physicians can play a vital role in this intersectionality of disability, climate change, and rehabilitation outcomes.

Background: Chronic sacroiliac joint (SIJ) pain is highly debilitating. Minimally invasive SIJ fusion has become a commonly performed surgical treatment for SIJ pain, with level I evidence showing clinically significant improvements in pain, function, and quality of life and a low adverse event rate. Primarily performed by surgeons, this procedure is increasingly being performed by interventional pain management (IPM) physicians.

Purpose: To evaluate the safety and effectiveness of lateral SIJ fusion performed by IPM physicians, compared with prior studies of similar devices.

Study design: Prospective, multicenter, single-arm clinical trial conducted at 15 U.S. sites.

Patient sample: A total of 112 patients with a diagnosis of SIJ pain, who met study eligibility criteria, underwent lateral SIJ fusion.

Outcome measures: SIJ pain (numerical rating scale [NRS]), Oswestry Disability Index (ODI), quality of life (Patient-Reported Outcomes Measurement Information System [PROMIS]-29), patient satisfaction, and device/procedure-related adverse events.

Methods: Medical and surgical history and patient-reported outcomes were assessed at baseline and follow-up at 1, 3, 6, 12, and 24 months postoperatively. Primary endpoint is change in SIJ pain from baseline to 6 months; statistical evaluation used a noninferiority approach with a 1-point noninferiority margin compared to prior studies of a similar device. Secondary endpoints included ODI, NRS, PROMIS-29, device/procedure-related adverse events, and evidence of fusion via computed tomography scan at 2 years. Twelve- and 24-month follow-up data collection is ongoing.

Results: Mean (SD) participant age was 64 (14) years and 68% female. No serious or device-related adverse events occurred. At 6 months, mean SIJ pain decreased 5.2 points (95% confidence interval [CI] 4.7-5.7), meeting the study's primary noninferiority endpoint (p < .001 for noninferiority, p < .001 for change from baseline). A majority (91%) had a ≥2-point improvement in SIJ pain. ODI improved by 25.8 points (95% CI 22.2-29.4, p < .001 vs. baseline).

Conclusion: Interim trial results support the safety and effectiveness of lateral SIJ fusion performed by IPM physicians. Clinically significant improvements in pain and disability are commensurate with results from surgeon-performed randomized trials and published literature. Results should be reproduced in randomized trials.

Background and objective: Previous work from this dataset found 45% prescribing frequency of any medications (35.1%, 33.5%, and 56.8% at institutions 1, 2, and 3 respectively), without significant difference between in-person and telemedicine. The current study examines medication prescription patterns in greater depth by type of medications.

Design: Multicenter retrospective study.

Setting: Three academic medical centers in the United States.

Participants: Patients with cancer or history of cancer.

Interventions: Cancer rehabilitation physiatry outpatient visits.

Main outcome measures: Frequency of medication types prescribed.

Results: A total of 1234 unique patients underwent 3006 visits (institutions 1, 2, and 3 with 614, 1638, and 754 visits, respectively). Most frequently prescribed medication types (percentage of total encounters followed by 95% confidence interval) included opioids (14.5%; 8.1%-21.1%), membrane stabilizers (11.3.%; 5.2%-17.3%), topical agents (8.7%; 2.7%-14.7%), antidepressants (8.3%; 5%-11.8%), muscle relaxants (5%; 1.8%-8.2%), analgesics (nonsteroidal anti-inflammatory agents or acetaminophen) (3.7%; 3.4%-4.1%), and injected agents (5%;1.7%-8.3%). Less frequent categories included bowel medications (2.4%; 0.9%-3.9%), benzodiazepines (2.6%; 0.7%-4.5%), antiemetics (1.8%; 0.3%-3.3%), antibiotics (0.7%; 0.4%-1.0%), sleep aids (1%; 0.5%-1.5%), antipsychotics (1%; 0.1-1.2%), oral corticosteroids (0.5%; 0.3%-0.7%), and cognitive medications (0.6%; 0.2%-1%). Other medications were prescribed in 9.2% (3.5%-14.9%) of encounters. Interinstitutional differences were seen for all medication categories (p < .001), except for nonopioid analgesics (p = .640), antibiotics (p = .4), and corticosteroids (p = .337).

Conclusion: Treating pain appears to be a predominant but not sole focus of medication prescription in this population. Results illuminate prescribing trends seen in actual practice and may serve to inform individual cancer rehabilitation physiatrist practice, as well as to provide insight into possible directions for future research, such as focusing on frequently prescribed medications in controlled trials, and further examination of "other" medications, which were prescribed at a higher frequency than anticipated. Limitations include that factors underlying the observations could not be determined, including overall acuity; cancer type, stage, or phase; probable impact of differences in dispensation of refills depending on medication type; variability in clinically intended purposes of medications for specific cases; and possible regulatory or institution-specific contexts.

Introduction: COVID-19 can result in persistent symptoms and functional impairment that significantly impact daily functioning, highlighting the need for targeted rehabilitation. However, there is a lack of data on what proportion of long COVID patients need rehabilitation and which types are required.

Objective: To estimate the rehabilitation needs of patients with long COVID.

Design: Retrospective, cross-sectional analysis of clinical data.

Setting: Post-COVID recovery clinic in British Columbia, Canada.

Participants: Individuals with long COVID, defined as having symptoms persisting beyond 3 months post infection, with the first clinic visit occurring within 6 months post infection.

Intervention: Not applicable.

Main outcome measures: We created thresholds based on objective tests and patient-reported outcomes to determine rehabilitation needs.

Results: Data from 3709 patients who visited the clinic between March 2020 and May 2023 were available for analysis; 33% met the study eligibility criteria (n = 1237). Patients were primarily women (65%) and white (57%), with a mean age of 49 ± 14 years. Two thirds had required hospitalization. The average time from infection to clinic visit was 136 ± 34 days. At 3-6 months post infection, the most common COVID-19 symptoms were fatigue, dyspnea, muscle weakness, and muscle/joint aches. Most patients exceeded the rehabilitation threshold for dyspnea (83%), fatigue (78%), frailty (74%), and posttraumatic stress disorder (58%). Quality of life was impaired for 80%. Neuropsychological symptoms like anxiety (42%) and depression (36%) were also prevalent. Reductions in 6-minute walk distance (≥25%) and sit-to-stand performance (≥50%) occurred in 26% and 55% of patients, respectively. The majority of participants (98%) exceeded at least one test threshold for rehabilitation, and most (85%) were eligible for more than one type. The most required types of rehabilitation were pulmonary rehabilitation (83%), mental health support (78%), and neurorehabilitation (70%).

Conclusion: The need for rehabilitation services among individuals experiencing long COVID in British Columbia is substantial. Use of predefined thresholds that incorporate measures of both symptom burden and functional impairment can effectively support the identification of high-need patients and their overall rehabilitation needs. Combined with clinicians' expertise, this approach can facilitate timely, evidence-based referrals to specialized care for those who need it.