AAPM&R consensus guidance on spasticity assessment and management

BACKGROUND

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care.

OBJECTIVE

To develop consensus-based practice recommendations to identify and address gaps in spasticity care.

METHODS

The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations.

RESULTS

The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity.

CONCLUSION

This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.

Individual, organizational, and policy strategies to enhance the retention and a sense of belonging for health care professionals in rehabilitation medicine

The retention of physicians and other health care professionals in rehabilitation medicine is a critical issue that affects patients' access to care and the quality of the care they receive. In the United States and globally, there are known shortages of clinicians including, but not limited to, physicians, nurses, physical therapists, occupational therapists, and speech-language pathologists. These shortages are predicted to worsen in the future. It is known that attrition occurs in a variety of ways such as a clinician reducing work hours or effort, taking a position at another organization, leaving the field of medicine altogether, stress-related illness, and suicide. Retention efforts should focus on stay factors by creating a positive culture that supports a sense of belonging as well as addressing a myriad of push and pull factors that lead to attrition. In this commentary, we provide a roadmap that includes examples of stay strategies for individuals and organizations to adopt that are aimed at enhancing the retention of rehabilitation medicine professionals.

Disparities in Access to Spasticity Chemodenervation Specialists in the United States: A Retrospective Cross-Sectional Study

OBJECTIVE

The aim of the study is to explore variations in access to spasticity chemodenervation specialists across several geographical, ethnic, racial, and population density factors.

DESIGN

This is a retrospective cross-sectional study on Medicare Provider Utilization and Payment Data. Providers with substantial adult spasticity chemodenervation practices were included. Ratios were assessed across geographical regions as well as hospital referral regions. A multivariate linear regression model for the top 100 hospital referral regions by beneficiary population was created, using backward stepwise selection to eliminate variables with P values > 0.10 from final model.

RESULTS

A total of 566 providers with spasticity chemodenervation practices were included. Unadjusted results showed lower access in nonurban versus urban areas in the form of higher patient:provider ratios (83,106 vs. 51,897). Access was also lower in areas with ≥25% Hispanic populations (141,800 vs. 58,600). Multivariate linear regression results showed similar findings with urban hospital referral regions having significantly lower ratios (-45,764 [ P = 0.004] vs. nonurban) and areas with ≥25% Hispanic populations having significantly higher ratios (+96,249 [ P = 0.003] vs. <25% Hispanic areas).

CONCLUSIONS

Patients in nonurban and highly Hispanic communities face inequities in access to chemodenervation specialists. The Medicare data set analyzed only includes 12% of the US patient population; however, this elderly national cross-sectional cohort represents a saturated share of patients needing access to spasticity chemodenervation therapy. Future studies should venture to confirm whether findings are limited to this specialization, and strategies to improve access for these underserved communities should be explored.

Assessing the Burden and Cost of COVID-19 Across Variants in Commercially Insured Immunocompromised Populations in the United States: Updated Results and Trends from the Ongoing EPOCH-US Study

INTRODUCTION/METHODS

EPOCH-US is an ongoing, retrospective, observational cohort study among individuals identified in the Healthcare Integrated Research Database (HIRD®) with ≥ 12 months of continuous health plan enrollment. Data were collected for the HIRD population (containing immunocompetent and immunocompromised [IC] individuals), individual IC cohorts (non-mutually exclusive cohorts based on immunocompromising condition and/or immunosuppressive [IS] treatment), and the composite IC population (all unique IC individuals). This study updates previous results with addition of the general population cohort and data specifically for the year of 2022 (i.e., Omicron wave period). To provide healthcare decision-makers the most recent trends, this study reports incidence rates (IR) and severity of first SARS-CoV-2 infection; and relative risk, healthcare utilization, and costs related to first COVID-19 hospitalizations in the full year of 2022 and overall between April 2020 and December 2022.

RESULTS

These updated results showed a 2.9% prevalence of immune compromise in the population. From April 2020 through December 2022, the overall IR of COVID-19 was 115.7 per 1000 patient-years in the composite IC cohort and 77.8 per 1000 patient-years in the HIRD cohort. The composite IC cohort had a 15.4% hospitalization rate with an average cost of $42,719 for first COVID-19 hospitalization. Comparatively, the HIRD cohort had a 3.7% hospitalization rate with an average cost of $28,848 for first COVID-19 hospitalization. Compared to the general population, IC individuals had 4.3 to 23 times greater risk of hospitalization with first diagnosis of COVID-19. Between January and December 2022, hospitalizations associated with first COVID-19 diagnosis cost over $1 billion, with IC individuals (~ 3% of the population) generating $310 million (31%) of these costs.

CONCLUSION

While only 2.9% of the population, IC individuals had a higher risk of COVID-19 hospitalization and incurred higher healthcare costs across variants. They also disproportionately accounted for over 30% of total costs for first COVID-19 hospitalization in 2022, amounting to ~ $310 million. These data highlight the need for additional preventive measures to decrease the risk of developing severe COVID-19 outcomes in vulnerable IC populations.

Examining Diversity Recruitment Efforts in US-Based Physical Medicine and Rehabilitation Residencies: A Survey of Program Directors on Gender, Ethnic and Racial Diversity, and Implications for Recruitment Efforts

As the population of the United States continues to grow and diversify, it is critical that the medical profession follows. This study aimed to evaluate aspects of the current landscape of diversity within physical medicine and rehabilitation by surveying program directors of US-based physical medicine and rehabilitation residencies. The secondary aim was to identify program characteristics that correlate with more diverse residency classes. An online, cross-sectional 17-question survey was distributed to program directors of all US-based physical medicine and rehabilitation residencies with known contact information (95/100), with a completed survey response rate of 53% (50/95). Race and ethnicity categories of the survey were based on those used by the US Census. The percentages of individuals identifying as women or those underrepresented in medicine in this survey were below those of the general US population, a trend also seen within the field of physical medicine and rehabilitation overall. Linear regression revealed no statistically significant association between the percentage of underrepresented in medicine residents and commonly used diversity recruitment initiatives. There was a significant association between the presence of a departmental role for diversity, equity and inclusion and the percentage of women residents (odds ratio, 1.13; P = 0.017). Continued research is required to identify additional strategies with demonstrated efficacy in recruiting diverse residency applicants.

Enhanced External Counterpulsation Improves Cognitive Function of Persons with Long COVID

OBJECTIVE

To determine the effects of Enhanced External Counterpulsation (EECP) in patients with long COVID and objectively assessed cognitive impairment.

DESIGN

A retrospective evaluation of long COVID patients referred for EECP, with cognitive sequela, and having completed an objective digital assessment before and after therapy. Patients had either cognitive impairment (CI) or no cognitive impairment (NCI) at baseline. We assessed changes in composite score using multi-factor ANOVA. Multiple linear and logistic regression analyses were conducted to evaluate several independent variables.

RESULTS

80 long COVID patients (38 CI vs 42 NCI) were included for analyses. All baseline characteristics were well matched. There was significant improvement in composite score post-EECP in those with objective cognitive impairment at baseline. There were no notable documented safety concerns.

CONCLUSION

This is the first study showing that EECP led to significant improvement in cognitive functioning of long COVID patients with objectively defined cognitive impairment. Although a lack of a negative control group is a limitation of this study, EECP appears to be highly safe and effective with the potential for widespread application.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Upper Limb Spasticity: The Quality of Online Patient Resources

OBJECTIVE

The aim of the study is to assess the quality, readability, content, accessibility, and structure of online resources for patients with upper limb spasticity.

DESIGN

This was a cross sectional study examined Internet searches across three search engines related to patient resources for upper limb spasticity. Search phrases for either hand or upper limb spasticity were used. The top 20 Websites from each search were evaluated using the four readability metrics and the DISCERN scale for quality assessment. YouTube videos with exact search phrases were evaluated using DISCERN. Descriptive statistical analyses were performed using SPSS software.

RESULTS

Thirty-six Websites and 33 videos met the inclusion criteria for this study. The average Flesh-Kincaid Grade Level of the Websites was 11.7 ± 3.1, showing low Website readability. According to this index, only two Websites were written at the suggested sixth-grade level (5.4%). With a maximum score of 75, the mean DISCERN score for both Websites and videos scored in the "good" range (53.5 ± 8 and 50.5 ± 6.6), respectively.

CONCLUSIONS

Current online resources for upper limb spasticity are good in quality but are written above the health literacy level of American citizens. Organizations should consider reviewing their present materials and developing high-quality patient education materials that are easier to understand.

Gender Representation of Editors at Journals Affiliated with Major U.S. Medical Societies

Objectives: To assess the gender composition of upper-level specialty-specific editor positions among United States (U.S.) medical society-affiliated journals and to evaluate the equitable inclusion of women and women physicians. Materials and Methods: The gender composition of upper-level (e.g., editor-in-chief, deputy) specialty-specific editor positions among 39 U.S. medical society-affiliated journals as of January 5, 2023, was analyzed. Editor positions below the level of associate editor were excluded. Parity (50:50 representation) and equity (compared with the proportion of practicing physicians in each medical specialty) benchmarks were utilized to determine if women are underrepresented in editor positions. Results: A total of 862 editor positions among 39 journals were assessed. Women held 32.9% (284/862) of positions (95% confidence interval [CI]: 29.9%-36.2%), significantly less than expected based on the U.S. population (p < 0.001). Physicians comprised 90.8% (783/862) of positions, of whom 30.4% (238/783) were women physicians (95% CI: 27.3%-33.7%), significantly less than expected (p < 0.001). Thirty-three (84.6%, 95% CI: 70.3%-92.8%) journals were below parity for women overall, whereas 34 (87.2%, 95% CI: 73.3%-94.4%) were below parity for women physicians. Fourteen (35.9%, 95% CI: 22.7%-51.6%) journals were below equity for women physicians. Notably, 13 (33.3%, 95% CI: 20.6%-49.0%) journals were below both parity and equity for women overall and women physicians. Conclusions: This study reveals mixed results in the equitable inclusion of women in editor positions of journals affiliated with U.S. medical societies. Despite the equitable inclusion of women in editorial roles being a remediable issue, approximately one third of journals affiliated with major U.S. medical societies remain inequitable.

Trends in gender, race, and ethnic diversity among prospective physical medicine and rehabilitation physicians

BACKGROUND

As the proportion of women and individuals who are underrepresented in medicine slowly rises, disparities persist in numerous arenas and specialties. In physical medicine and rehabilitation (PM&R), there is a continued need to focus on diversity among trainees. This study aims to evaluate diversity among PM&R applicants and residents over the past 6 years.

OBJECTIVE

To describe the demographic trends in PM&R over the last 6 years and compare those findings with trends in other specialties.

DESIGN

Surveillance.

SETTING

Analyses of national databases from self-reported questionnaires.

PARTICIPANTS

The study consists of 126,833 medical school matriculants, 374,185 resident applicants, and 326,134 resident trainees over the last 6 years.

MAIN OUTCOME MEASURES

Self-reported demographic data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education were analyzed for medical school matriculants, PM&R applicants, and current residents for the cycles of 2014-2015 to 2019-2020. The data were then comparatively reviewed between PM&R and other medical specialties.

RESULTS

In the 6 cycles evaluated, women accounted for 36%-39% of PM&R residents, but 47%-48% in non-PM&R specialties. Women applicants to the PM&R specialty averaged 34.4% over the 6 years analyzed, which was the fourth lowest of the 11 specialties examined. Black or African American and Hispanic, Latino, or of Spanish Origin populations each accounted for only 6% of PM&R residents. PM&R demonstrated a noticeably higher proportion of White (62.1% vs. 60.3%) and an observably lower proportion of Black or African American (6.0% vs. 7.1%) and Hispanic, Latino, or of Spanish Origin (6.3% vs. 7.9%) residents compared with non-PM&R specialties.

CONCLUSION

There is underrepresentation of women and multiple racial and ethnic minority groups in the field of PM&R from applicants to trainees demonstrating a need to improve recruitment efforts.

Investigation of Health Behavior on Burnout Scores in Women Physicians who Self-Identify as Runners: A Cross-Sectional Survey Study

As the proportion of women in the physician workforce increases, burnout in this population warrants further investigation. Exercise is an often-proposed strategy to combat burnout. Evaluating physical activity across a cohort of women physicians can assess associations of health behaviors with burnout. Cross-sectional study of women attending physicians in the United States who are actively engaged in a social media group for runners. An electronic survey comprised of 60 questions covering demographics, health behaviors, and burnout was administered. A healthy lifestyle subgroup (HLS) was defined based on American Heart Association physical activity and nutrition recommendations. We determine the prevalence of burnout and investigate associations between health behavior factors and burnout. Of the 369 included surveys, most respondents were at least six years out from medical training (85.9%) and White (74.5%). Forty-two percent experienced burnout symptoms. Time exercising was significantly associated with fruit/vegetable consumption (P=.00002). There was no significant difference in burnout between the HLS compared to others (P = .37). This group of self-reported physically active women physicians was found to have a lower prevalence of burnout when compared to other women physicians. Exercise and nutrition may be protective against burnout in women physicians but deserve further investigation.

Healthcare resource utilization and costs among patients with post-stroke spasticity before and after spasticity management including onabotulinumtoxina

BACKGROUND

Real-world data regarding the impact of onabotulinumtoxinA on healthcare resource utilization and costs for post-stroke spasticity are scarce.

OBJECTIVE

To compare differences in 12-month healthcare resource utilization and costs before and after post-stroke spasticity management including onabotulinumtoxinA.

METHODS

This retrospective claims analysis of IBM MarketScan Commercial and Medicare Supplemental databases included adults with ≥ 1 onabotulinumtoxinA claim for post-stroke spasticity (1 January 2010 to 30 June 2018) and continuous enrolment for ≥ 12 months pre- and post-index (first onabotulinumtoxinA claim date). All-cause and spasticity-related healthcare resource utilization and costs were compared 12 months pre- and post-index (McNemar's χ2 test or paired t-test). A subgroup analysis assessed effect of stroke-to-index interval on costs.

RESULTS

Among 735 patients, mean (standard deviation) stroke-date-to-index-date interval was 284.5 (198.8) days. Decreases were observed post-index for mean all-cause outpatient (62.9 vs 60.5; p ≤ 0.05) and emergency department visits (1.1 vs 0.8; p ≤ 0.0001), and hospital admissions (1.5 vs 0.4; p ≤ 0.0001). Increase in prescription fills (43.0 vs 53.7) was seen post-index. Post-index decreases in all-cause (-66%) and spasticity-related (-51%) costs were driven by reduced inpatient care costs. Findings were consistent regardless of stroke-date-to-index-date interval.

CONCLUSION

Significant reductions in healthcare resource utilization and costs were observed after 1 year of post-stroke spasticity management including onabotulinumtoxinA. Long-term studies are needed to establish causality.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Immunologic and Autoimmune-Related Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Clinical Symptoms and Mechanisms of Disease

The COVID-19 pandemic has resulted in a significant number of people developing long-term health effects of postacute sequelae SARS-CoV-2 infection (PASC). Both acute COVID-19 and PASC are now recognized as multiorgan diseases with multiple symptoms and disease causes. The development of immune dysregulation during acute COVID-19 and PASC is of high epidemiologic concern. Both conditions may also be influenced by comorbid conditions such as pulmonary dysfunction, cardiovascular disease, neuropsychiatric conditions, prior autoimmune conditions and cancer. This review discusses the clinical symptoms, pathophysiology, and risk factors that affect both acute COVID-19 and PASC.

Assessing the risk and costs of COVID-19 in immunocompromised populations in a large United States commercial insurance health plan: the EPOCH-US Study

OBJECTIVE

To estimate the prevalence of patients with an immunocompromising condition at risk for COVID-19, estimate COVID-19 prevalence rate (PR) and incidence rate (IR) by immunocompromising condition, and describe COVID-19-related healthcare resource utilization (HCRU) and costs.

METHODS

Using the Healthcare Integrated Research Database (HIRD), patients with ≥1 claim for an immunocompromising condition of interest or ≥2 claims for an immunosuppressive (IS) treatment and COVID-19 diagnosis during the infection period (1 April 2020-31 March 2022) and had ≥12 months baseline data were included. Cohorts (other than the composite cohort) were not mutually exclusive and were defined by each immunocompromising condition. Analyses were descriptive in nature.

RESULTS

Of the 16,873,161 patients in the source population, 2.7% (n = 458,049) were immunocompromised (IC). The COVID-19 IR for the composite IC cohort during the study period was 101.3 per 1000 person-years and the PR was 13.5%. The highest IR (195.0 per 1000 person-years) and PR (20.1%) were seen in the end-stage renal disease (ESRD) cohort; the lowest IR (68.3 per 1000 person-years) and PR (9.4%) were seen in the hematologic or solid tumor malignancy cohort. Mean costs for hospitalizations associated with the first COVID-19 diagnosis were estimated at nearly $1 billion (2021 United States dollars [USD]) for 14,516 IC patients, with a mean cost of $64,029 per patient.

CONCLUSIONS

Immunocompromised populations appear to be at substantial risk of severe COVID-19 outcomes, leading to increased costs and HCRU. Effective prophylactic options are still needed for these high-risk populations as the COVID-19 landscape evolves.

Neurologic and Neuromuscular Sequelae of COVID-19

It is known that there can be neurologic complications related to acute infection with SARS-CoV-2, the virus that causes COVID-19. Currently, there is a growing body of evidence that postacute sequelae of SARS-CoV-2 infection can manifest as neurologic sequelae as a result of direct neuroinvasion, autoimmunity, and possibly lead to chronic neurodegenerative processes. Certain complications can be associated with worse prognosis, lower functional outcome, and higher mortality. This article provides an overview of the known pathophysiology, symptoms presentation, complications and treatment approaches of the post-acute neurologic and neuromuscular sequelae of SARS-CoV-2 infection.

Autonomic Dysfunction Related to Postacute SARS-CoV-2 Syndrome

Persistence of symptoms beyond the initial acute phase of coronavirus disease-2019 (COVID-19) is termed postacute SARS-CoV-2 (PASC) and includes neurologic, autonomic, pulmonary, cardiac, psychiatric, gastrointestinal, and functional impairment. PASC autonomic dysfunction can present with dizziness, tachycardia, sweating, headache, syncope, labile blood pressure, exercise intolerance, and "brain fog." A multidisciplinary team can help manage this complex syndrome with nonpharmacologic and pharmacologic interventions.

Acute and post-acute sequelae of SARS-CoV-2 infection: a review of risk factors and social determinants

SARS-CoV-2 infection leading to Coronavirus Disease 2019 (COVID-19) has caused more than 762 million infections worldwide, with 10-30% of patients suffering from post-acute sequelae of SARS-CoV-2 infections (PASC). Initially thought to primarily affect the respiratory system, it is now known that SARS-CoV-2 infection and PASC can cause dysfunction in multiple organs, both during the acute and chronic stages of infection. There are also multiple risk factors that may predispose patients to worse outcomes from acute SARS-CoV-2 infection and contribute to PASC, including genetics, sex differences, age, reactivation of chronic viruses such as Epstein Barr Virus (EBV), gut microbiome dysbiosis, and behavioral and lifestyle factors, including patients' diet, alcohol use, smoking, exercise, and sleep patterns. In addition, there are important social determinants of health, such as race and ethnicity, barriers to health equity, differential cultural perspectives and biases that influence patients' access to health services and disease outcomes from acute COVID-19 and PASC. Here, we review risk factors in acute SARS-CoV-2 infection and PASC and highlight social determinants of health and their impact on patients affected with acute and chronic sequelae of COVID-19.

Five Strategies Leaders in Academic Medicine Can Implement Now to Enhance Gender Equity

Abundant disparities for women in medicine contribute to many women physicians considering leaving medicine. There is a strong financial and ethical case for leaders in academic medicine to focus on strategies to improve retention. This article focuses on five immediate actions that leaders can take to enhance gender equity and improve career satisfaction for all members of the workplace.

Occupational Characteristics Associated With Professional Fulfillment and Burnout Among US Physiatrists

INTRODUCTION

Multiple national studies suggest that among physicians, physiatrists are at increased risk for occupational burnout.

OBJECTIVE

The aim of the study is to identify characteristics of the work environment associated with professional fulfillment and burnout among US physiatrists.

DESIGN

Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists.

SETTING

Online interviews, focus groups, and survey were conducted.

PARTICIPANTS

The participants are physiatrists in the American Academy of Physical Medicine and Rehabilitation Membership Masterfile.

MAIN OUTCOME MEASURES

Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.

RESULTS

Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items, Cronbach α = 0.86); integration of physiatry into patient care (3 items, Cronbach α = 0.71); personal-organizational values alignment (3 items, Cronbach α = 0.90); meaningfulness of physiatrist clinical work (6 items, Cronbach α = 0.90); teamwork and collaboration (3 items, Cronbach α = 0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age, 52 yrs; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio = 1.96; 95% confidence interval = 1.45-2.69), integration of physiatry into patient care (odds ratio = 1.77; 95% confidence interval = 1.32-2.38), personal-organizational values alignment (odds ratio = 1.92; 95% confidence interval = 1.48-2.52), meaningfulness of physiatrist clinical work (odds ratio = 2.79; 95% confidence interval = 1.71-4.71), and teamwork and collaboration score (odds ratio = 2.11; 95% confidence interval = 1.48-3.03) was independently associated with higher likelihood of professional fulfillment.

CONCLUSIONS

Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in US physiatrists. Variation in these domains by practice setting and subspecialty suggests that tailored approaches are needed to promote professional fulfillment and reduce burnout among US physiatrists.

Distal and Proximal Predictors of Rehospitalization Over 10 Years Among Survivors of TBI: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study

OBJECTIVE

To describe the rates and causes of rehospitalization over a 10-year period following a moderate-severe traumatic brain injury (TBI) utilizing the Healthcare Cost and Utilization Project (HCUP) diagnostic coding scheme.

SETTING

TBI Model Systems centers.

PARTICIPANTS

Individuals 16 years and older with a primary diagnosis of TBI.

DESIGN

Prospective cohort study.

MAIN MEASURES

Rehospitalization (and reason for rehospitalization) as reported by participants or their proxies during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury.

RESULTS

The greatest number of rehospitalizations occurred in the first year postinjury (23.4% of the sample), and the rates of rehospitalization remained stable (21.1%-20.9%) at 2 and 5 years postinjury and then decreased slightly (18.6%) at 10 years postinjury. Reasons for rehospitalization varied over time, but seizure was the most common reason at 1, 2, and 5 years postinjury. Other common reasons were related to need for procedures (eg, craniotomy or craniectomy) or medical comorbid conditions (eg, diseases of the heart, bacterial infections, or fractures). Multivariable logistic regression models showed that Functional Independence Measure (FIM) Motor score at time of discharge from inpatient rehabilitation was consistently associated with rehospitalization at all time points. Other factors associated with future rehospitalization over time included a history of rehospitalization, presence of seizures, need for craniotomy/craniectomy during acute hospitalization, as well as older age and greater physical and mental health comorbidities.

CONCLUSION

Using diagnostic codes to characterize reasons for rehospitalization may facilitate identification of baseline (eg, FIM Motor score or craniotomy/craniectomy) and proximal (eg, seizures or prior rehospitalization) factors that are associated with rehospitalization. Information about reasons for rehospitalization can aid healthcare system planning. By identifying those recovering from TBI at a higher risk for rehospitalization, providing closer monitoring may help decrease the healthcare burden by preventing rehospitalization.

Training Characteristics, Academic Accomplishments, and Motivation of Current Program Directors in Physical Medicine and Rehabilitation

ABSTRACT

This study aimed to report the training characteristics, academic accomplishments, and motivation of current US academic physical medicine and rehabilitation program directors.A 22-question survey was developed and disseminated via email in May 2020 to 91 current residency program directors who are members of the Association of Academic Physiatrists Residency Fellowship Program Director Committee. Follow-up emails were sent 2 and 4 wks after initial distribution, and the survey was closed after 6 wks in June 2020. Data collected were deidentified. Descriptive analysis was performed.Response rate was 49.5% (45/91); 64.4% of program directors were men, and 35.6% were women. Of the respondents, 75.4% were White/Caucasian, 6.7% were Hispanic/Latinx, 15.6% were Asian, and 2.2% were Black/African American. Moreover, 56% (9/16) of female program directors vs. 0% (0/29) of male program directors reported experiencing sex discrimination in the workplace.Four percent of program directors were full professors in physical medicine and rehabilitation when first appointed, 17% were associate professors, and 72% were assistant professors. Thirty-four percent of program directors had at least six peer-reviewed publications when first appointed.This survey provides insight to the training characteristics, accomplishments, and motivation of current program directors for physiatrists aspiring to enter these ranks and highlights the underrepresentation of women/minorities among leadership positions in physical medicine and rehabilitation.

Challenges and Opportunities in Academic Physiatry: An Environmental Scan

ABSTRACT

Environmental scans determine trends in an organization's or field's internal and external environment. The results can help shape goals, inform strategic decision making, and direct future actions. The Association of Academic Physiatrists convened a strategic planning group in 2020, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice. This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the Association of Academic Physiatrists and the entire field of academic physiatry (also known as physical medicine and rehabilitation, physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized within the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment. The challenges and opportunities presented here can provide a roadmap for the field to thrive within the complex and evolving healthcare systems in the United States and globally.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Evaluating Diversity and Inclusion Content on Graduate Medical Education Websites

Websites are important tools for programs to provide future residency applicants with freely accessible information regarding their program, including diversity, equity, and inclusion (DEI) initiatives.

OBJECTIVE

To describe the variability of DEI content in residency programs and compare DEI website content by specialty.

METHODS

Using the 2021 Accreditation Council for Graduate Medical Education (ACGME) list of residency programs, residency training websites were identified and evaluated. Information was extracted from program websites as indicators of DEI content. Chi-square analysis and one-way ANOVA were chosen to assess for statistical differences.

RESULTS

In total, 4644 program websites representing 26 specialties were assessed. Among all the programs, the average DEI completeness of a program website was 6.1±14.6% (range 0-100%). While 6.2% of all programs had a diversity webpage, only 13.3% included a commitment to DEI, and few programs (2.7%) provided information about underrepresented in medicine (URiM) faculty.

CONCLUSIONS

Graduate medical education programs can enhance information for current and prospective applicants about DEI initiatives on their websites. Including DEI initiatives on residency websites may improve diversity recruitment efforts.

Lasting Solutions for Advancement of Women of Color

Despite efforts to improve parity in the biomedical workforce, gender bias persists related to equitable pay, promotion, speaking opportunities, journal editorial positions, research funding, and leadership positions. This bias becomes more prominent for women of color and women with other intersectional identities who come from underrepresented groups. It is critical to understand the barriers that women face and why the pathway is especially challenging for women of color. In this commentary, the authors cite research related to the effects of institutional gender bias in academic medicine, including research on bias against women of color. As academic leaders who come from underrepresented groups, the authors are aware that traditional approaches to reducing this bias have not worked well, and they instead highlight promising strategies aimed at filling the pathway to leadership with women of color who are qualified and ready to take the helm. They address solutions to ensure the academic pathway is supportive. They also provide several recommendations, including: offering more opportunities for mentorship and sponsorship, improving access to formal leadership programming, modeling successful upstander initiatives, recognizing the growing role of minority-based medical societies, implementing early-career education, increasing journal editorial board representation, and expanding promotion criteria. Appropriate training, education, and partnership with internal and external stakeholders are necessary to advance leadership equity for women of color in academic medicine.

Organizations in science and medicine must hold each other accountable for discriminatory practices

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators.

A Rapid Response for Burnout Among Inpatient Physiatrists: A Survey of Leaders of Inpatient Rehabilitation Facilities

INTRODUCTION

Symptoms of burnout are highly prevalent among physiatrists, and prior studies have helped identify key contributors to this epidemic of burnout. Little is known about the physician stressors unique to those providing care in inpatient rehabilitation facilities (IRFs) and what strategies such facilities have utilized to help mitigate burnout among inpatient physiatrists.

OBJECTIVE

To identify what IRF leaders perceive as stress points contributing to burnout among inpatient rehabilitation physicians and what, if any, interventions their programs have implemented to help mitigate physician burnout.

DESIGN

10 item cross-sectional survey study of IRF physician and non-physician leaders in the United States.

PARTICIPANTS

104 physicians serving in the roles of IRF Medical Director, Director of Rehabilitation, and/or Executive Leadership and 19 non-physician IRF leaders.

RESULTS

Regulatory demands, late admissions, understaffing, and on-call responsibilities were the major stress points most identified as contributing to physician burnout among both the physician and non-physician respondents. The utilization of advanced practice providers and hospitalists were the most common system changes reportedly used to help mitigate physician burnout. Although 57.8% of physician leaders felt late admissions were a major stress point for physicians, only 18.2% of those responding reported having implemented admission cut-off times.

CONCLUSIONS

There are stressors unique to the practice of inpatient rehabilitation that are likely contributing to physiatrist burnout, including late admissions and on-call responsibilities. Many IRFs have begun to implement system changes to help mitigate burnout among inpatient physiatrists. The utilization of non-physiatrist providers is a commonly reported strategy. Future studies are needed to determine the effectiveness of such a strategy on reducing symptoms of burnout among IRF physicians as well as its impact on IRF patient outcomes. This article is protected by copyright. All rights reserved.

Factors Associated With Burnout in Physical Medicine and Rehabilitation Residents in the United States

OBJECTIVES

The aims of the study were to determine the prevalence of burnout in physical medicine and rehabilitation residents in the United States and to identify the personal- and program-specific characteristics most strongly associated with residents reporting burnout.

DESIGN

This was a cross-sectional survey of US physical medicine and rehabilitation residents. Emotional exhaustion, depersonalization, and burnout were assessed using two validated items from the Maslach Burnout Inventory. Associations of burnout with demographics and personal factors, residency program characteristics, perceived program support, and work/life balance were evaluated.

RESULTS

The survey was completed by 296 residents (22.8%), with 35.8% of residents meeting the criteria for burnout. Residents' perception of not having adequate time for personal/family life was the factor most strongly associated with burnout (χ2 = 93.769, P < 0.001). Residents who reported inappropriate clerical burden and working more than 50 hrs/wk on inpatient rotations were most likely to report that they did not have adequate time for personal/family life. Faculty support (χ2 = 41.599, P < 0.001) and performing activities that led residents to choose physical medicine and rehabilitation as a specialty (χ2 = 93.082, P < 0.001) were protective against burnout.

CONCLUSIONS

Residents reporting having inadequate time for their personal/family life was most strongly associated with physical medicine and rehabilitation resident burnout, although many personal and program characteristics were associated with burnout.

Awareness of Physical Medicine and Rehabilitation as a Specialty Among US Medical Students

ABSTRACT

The objectives were to assess US medical students' awareness about physical medicine and rehabilitation, their career goals that may align with physical medicine and rehabilitation, and their exposure to physical medicine and rehabilitation and to compare the demographics of those applying to, interested, or not interested in physical medicine and rehabilitation residency. This was a descriptive cross-sectional study. An online survey was distributed to 76 medical schools, and 2067 students responded. First-generation and Hispanic/Latino students are less likely to know about physical medicine and rehabilitation. Medical students who heard about physical medicine and rehabilitation before or during college or who are first-generation students to attend medical school are more likely to be interested in physical medicine and rehabilitation. Medical students identified as female, Black or African American, and more advanced in medical training have lesser interest. Rotating in physical medicine and rehabilitation at their home institution and shadowing a physical medicine and rehabilitation physician also increase the likelihood of respondents to apply to physical medicine and rehabilitation residency. This study highlights that female students and underrepresented minorities in medicine are less likely to know about physical medicine and rehabilitation or be interested in physical medicine and rehabilitation. First-generation medical students know less about the field but the ones who do have increased interest in physical medicine and rehabilitation. These findings support the need for pipeline programs to improve exposure, recruitment, development, promotion, and retention of first-generation minorities and women into physical medicine and rehabilitation.

Training Characteristics, Academic Accomplishments, and Motivation of Current Chairs in Physical Medicine and Rehabilitation

OBJECTIVE

The aim of the study was to report the training characteristics, academic accomplishments, and motivation of current United States academic physical medicine and rehabilitation chairs.

DESIGN

The authors developed a 23-question survey that was disseminated via e-mail to 86 current chairs who were members of the Chairs Council from the Association of Academic Physiatrists in May 2020. Follow-up e-mails were sent 2 and 4 wks after the initial distribution, and the survey closed after 6 wks in June 2020. The data collected were deidentified. Descriptive analysis was performed.

RESULTS

Forty-nine chair responses were received, which had a response rate of 60%. A total of 69.4% of the chairs (32 of 49) were men and 30.6% (17 of 49) were women. A total of 75.5% (37 of 49) were White/Caucasian, 12.2% (6 of 49) Hispanic/Latinx, 10.2% (5 of 49) Asian, and 2% (1 of 49) were Black/African American. A total of 8.2% of the chairs (4 of 49) reported having a disability. Sixty-seven percent of the female chairs (10 of 15) reported experiencing gender discrimination in the workplace versus 3% of male chairs (1 of 34). Twenty-nine percent of the chairs were full professors in physical medicine and rehabilitation when first appointed, 57.1% associate professors, and 6% assistant professors. A total of 73.5% of the chairs had served as a reviewer for a peer-reviewed publication. Fifty-two percent of the chairs had a leadership role in a national physical medicine and rehabilitation organization. Fifty-eight percent of the chairs had at least 16 peer-reviewed publications when first appointed.

CONCLUSIONS

This survey provides insight to the training characteristics, accomplishments, and motivation of current chairs for physiatrists aspiring to enter these ranks. It also highlights the underrepresentation of women and minorities among leadership positions in physical medicine and rehabilitation.

Author Diversity on Clinical Practice Guideline Committees

ABSTRACT

Reports have demonstrated that women overall and women physicians, in particular, are underrepresented as authors of clinical practice guidelines. This analysis used publicly available information to explore the diversity of rehabilitation-related clinical practice guideline authors by gender, race, and ethnicity. Primary analysis identified authors' gender, race, ethnicity, and visible minority status. Two sets were analyzed: (1) clinical practice guidelines by Department of Veterans Affairs (VA) categorized as "Rehabilitation" or "Pain" (n = 7; VA clinical practice guidelines) and (2) a set (n = 10) published in the United States (US) from 2019 to 2021 that were selected because of low numbers of inclusion at less than 20% women authors. Key findings include that among physician authors, both the VA and US clinical practice guidelines underrepresented women (15 [24.2%] and 27 [16.7%], respectively) and those coded as a racial or ethnic minority were particularly underrepresented. Notably, women authors overall were equally represented (92 [50.0%]) in the VA clinical practice guidelines. The US clinical practice guidelines had women authors who were underrepresented (36 [19.0%]). Secondary analysis of the entire set of VA clinical practice guidelines (n = 21) found gaps in diversity-related content. Clinical practice guidelines have far-reaching health and economic impacts, and addressing disparities in the diversity of author teams and/or gaps in diversity-related content is of paramount importance.

Prevalence and Treatment Characteristics of Spastic Hypertonia on First-Time Admission to Acute Inpatient Rehabilitation

OBJECTIVE

The aim of the study was to report the prevalence of spasticity and treatment patterns during first-time admission to inpatient rehabilitation after acute stroke, traumatic brain injury, and spinal cord injury.

DESIGN

This is a retrospective cohort study.

METHODS

A review of 285 adult patients consecutively admitted to inpatient rehabilitation was conducted. Patients with a history of spasticity and inpatient rehabilitation course and those younger than 18 yrs were excluded. Main outcome measures are as follows: admitting diagnosis, length of stay, time from injury to admission, acute transfer rate, prevalence and severity of spasticity using Modified Ashworth Scale at admission and discharge, Functional Independence Measure scores at admission and discharge, Functional Independence Measure efficiency, and treatments for spasticity.

RESULTS

Stroke patients had the highest prevalence of spasticity: 68% on admission and 50% at discharge. In traumatic brain injury, spasticity prevalence was 55% on admission and 30% at discharge. In spinal cord injury, spasticity prevalence was 48% on admission and 46% at discharge. Patients with spinal cord injury received the most medications to control spasticity, whereas those with traumatic brain injury and stroke received the most procedural interventions.

CONCLUSIONS

Spasticity is a common sequela of upper motor neuron injury for patients admitted to inpatient rehabilitation. Early recognition and management are essential to prevent contractures, minimize pain, and maximize functional recovery.

Development and Implementation of an International Virtual Didactic Series for Physical Medicine and Rehabilitation Graduate Medical Education During COVID-19

ABSTRACT

Coronavirus disease of 2019 presented significant challenges to residency and fellowship programs. Didactic lectures were particularly affected as redeployment of faculty and trainees, limitations on in-person gathering, and other barriers limited opportunities for educational engagement. We sought to develop an online didactic series to address this gap in graduate medical education.Lecturers were recruited via convenience sample and from previous Association of Academic Physiatrists presenters from across the United States and Canada; these presented via Zoom during April and May 2020. Lecturers and content reflected the diverse nature of the specialty. Learning objectives were adapted from the list of board examination topics provided by the American Board of Physical Medicine and Rehabilitation.Fifty-nine lectures were presented. Maximum concurrent live viewership totaled 4272 and recorded lecture viewership accounted for an additional 6849 views, for a total of at least 11,208 views between the date of the first lecture (April 9, 2020) and May 1, 2021. Live viewers of one of the lectures reported participating from several states and 16 countries.The Association of Academic Physiatrists-led virtual didactics augmented graduate medical education during the coronavirus disease of 2019 pandemic, and data confirm that the lectures have continued to enjoy a high level of viewership after the cessation of live lectures.

Analysis of Physician Compensation Studies by Gender, Race, and Ethnicity

Purpose:

This report investigated physician compensation studies by gender, race, and ethnicity.

Methods:

Published U.S. physician compensation studies were assessed.

Results:

Of the 47 data sets within 46 studies, 36 analyzed compensation by gender and 32 (88.9%) found disparities. Thirteen and eight analyzed for race and ethnicity, with disparities found in four (30.8%) and none, respectively. The sample sizes of the four data sets with differences by race were among the largest in the subset.

Conclusion:

Most studies demonstrate pay disparities for women, but not for people who identify with underrepresented race/ethnic groups; however, small sample sizes may affect results.