PM&R最新文献

By the end of residency, physical medicine and rehabilitation (PM&R) residents are expected to align patient values with treatments using goals of care (GOC) discussions. Like other procedural skills, GOC communication skills are best learned through simulation training and deliberate practice and feedback rather than lectures. However, educational resources to effectively impart these skills are often lacking. How can educators design effective GOC communication curricula with limited time and resources? This article presents two teaching techniques grounded in adult learning theory that educators can apply to increase teaching effectiveness. Additionally, a 2-hour GOC curriculum for PM&R residents is outlined, its feasibility and acceptability are discussed, and preliminary efficacy data are shared.

Background: Artificial intelligence has begun to replace human power in many areas today.

Objective: To assess the performance of Chat Generative Pretrained Transformer (ChatGPT) on examinations administered to physical medicine and rehabilitation (PM&R) residents.

Design: Cross-sectional study.

Setting: Tertiary-care training and research hospital, department of physical medicine and rehabilitation.

Participants: ChatGPT-4o and PM&R residents.

Intervention: ChatGPT was presented with questions from the annual nationwide in-training exams administered to PM&R residents at different postgraduate years. The exam is a national requirement for the majority of PM&R residents in Turkey and is administered annually.

Main outcome measures: The responses to these multiple-choice questions were evaluated as correct or incorrect, and ChatGPT's performance was then compared to that of the residents of each postgraduate year (PGY) term. The time taken by ChatGPT to answer each question was also recorded. Additionally, its learning ability was assessed by reasking the questions it initially answered incorrectly, this time providing the correct answers to evaluate improvement.

Results: ChatGPT received a score of 88 out of 100 points in the PGY1 exam, 84 points in the PGY2 exam, 78 points in the PGY3 exam, and 80 points in the PGY4 exam. When compared with the performance distribution of residents, ChatGPT ranked in the 40th-50th percentile for PGY1, 70th-80th percentile for PGY2, 30th-40th percentile for PGY3, and 40th-50th percentile for PGY4. It has been demonstrated that ChatGPT has achieved a learning rate of 65%.

Conclusion: Despite the potential of ChatGPT to surpass PM&R physicians in terms of learning capabilities and extensive knowledge network, several functional limitations remain. In its current form, it is not capable of replacing a physician, especially in the field of PM&R, where clinical examination and patient interaction play a critical role.

Background: Musculoskeletal injections are a common clinical procedure, often intended to reduce joint or muscular pain in patients. Further identification is warranted to identify additional clinical variables that may lead to increased or decreased pain perception with musculoskeletal injections.

Objective: To examine clinical, demographic, and injection-related factors with patient-perceived pain during musculoskeletal injections, which expands upon prior studies.

Design: Cross-sectional study.

Setting: Retrospective study involving outpatient orthopedic clinics. Consecutive adult patients (age ≥ 18 years) undergoing musculoskeletal injections were reviewed.

Patients: A total of 1371 injections from 935 patients were eligible for the analysis. Exclusion criteria included cognitive disability, non-English-speaking patients, and aphasia.

Interventions: N/A.

Main outcome measures: Patients reported their pre-, intra-, and postprocedural pain on a numerical scale from 0 to 10. Pain scores, demographics, and injection specifics were analyzed after retrospective chart review for their effect on intraprocedural pain.

Results: A total of 1371 injections (62.4% female, mean age 58.6 ± 16.1 years, body mass index 29.6 ± 7.3 kg/m²) were included for analysis. The median intraprocedure pain score was 2. According to the multivariate linear regression model, female gender (B = 0.42; 95% confidence interval [CI] = 0.15-0.69; p < .01), ultrasound image guidance (B = 0.66; 95% CI = 0.22-1.10; p < .01), presence of a trainee (B = 0.44; 95% CI = 0.15-0.73 p < .01), and body mass index (B = 0.04; 95% CI = 0.01-0.06; p < .01) were significantly associated with greater intraprocedure pain score, whereas use of sodium bicarbonate (B = -0.68; 95% CI = -1.01 to -0.35; p < .01), age (B = -0.01; 95% CI = -0.02 to -0.01; p = .04), and injectate volume (B = -0.06; 95% CI = -0.13 to -0.01; p = .04) had significant, inverse associations with intraprocedure pain score. The logistic regression model showed the significant association of presence of trainee (odds ratio = 1.86; 95% CI = 1.23-2.83; p < .01) to intraprocedure pain score of ≥1 (vs. 0).

Conclusions: This study identified clinical and demographic variables associated with worsened injection pain that may improve the counseling and expectations of patients and ideally lead to reduction in experienced procedural pain. Lower pain scores were associated with use of sodium bicarbonate, absence of a trainee, palpation guidance, and male gender of the patient.

Background: Radiofrequency ablation (RFA) of neuromas has emerged as a potential treatment option for refractory neuroma-associated postamputation pain (PAP).

Objective: To evaluate the feasibility of using internally cooled radiofrequency ablation (C-RFA) for treating neuroma-associated PAP.

Design: Prospective single-arm pilot study.

Setting: Tertiary academic medical center.

Participants: Eight participants with neuroma-associated PAP (mean age 56.5 [interquartile range, 50.5-68.5] years; mean body mass index 30.2 [interquartile range, 26.3-34.8] kg/m²).

Intervention: Participants were recruited and treated with C-RFA between 2019 and 2023.

Main outcome measures: Pain and functional outcomes were assessed at 1, 3, 6, and 12 months after C-RFA using Numeric Rating Scale (NRS), Groningen Activity Restriction Scale (GARS), Patient Global Impression of Change (PGIC), and Medication Quantification Scale III (MQS-III). Responder definitions for each outcome measure were ≥50% NRS reduction, ≥30% GARS improvement, ≥6 on PGIC, and ≥6.8-point MQS-III reduction.

Results: NRS responder rates at 1, 3, 6, and 12 months were 25.0% (95% CI, 7.0%-59.1%), 50.0% (95% CI, 21.5%-78.5%), 37.5% (95% CI, 13.7%-69.4%), and 50.0% (95% CI, 21.5%-78.5%), respectively. Responder rates for GARS were 25.0% (95% CI, 7.1%-59.1%) at 1 month and 12.5% (95% CI, 2.2%-47.1%) at 3, 6, and 12 months. The proportion of PGIC responders was 37.5% (95% CI, 13.7%-69.4%) at 1 and 3 months and 12.5% (95% CI, 2.2%-47.1%) at 6 and 12 months. MQS-III responder rates were 25.0% (95% CI, 7.1%-59.1%) at 1 month, 12.5% (95% CI, 2.2%-47.1%) at 3 months, and 37.5% (95% CI, 13.7%-69.4%) at 6 and 12 months. There were no complications associated with the C-RFA procedure.

Conclusions: These findings indicate the feasibility of neuroma C-RFA as a treatment for refractory neuroma-associated PAP but also suggest that further patient selection and C-RFA technique optimization are warranted before investigating this treatment paradigm in a larger prospective study.

Background: In-reach rehabilitation is a relatively new model of care available in a small number of Australian public hospitals. These multidisciplinary teams deliver evidence-based structured rehabilitation to carefully selected patients during acute care. There are no published rehabilitation outcomes in heart and/or lung transplant recipients.

Objective: To describe the rehabilitation outcomes of a cohort of heart and/or lung transplant recipients.

Design: Retrospective cohort study.

Setting: One metropolitan institution with the largest heart and lung transplant service in Australia.

Patients: Between 2014 and 2023, a total of 957 heart and/or lung transplants were performed at this institution.

Intervention: In-reach rehabilitation was delivered to selected patients during the 10-year period. However, from 2019 onwards, patients were proactively screened by the rehabilitation team for eligibility as well as referred from the acute transplant teams.

Main outcome measures: Functional independence measure (FIM) changes and percentage of patients going to inpatient rehabilitation after completion of acute care.

Results: In-reach rehabilitation was received by 223 (24.3%) patients. With the exception of three patients (who died), the vast majority were able to complete an in-reach rehabilitation program and were discharged to the community (n = 98, 43.9%), inpatient rehabilitation (n = 119, 53.4%), or transferred to another hospital (n = 3, 1.3%), demonstrating feasibility. Across the cohort, the median admission and discharge FIM scores were 77.0 (interquartile range, 60-94.8) and 100 (interquartile range, 77-118), respectively, demonstrating significant functional improvements from start to finish of the in-reach rehabilitation program (p < .001). Over this period, the number of patients discharged to inpatient rehabilitation decreased as a proportion of the total number of transplants (25.7% in 2014, 47.8% in 2017, 34.7% in 2019, 26.2% in 2021, 8.0% in 2023). Proactive rehabilitation screening implemented from 2019 allowed for earlier and longer program delivery to more patients.

Conclusions: In-reach rehabilitation is feasible in acute care after heart and/or lung transplantation and was associated with functional improvements. The addition of proactive rehabilitation screening appeared to improve the effectiveness of the in-reach rehabilitation program.

Background: All physicians will care for persons with disabilities over the course of their careers. However, most medical school curricula do not adequately prepare students to recognize and address the specific needs of persons with disabilities. Despite physician requirements under the Americans with Disabilities Act (ADA), patients with disabilities may receive substandard care due to a lack of accommodations.

Objective: To examine the effect of a physical medicine and rehabilitation (PM&R) clerkship on fourth-year medical students' understanding of physician responsibilities under the ADA as well as comfort levels when caring for persons with disabilities.

Design: Subjective pre- and postintervention surveys.

Setting: A single institution U.S. allopathic medical school.

Participants: All fourth-year medical students enrolled in the mandatory PM&R clerkship during the 2022-2023 academic year were eligible for participation in the study. Surveys were distributed to all eligible students and 99 students successfully completed both surveys for inclusion in the study.

Interventions: For the 2022-2023 academic year, the mandatory 2-week PM&R clerkship included didactic lectures on the ADA and additional interactive, first-hand accounts from persons living with a disability.

Main outcome measures: The change from medical students' baseline to postclerkship knowledge regarding the ADA responsibilities for physicians and overall comfort in working with persons with a physical disability.

Results: Medical students' overall knowledge of the clinical and financial responsibilities of physicians under the ADA and comfort in interacting with persons with disabilities improved following the clerkship (p < .001).

Conclusions: These findings highlight the importance of disability education as part of medical school curricula to improve medical student knowledge about physician responsibilities under the ADA and overall comfort level in caring for persons with disability. Further studies are needed to determine if these results carry over into clinical practice to combat the health care disparities experienced by persons with disabilities.

Background: Mild traumatic brain injury (mTBI) is common among military service members. Moderate-to-vigorous aerobic exercise (MVAE) is a modifiable behavior with potential benefits for individuals following mTBI but is poorly understood for long-term mTBI health.

Objective: To explore the associations between mTBI history and MVAE participation and appreciate their association with health-related quality of life (HR-QOL) among service members and Veterans.

Methods: Data from a larger study were used in these secondary cross-sectional analyses. Lifetime mTBI history (0, 1-2, 3+) was captured via validated structured interviews. Self-reported weekly MVAE (none, below, meeting, or ≥2 times the recommendation) was recorded from the Behavioral Risk Factor Surveillance System questionnaire. Participants' HR-QOL was self-reported via Traumatic Brain Injury-Quality of Life instrument and the Patient Health Questionnaire-9 (depression symptoms). Univariate mTBI history and MVAE associations were assessed via Pearson's chi-square and Kendall's Tau. Multivariable linear regression models with unstandardized beta values and 95% confidence intervals were fit for each HR-QOL questionnaire outcome, with current age, sex, and posttraumatic stress disorder symptoms as covariates (α = .05).

Results: Among the 1995 participants (87.7% male; aged 41.7 ± 10.1 years), those meeting or exceeding (≥2 times) MVAE recommendations had significantly higher HR-QOL for fatigue, executive function, pain interference, resilience, social participation, and depression than the inactive MVAE group. Exceeding MVAE recommendations by ≥2 times was also significantly associated with better self-reported cognition - general concerns. Those who participated in exercise but didn't meet the MVAE recommendations had higher pain interference, social participation, and depression scores compared to the inactive group. More lifetime mTBIs were associated with worse HR-QOL across all domains. Level of MVAE participation was not dependent on mTBI history.

Conclusions: More MVAE was associated with better TBI-related HR-QOL regardless of mTBI history. MVAE is recommended for service members and Veterans due to these findings and previously reported health benefits.