PM&R最新文献

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: Muscle weakness is common and significantly affects persons with multiple sclerosis (PwMS), with dysfunction in upper limb (UL) muscle groups occurring in approximately 60% of PwMS.

Objective: To develop gender-specific regression-based prediction equations, with 95% confidence intervals for maximal bilateral UL isometric strength (shoulder abduction and adduction, wrist flexion and extension) and hand grip strength in PwMS.

Design: Cross-sectional study.

Setting: Comprehensive MS center.

Participants: 256 PwMS.

Interventions: Not Applicable.

Main outcome measures: Shoulder abduction and adduction and wrist flexion and extension isometric strength (Biodex System 4 Pro Dynamometer) and hand grip strength (Jamar handheld dynamometer) were measured. Disease characteristics (disability and disease duration) and demographics (age, height, and weight) were collected. Regression-based predictive equations were generated for the UL muscle groups for each gender and limb, using age, height, weight, disability, and disease duration as covariates. Variables were compared between genders using the Mann-Whitney U test. Maximal voluntary contraction (MVC) reference values (mean ± SD) were reported based on age (<30, 30-39, 40-49, 50-59, 60-69 years) and disability (mild, moderate, severe ambulant, and severe nonambulant) for each gender and limb.

Results: Regression-based equations were developed for both genders' strongest and weakest limb, accounting for age, height, weight, disability, and disease duration. MVC was higher in men than women (p < .001) in all muscle groups. Overall, MVC was significantly related to age in 14, height in 5, weight in 6, disability in 14, and disease duration in none of the 20 models.

Conclusion: This is the first study to provide regression-based prediction equations for strongest and weakest MVC of UL muscle groups and demonstrated an inverse relationship between MVC with disability and age. Regression-based reference strength values can help clinicians understand muscular strength along a spectrum of PwMS and can aid in goal setting and education for realistic outcomes.

Health care is a major driver of greenhouse gas emissions and is closely intertwined with industrial processes responsible for air, water, and soil pollution. Chronic pain - particularly as it relates to spine and musculoskeletal diagnoses - comprises a significant portion of health care utilization and affects millions of people worldwide. Despite the prevalence of chronic spine and musculoskeletal pain, there has been limited discussion of the environmental impacts of outpatient clinics and interventional processes as they relate to these conditions. This narrative review explores the environmental impact related to diagnostics, pharmacologics, and common nonoperative interventional procedures utilized in the management of patients with chronic musculoskeletal and spine pain. Topics explored include energy utilization, production and disposal of pharmaceuticals, and waste production from interventional procedures. This study aims to educate providers involved in spine and musculoskeletal disease management regarding the possible environmental consequences of their practices. The article also focuses on modifying approaches to patient care to those that are more sustainable as well as highlighting areas in need of further investigation.

Background: Low-value care is the use of substitutive/ineffective/harmful strategies based on available evidence, and it is considered one of the main contributors to the burden related to low back pain in health care systems. The use of routine imaging for patients with low back pain is the main example of inappropriate care. Therefore, understanding the perceptions of medical doctors and patients from Brazil about this practice may help propose strategies to reduce imaging rates.

Objective: To investigate the perceptions of medical doctors and patients about imaging for the diagnosis of nonspecific low back pain.

Design: A qualitative study using the framework analysis method.

Settings: Primary and secondary care.

Participants: Fifteen patients with low back pain and 15 doctors participated in this study.

Data collection: Sociodemographic data were collected from all participants, and the interviews were performed using a set of questions created based on the literature.

Main results: Patients and doctors believe that the main reason for ordering imaging tests is to identify the source of pain, and imaging could be useful for tracking disease progression over time or if there is a lack of improvement after treatment. Patients' expectations and pressures play a role in the decision to order imaging tests, but clinicians believe that education is the preferred strategy to reduce imaging rates.

Conclusion: Identifying the source of pain, tracking the disease progression, and patients' expectations and pressures were the main drivers of imaging requests for low back pain. Educational strategies were suggested to reduce the use of routine imaging.

Osteoarthritis affects a significant portion of U.S. adults, and knee osteoarthritis contributes to 80% of disease burden. Previous data have shown that non-White patient populations often report worse symptoms and less favorable outcomes following arthroplasty, a definitive treatment for knee osteoarthritis. There is a lack of demographics data on race/ethnicity, as well as socioeconomic status (SES) and social determinants of health (SDOH), in knee osteoarthritis treatment guidelines and knee arthroplasty research. In addition, there is underrepresentation of non-White patient populations in the existing treatment guidelines for knee osteoarthritis. Over the past decade, orthobiologics have emerged as an alternative to surgical intervention. Our hypothesis is that there would be a similar lack of reporting of demographics data and underrepresentation of non-White populations in studies pertaining to orthobiologics, including evaluating differences in outcomes. This study reviewed U.S.-based research in orthobiologics as a treatment option for knee osteoarthritis. We identified a lack of demographics reporting in terms of race/ethnicity, and none of the studies reported SES or SDOH. Non-White populations were underrepresented; White patients contributed to 80% or more of all study populations that reported race/ethnicity. None studied the correlation between symptoms and outcome measures, and the race/ethnicity, SES, and SDOH of the patients. Based on a review of existing literature, we strongly advocate for ongoing research encompassing patients of all races/ethnicities, SES, and SDOH, and an exploration into potential variations in symptoms and outcomes among distinct population subgroups. Furthermore, SES barriers may influence health care delivery on orthobiologics for disadvantaged populations.

As health care attempts to bridge the gap between evidence and practice, the concept of the learning health system (LHS) is becoming increasingly relevant. LHS integrates evidence with health systems data, driving health care quality and outcomes through updates in policy, practice, and care delivery. In addition, LHS research is becoming critically important as there are several initiatives underway to increase research capacity, expertise, and implementation, including attempts to stimulate increasing numbers of LHS researchers. Physical Medicine & Rehabilitation (PM&R) physicians (physiatrists), nurses, therapists (physical therapists, occupational therapists, speech therapists, clinical psychologists), and scientists are affiliated with LHSs. As LHS research expands in health care systems, better awareness and understanding of LHSs and LHS research competencies are key for rehabilitation professionals including physiatrists. To address this need, the Agency of Healthcare Research and Quality (AHRQ) identified 33 core competencies, grouped into eight domains, for training LHS researchers. The domains are: (1) Systems Science; (2) Research Questions and Standards of Scientific Evidence; (3) Research Methods; (4) Informatics; (5) Ethics of Research and Implementation in Health Systems; (6) Improvement and Implementation Science; (7) Engagement, Leadership, and Research Management; and the recently added (8) Health and Healthcare Equity and Justice. The purpose of this commentary is to define LHS and its relevance to physiatrists, present the role of implementation science (IS) in LHSs and application of IS principles to design LHSs, illustrate current LHS research in rehabilitation, and discuss potential solutions to improve awareness and to stimulate interest in LHS research and IS among physiatrists in LHSs.

Introduction: The timely translation of evidence-based programs into real-world clinical settings is a persistent challenge due to complexities related to organizational context and team function, particularly in inpatient settings. Strategies are needed to promote quality improvement efforts and implementation of new clinical programs.

Objective: This study examines the role of CONNECT, a complexity science-based implementation intervention to promote team readiness, for enhancing implementation of the 'Assisted Early Mobility for Hospitalized Older Veterans' program (STRIDE), an inpatient, supervised walking program.

Design: We conducted a stepped-wedge cluster randomized trial using a convergent mixed-methods design. Within each randomly assigned stepped-wedge sequence, Veterans Affairs Medical Centers (VAMCs) were randomized to receive standardized implementation support only or additional training via the CONNECT intervention. Data for the study were obtained from hospital administrative and electronic health records, surveys, and semi-structured interviews with clinicians before and after implementation of STRIDE.

Setting: Eight U.S. VAMCs.

Participants: Three hundred fifty-three survey participants before STRIDE implementation and 294 surveys after STRIDE implementation. Ninety-two interview participants.

Intervention: CONNECT, a complexity-science-based intervention to improve team function.

Main outcome measures: The implementation outcomes included STRIDE reach and fidelity. Secondary outcomes included validated measures of team function (i.e., team communication, coordination, role clarity).

Results: At four VAMCs randomized to CONNECT, reach was higher (mean 12.4% vs. 3.8%), and fidelity was similar to four non-CONNECT VAMCs. VAMC STRIDE delivery teams receiving CONNECT reported improvements in team function domains, similar to non-CONNECT VAMCs. Qualitative findings highlight CONNECT's impact and the influence of team characteristics and contextual factors, including team cohesion, leadership support, and role clarity, on reach and fidelity.

Conclusion: CONNECT may promote greater reach of STRIDE, but improvement in team function among CONNECT VAMCs was similar to improvement among non-CONNECT VAMCs. Qualitative findings suggest that CONNECT may improve team function and implementation outcomes but may not be sufficient to overcome structural barriers related to implementation capacity.

Background: Understanding of students' musculoskeletal health under home-schooling during the COVID-19 pandemic is limited.

Objectives: (1) To investigate the prevalence and severity of musculoskeletal symptoms in home-schooled adolescents during the COVID-19 pandemic. (2) To evaluate the effect of an online exercise + ergonomics advice protocol on symptoms, compared with ergonomics advice alone.

Design: Cross-sectional symptom survey identifying eligible participants, followed by a pragmatic randomized controlled trial.

Setting: Online classes.

Participants: Survey: 354 students (mean 16.6 years).

Trial: 188 students with upper body musculoskeletal symptoms.

Interventions: Randomization to three groups (physical therapy exercises + ergonomics postural advice, ergonomics postural advice alone, nonintervention control) stratified by the site of symptoms (neck, shoulder, upper back). Interventions were orally delivered online (via WhatsApp) supplemented with written/illustrative material. Follow-up occurred at 8 weeks.

Outcome measures: Survey: prevalence of symptoms (Nordic Questionnaire).

Trial: primary outcome = change in intensity of upper body symptoms (visual analogue scale); secondary outcome = number of participants reporting improvement in upper body symptoms.

Results: The 12-month prevalence of musculoskeletal disorders in the survey was 38% neck, 28% shoulder, and 35% upper back, with mean pain intensity of 3.6, 3.9, and 3.8, respectively, on 0-10 visual analogue scale: Two-thirds reported symptoms in multiple anatomical regions. In the trial, there was no statistically significant difference between the exercise + ergonomics group and ergonomics alone group on the primary outcome, yet both groups showed reduced symptom intensity compared with control (p < .001). More participants in the exercise + ergonomics group reported improvement than in the ergonomics advice alone group (p < .02).

Conclusions: The prevalence of musculoskeletal symptoms was relatively high in home-schooled adolescents. Symptoms can be reduced by ergonomics advice with or without exercises, but the effect is enhanced by the addition of physical therapy exercises. The latter approach may be considered for improving schoolchildren's musculoskeletal health in the usual classroom setting.