PM&R最新文献

Background: Telehealth provides remote clinical care for patients using communications technology. The increased use of telehealth during the COVID-19 pandemic compels us to better understand telehealth's costs, value, and limitations.

Objective: To describe barriers to access and costs of care for telehealth patients among an outpatient musculoskeletal cohort. This study also evaluates patients' perceptions of telehealth as a means of care delivery during the COVID-19 pandemic.

Design: Cross-sectional study.

Setting: Tertiary academic institution.

Patients: Adult patients attending telehealth visits in an academic physiatry department.

Interventions: N/A MAIN OUTCOME MEASURES: Telehealth-related barriers, costs, and perceptions were assessed using a one-time survey.

Results: A total of 262 patients (mean age: 59.6 ± 15.5 years, median: 62 [interquartile range, 49-72]) completed the survey from November 23, 2020 to February 14, 2021 (completion rate: 28.3%; 262/926). Comfort levels with technology averaged 8.5 ± 2.0 out of 10 (median: 9 [interquartile range, 8-10]), and all but one patient had existing access to the electronic device used for their telehealth visit. Most patients (89.7%) had previously received in-person care for the same issue. Concern about the pandemic was the top reason for receiving telehealth care. For almost all patients, the only costs related to telehealth were direct costs of care. In contrast, patients reported they would have spent an average of $25.14 (median: $10 [interquartile range, $0-$40]) on travel if their visit had been in person. Of the 141 patients who were employed or students, 25.5% reported taking time away from work or school to attend the telehealth visit, whereas 85.1% reported they would have needed to take time away from work or school if the visit had been in-person. Satisfaction with telehealth visits averaged 9.1 out of 10 (median: 10 [interquartile range, 9-10]), and 71.6% of patients reported a better impression of telehealth compared to 1 year ago.

Conclusions: Our findings illustrate that telehealth is a low-cost form of health care delivery that has high satisfaction for the patient. This is particularly beneficial in the musculoskeletal patient population who may face additional physical barriers to accessing care in person.

Background: Although surgery provides symptomatic relief for many patients with nonarthritic hip-related pain, not all patients are ideal surgical candidates, are interested in pursuing surgery, or require surgery for symptomatic relief. Nevertheless, evidence is limited regarding patients' satisfaction with nonoperative management.

Objective: To identify the rate of satisfactory response to nonoperative management for nonarthritic hip-related pain at 12-month follow-up. A secondary purpose was to identify possible predictors of response to nonoperative management.

Design: Pragmatic, prospective cohort study.

Setting: Two U.S. tertiary medical centers.

Patients: Participants ranging in age from 15-40 years who were diagnosed by a surgical or nonsurgical orthopedic clinician with nonarthritic hip-related pain and were advised to initiate nonoperative management.

Interventions: Participants received brief instruction on movement pattern related activity modifications for hip-related pain. They otherwise followed the standard care treatment plan recommended by their treating clinician.

Main outcome measurements: The proportion of patients at 12-month follow-up who endorsed both (1) not having scheduled or undergone hip surgery and (2) answering "Yes" to "Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?"

Results: Among 88 patients (mean [SD] age 27 [8] years, 71 [81%] female), 59% (95% confidence interval [CI] 48%-70%) (n = 45/76) who completed follow-up reported satisfactory symptom response with nonoperative management at 12-month follow-up. Predictors of not achieving a satisfactory response included worse baseline symptom severity (odds ratio [OR] 1.04 per International Hip Outcome Tool-12 point [95% CI 1.01-1.07], p = .023) and a preference at baseline for procedural treatment such as injection or surgery (OR 0.13 [95% CI 0.04-0.46], p = .001).

Conclusions: In a pragmatic analysis of patients presenting for tertiary orthopedic care, 59% of patients with nonarthritic hip-related pain were satisfied with their response to nonoperative management at 12-month follow-up. This information can be shared with patients to facilitate informed decision making.

Study registration: ClinicalTrials.gov, NCT04069507.

Objective: Case studies suggest self-manipulation of the cervical spine may result in adverse events (AEs). Self-management with self-manipulation is understudied. Thus, this systematic review (prospectively registered via International Prospective Register of Systematic Reviews #CRD42024540358) aimed to identify published cases of AEs following cervical self-manipulation, rate the severity of the events, report individual case characteristics, and characterize the method of cervical self-manipulation in each case.

Methods: Multiple databases were comprehensively searched for observational studies describing AEs following cervical spine self-manipulation from inception to May 2024. Screening, risk of bias (modified Joanna Briggs Institute checklist), and data extraction were each performed individually by two separate reviewers. Extracted data included case demographics, time between self-manipulation and AE, symptoms preceding self-manipulation, final AE diagnosis, AE treatments, and disposition after AE diagnosis and treatment. The primary outcome was AE severity, graded as mild, moderate, severe, or catastrophic.

Results: Searches yielded 5714 unique articles; 24 were included describing 24 unique cases (71% male; mean age 34 years). Half the cases were precipitated by neck pain or stiffness (n = 12), involved cervical self-manipulation via the use of one's own hands (n = 15), and described a "sudden" or "immediate" onset of AE following cervical self-manipulation (n = 12). Adverse events were classified as mild (n = 4, 17%), moderate (n = 7, 29%), severe (n = 9, 38%), and catastrophic (n = 4, 17%). Of the four AEs categorized as catastrophic, two were fatalities. Almost all AEs occurred within 2 days following self-manipulation (n = 22).

Conclusion: Few cases of AEs following cervical self-manipulation have been reported. Although this practice has the potential for serious AEs, we did not identify evidence that such AEs are a common phenomenon. With very low certainty, this practice has the potential for serious harms. Further research is needed to describe the motivations for using cervical self-manipulation, its prevalence, incidence of associated AEs, and factors predisposing to AEs.

Background: Medial branch blocks (MBB) and radiofrequency ablations (RFA) are common diagnostic, prognostic, and interventional procedures performed for the management of cervical and lumbar spine facetogenic pain. Although these procedures have established utility as pain management strategies, it is unclear if the disruption in function of the medial branch nerve leads to patient balance impairment.

Objective: (1) To determine if there was a difference in postural balance, measured using a head mountable physiological vibration acceleration (Phybrata) sensor, between those pursuing cervical or lumbar MBBs/RFAs compared to an asymptomatic healthy cohort (HC). (2) To determine differences in balance and sensory reweighting prior to and following MBBs/RFAs, and the association with clinical measures of pain and balance using the 4-Stage Balance Test.

Design: Quasiexperimental study with matched controls.

Setting: Community multidisciplinary chronic musculoskeletal pain practice.

Participants: Sixty individuals with chronic axial back pain and 60 age-/gender-matched healthy individuals.

Interventions/main outcome measures: Standing balance measures recorded with the Phybrata sensor, subjective report of pain (numerical rating scale), and clinical measures of balance (4-Stage Balance Test) were analyzed before and after participants underwent MBBs/RFAs and compared to an asymptomatic HC.

Results: Participants with axial spinal pain of facet joint origin (≥ 50% relief post MBB/RFA) demonstrated balance degradation when standing with eyes closed, when compared to participants with nonspecific axial spinal pain (< 50% pain relief) or HCs - both prior to and following MBBs/RFAs. Following MBBs/RFAs, participants undergoing C2/3 procedures demonstrated increased postural sway. The remainder of participants with axial spinal pain did not show any further balance deficits, with corresponding sensory reweighting adaptation. Phybrata measures were not associated with pain location or pain intensity prior to or after MBBs/RFAs.

Conclusions: These results suggest the risk of developing significant balance impairments following MBB/RFA procedure of either the cervical (excluding C2/3) or lumbar spine is low, although residual balance deficits remain.

Background: The effectiveness of platelet-rich plasma (PRP) injections in chronic tendinopathies remains debated. Although the product's characteristics play a role, the impact of postinjection recommendations remains poorly investigated.

Objective: To establish principles and guidelines for post-PRP injection rehabilitation and return to activity/sports.

Design: We conducted a Delphi survey based on a "recommendations by formal consensus" methodology. Three clinicians and researchers of the GRIIP (International Research Group on Platelet Injections), experts in sports medicine and rehabilitation, performed a comprehensive literature review of MEDLINE, searching for (1) rehabilitation protocols after PRP injection for chronic tendinopathy and (2) fundamental studies of tendon healing. This review highlighted the main points to be clarified to establish a standardized post-PRP injection protocol. Fourteen points were identified, grouped into three dimensions (immediate postprocedure, rehabilitation, and follow-up and resumption of sports/activity). With a modified Delphi method, the propositions were submitted to a panel of 23 experts from five French-speaking countries. The recommendations were classified as appropriate or not appropriate, with strong or relative agreement, or uncertain when consensus was not reached.

Results: Ten recommendations (postprocedure avoidance of nonsteroidal anti-inflammatory drugs, rehabilitation principles and timeline, follow-up) were classified as appropriate: six with strong and four with relative agreement; four propositions regarding immediate postprocedure were deemed uncertain.

Conclusion: Agreement was reached for 10 of the 14 recommendations but with low level of evidence, mainly based on experts' opinion. This work should help standardize a post-PRP injection protocol for chronic tendinopathies, which will minimize bias due to variations in rehabilitation protocols in further studies.

Background: Activity Measure for Post-Acute Care (AM-PAC) score is used in discharge planning for patients with acute ischemic stroke from a large vessel occlusion (AIS-LVO). Prolonged venous transit (PVT) is a binary, qualitative measure visually ascertained from computed tomography perfusion imaging time-to-maximum (Tmax) maps. PVT has been associated with unfavorable recovery and mortality.

Objective: To assess the robustness of PVT by evaluating its association with AM-PAC.

Methods: Consecutive adult patients with AIS-LVO treated successfully with reperfusion therapy were retrospectively reviewed. PVT+ is defined as Tmax $\ge$ 10 seconds timing on at least one of the following: superior sagittal sinus and/or torcula. PVT- lacks this in both regions. Primary outcome was favorable AM-PAC score, defined as having both Basic Mobility Score $\ge$ 17 and Daily Activity Score $\ge$ 19. Logistic regressions in unmatched and 1:1 propensity score-matched cohorts were performed.

Results: Among 121 patients, the median age was 72 (interquartile range, 64-81) years. Favorable AM-PAC scores occurred less often in PVT+ than PVT- patients (10.5% vs. 45.8%). PVT+ was associated with significantly reduced odds of favorable AM-PAC score in multivariable regressions (PVT+ vs. PVT- odds ratio [OR]: 0.11, 95% confidence interval [CI]: 0.03-0.48, p = .01); the significant association furthermore persisted in the matched cohort analysis (PVT+ vs. PVT- OR: 0.73, 95% CI: 0.60-0.88, p < .001).

Conclusion: PVT+ is independently associated with lower odds of favorable AM-PAC scores at discharge. Logistically-consistent associations with short-term and long-term clinical outcomes augment our understanding of PVT and further establish the potential of this novel imaging parameter as an informative metric in clinical practice.

Objective: To review and analyze the association between muscle fat infiltration (MFI) and pain intensity, disability, and cervical alignment in individuals with nonspecific neck pain. TYPE: Systematic review study.

Literature survey: Nonspecific neck pain is associated with muscular changes, including fatty infiltration, which may contribute to chronic symptoms and functional limitations. Prior studies have examined morphological muscle changes across various neck pain populations; however, specific evidence regarding the relationship between MFI and clinical outcomes in nonspecific neck pain remains limited and inconsistent.

Methodology: A systematic search of the Web of Science, PubMed, MEDLINE, and CINAHL databases was performed. This analysis included analytical cross-sectional studies published from 2003 to May 2025 that used structural medical imaging to examine fatty infiltration of neck muscles in participants aged 18-65 years with nonspecific neck pain lasting >3 months. Only articles written in English that were accessible to the authors were considered. Studies were excluded if they did not meet any of the aforementioned criteria.

Synthesis: Across included studies (n=4), higher MFI in cervical extensor muscles was consistently associated with greater pain intensity and disability. Evidence for a relationship between MFI and cervical alignment was inconsistent, with some studies reporting a negative association between MFI and cervical lordosis, while others found no correlation. Variability in imaging methods and clinical measures contributed to heterogeneity between studies.

Conclusion: The study results suggest a correlation between fatty infiltration and nonspecific neck pain features, such as pain level and neck disability, whereas cervical lordosis does not appear to be correlated. These findings highlight the importance of rehabilitation programs to reduce MFI and enhance muscle functions, which may alleviate symptoms.

Background: Individuals with severe visual impairments frequently refrain from regular physical activity due to multiple barriers, including transportation difficulties, financial constraints, and limited availability of exercise programs tailored to their needs. These factors often contribute to a gradual decline in mobility and independence.

Objective: To evaluate the feasibility of a self-administered, audio-guided training protocol designed to improve mobility in people with severe visual impairments.

Design: Nonrandomized controlled clinical trial (number: NCT05956730).

Participants: Nineteen adults (55.5 ± 14.8 years, 52% females) with severe low vision or blindness, met the inclusion criteria and completed all the assessments.  Interventions: Participants were assigned to an audio-guided (AUD) group performing a 3-month home-based training or a supervised (SUP) group performing identical training in a gym.

Outcome measures: Mobility assessment, including Timed Up and Go Low Vision version (TUG-LV), 1-minute sit-to-stand (1-MSTS), the 3-minute step (3-MSTEP), and Sit and Reach (SR) tests, was conducted every 4 weeks. Physical activity level, satisfaction profile, visual functioning, and caregiver burden were recorded.

Results: Participants reported no injuries or physical issues, and adherence was >95%. Both AUD and SUP showed enhancements in TUG-LV, 1-MSTS, 3-MSTEP, and SR (time, p <.001), with differences between groups in 1-MSTS and 3-MSTEP (time × group, p = .04). Physical activity level and satisfaction in physical functioning increased over time (p = .002; p = .03), with no time per group interaction (p = .76; p = .37). No significant changes were noted in visual functioning or caregiver burden.

Conclusions: Although supervised training showed slightly greater improvements in some outcomes, audio-guided training is feasible, offering a valuable alternative to enhance mobility when supervision is not viable.

Background: Physical medicine and rehabilitation (PM&R) has grown considerably and currently has >100 American College of Graduate Medical Education-accredited residency programs throughout the United States. Comparison of the different applicant types across U.S. allopathic (US-MD), U.S. osteopathic (US-DO), and international medical graduates (IMG) associated with success in matching to this specialty has been limited. We sought to identify the factors that allowed a successful match across different applicant types over a 10-year period.

Method: The National Resident Matching Program Charting Outcomes data were analyzed from 2014 to 2024, with data released biennially, for US-MD, US-DO, and IMG applicants. The factors collected include mean medical licensing examination scores; the number of programs ranked; research, volunteer, and work experiences, as well as research products (including abstracts, publications, or presentations).

Results: Standardized exams greatly impacted match success across all applicant types, with a greater difference in mean medical licensing examination scores for matched compared to unmatched applicants, whereas significantly greater means of extracurriculars additionally contributed to matching for US-DO and IMG applicants. The number of programs ranked was significantly greater in successful matches across all applicant types compared to their unmatched colleagues. When comparing all three applicant pools that successfully matched, the average number of volunteer experiences and programs ranked were the only significantly varying differences, with US-MD and US-DO applicants with greater numbers of programs ranked and volunteer experiences than IMG applicants.

Discussion: Though the residency application process has been constantly changing over the years, including the MD/DO residency merger, transition to Pass/Fail board examinations, and limitations to the number of experiences allowed on applications, these data provide a baseline understanding of the factors associated with successful match into the field of PM&R.

Conclusion: Information on the factors impacting a successful match may be useful to future applicants and program directors in the field of PM&R.