Physical Medicine & Rehabilitation

Making patients fit for surgery: introducing a four pillar multimodal prehabilitation program in colorectal cancer Background Considering the relation between preoperative functional capacity and postoperative complications, enhancing a patients functional capacity prior to surgery with a prehabilitation program may facilitate faster recovery and improve quality of life. However, time before surgery is short, mandating a multimodal and high-intensity training approach. This study investigated feasibility and safety of a prehabilitation program for colorectal cancer. Methods Multimodal prehabilitation was offered to patients eligible for participation. They were assigned to an intervention or control group by block randomisation. The prehabilitation program consisted of four interventions: in-hospital high-intensity endurance and strength training, high-protein nutrition, smoking cessation and psychological support. Program attendance, patient satisfaction, adverse events and functional capacity were determined. Results Fifty patients participated in this study (prehabiilitaiton 20, control 30). Program evaluation revealed a high (90%) attendance rate and high level of patient satisfaction. No adverse events occurred. Endurance and/or strength were improved. 86% of patients with prehabilitation recovered to their baseline functional capacity 4 weeks post-operatively, 40% in the control group (p<0.01). Conclusions Multimodal prehabilitation including high-intensity training for colorectal cancer patients is feasible, safe and effective. A randomized controlled trial (NTR5947) was initiated to determine whether prehabilitation may lower morbidity and mortality rates in colorectal surgery. Corresponding author + request for reprints: S.J. van Rooijen MD PhD, Máxima Medical Center, Department of Surgery, P.O. Box 7777, Veldhoven, the Netherlands, stefanvanrooijen@msn.com / prehab.resurge@mmc.nl This pilot was financially supported (MMC2620) by the National Foundation against Cancer (Nationaal Fonds tegen Kanker). FrieslandCampina provided the Refit®TMP 90 Shakes. The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating Physician Knowledge of Commonly Prescribed Inpatient Rehabilitation Unit Discharge Medication's Costs: An Observational Study The objective of this study was to assess physiatrists' knowledge of the cost of medications commonly prescribed at discharge from inpatient rehabilitation units across the spectrum of practice experience from residents to attending physicians. Investigators contacted 92 pharmacies across 4 major regions of the United States (U.S.) and averaged the cash price of each medication. An electronic survey was created highlighting 17 medications in which physicians estimated the cost of a medication per pill and per month for a 30-day supply. Surveys were sent to all ACGME-accredited programs across the U.S.; 43 participants responded to the survey. Most respondents overestimated the cost of the medications chosen for the survey. There was no significant difference between medication cost knowledge and practice experience (p = 0.497) or post-graduate year of training (p = 0.593). This raises awareness that physiatrists may not know the cost of medications they commonly prescribe at discharge, which may have implications on patient medication compliance, quality of care and patient satisfaction. Correspondence: Allison Capizzi, MD, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132. Office Phone: 801-585-2589. Mobile: 805-403-1763. Fax: 801-587-5757 Author Disclosures: No authors involved in this study have any competing interests, financial benefits, funding, grants or equipment to disclose. This material has not been presented at an AAPM&R Annual Assembly. Funding: No funding was acquired in completion of this project Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense Between 2015 and 2017, the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) developed a Clinical Practice Guideline (CPG) for Rehabilitation of Lower Limb Amputation to address key clinical questions. A multidisciplinary workgroup of VA and DoD amputation care subject-matter-experts was formed and an extensive literature search was performed which identified 3,685 citations published from January 2007 through July 2016. Articles were excluded based upon established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded utilizing the National Academies of Science GRADE criteria. Recommendations were formulated following extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semi-rigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this CPG utilized the best available evidence from the past 10 years to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation. Corresponding Author: Joseph B. Webster, M.D.; 1201 Broad Rock Boulevard, Richmond, VA 23112, 804-675-7036, joseph.webster@va.gov Disclosure: This work represents the opinions of the authors and not necessarily those of any government agency, academic institution or healthcare agency. This work was fully funded by the Departments of Defense and Veterans Affairs. No funding was received from any commercial entity. Material was presented at the 2018 AAPM&R Annual Assembly on October 26, 2018. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Authors' Response to the Letter to the Editor on "An Obvious and Potentially Neglected Cause of Buttock Pain: Gluteus Maximus Dysfunction" No abstract available

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-cause Mortality, Cardiovascular Performance and Functional Performance Objective Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a Stroke Recovery Program(SRP) integrating modified cardiac rehabilitation(CR) for stroke survivors. Design This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified CR, 473 chose standard of care rehabilitation(non-participants) and a group(n=174) were excluded. The feasibility study assessed: safety/mortality/pre-post cardiovascular-performance/pre-post function/patient/staff-perspective. In addition to the feasibility study, a non-randomized subgroup analysis compared SRP-participants(n=76) to matched pairs of non-participants(n=66, with 10 non-participants used more than once) for mortality/pre-post function. Results The feasibility study showed the SRP to have:1)excellent safety, 2)markedly low 1-year post-stroke mortality from hospital admission(1.47%) compared to national rate of 31%,1 3)improved cardiovascular-performance over 36 sessions(103% increase in Metabolic Equivalent of Tasks times minutes), 4)improved function in Activity Measure of Post-Acute Care(AM-PAC)TM domains(P<0.001), 5)positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to:1)positively impact mortality; non-participants had a 9.09 times higher hazard of mortality(P=0.039), and 2)improve function in AM-PACTM domains(P<0.001). Conclusion Stroke survivors receiving a SRP integrating modified CR may potentially benefit from reductions in all-cause mortality, and improvements in cardiovascular-performance and function. Corresponding Author: Sara J. Cuccurullo, M.D., JFK Johnson Rehabilitation Institute, 65 James Street, Edison, NJ 08818, Phone 732-321-7000 X62780; Fax 732-744-5846; Email: Sara.Cuccurullo@hackensackmeridian.org Disclosures: This study was supported in part by a Project Grant from the NorthEast Cerebrovascular Consortium (NECC) awarded to Dr. Cuccurullo and Dr. Fleming. NuStep® cross-training bicycles were provided in-kind. The statistical analysis performed for this study has not been presented in another format. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Comments on "An Obvious and Potentially Neglected Cause of Buttock Pain: Gluteus Maximus Dysfunction" No abstract available

Physical Medicine and Rehabilitation: Trends in Graduate Medical Education and Sub-Specialization Amidst Changing Demographics With an aging and growing U.S. population, American healthcare faces an impending physician shortage. This is important for the field of Physical Medicine and Rehabilitation (PM&R), as physiatrists' skills in managing chronic conditions and functional outcomes are especially relevant to an older population. The present study was designed to better understand the future PM&R workforce, by recording and analyzing the quantities of ACGME-accredited PM&R graduate medical education programs and positions between 2001-02 and 2017-18. Results indicated that PM&R graduate medical education has grown since 2001-02, especially in subspecialties such as Pediatric Rehabilitation and Sports Medicine. However, the growth in PM&R residency positions has been three-fold lower than that of total GME. In addition, sub-specialization has become increasingly prevalent, and residency positions have declined relative to the population of older adults. The future identity of PM&R will continue to develop as professional and demographic trends shape this important medical specialty. Correspondence to: Aldis H. Petriceks, Stanford University School of Medicine, 269 Campus Dr., CCSR 0135A, Stanford, CA 94305. Email: aldisp@stanford.edu. Phone: 650-796-0340. Fax: 650-498-5394. Author Disclosures: The authors declare no competing interests; no funding, grants, or equipment received for this project; no financial benefits incurred from this project; and no previous presentation of this research in any form. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

TIME EFFECTOF INTRA-ARTICULAR INJECTION WITH TRIAMCINOLONE HEXACETONIDE AND ITS CORRELATIONS: A CASE – CONTROL PROSPECTIVE 12 MONTH STUDY Objective To assess the time effect of intra-articular (IA) injection with triamcinolone hexacetonide (TH) in rheumatic patients. Design A prospective case-control study with patients submitted to one IA injection with TH. Patients were followed monthly (12 months) for pain and swelling. Results 262 joints were assessed in 158 patients with mean age of 60 (±13.7) years. Remission were observed at 3, 6 and 12 months in 142 (54.19%), 111 (42.36%) and 105 (40.07%) joints, respectively.The mean time effect were 8 (±4.0) months; 8.4 (±3.9) for rheumatoid arthritis (RA) patients and 6.9 (±4.0) for osteoarthritis patients (p=0.012); and 10.4 (±2.7) months for small; 7.7 (±4.1) for medium and 6.8(±4.0) for large joints. The joints were divided into two groups: long-term group (LTG- time effect of IA injection longer than six months) and short-term group (STG).Variables associated (p <0.05) with LTG: RA, small and medium-sized joints, female gender, lower pain and swelling VAS scores and use of leflunomide. Variables associated with STG: receiving only one IA injection, hypertension, diabetes mellitus, biological therapy. Conclusion The time effect of IA injection with TH was 8.0 (±4.0) months. The associated predictors were RA, small and medium-sized joints, lower pain/swelling VAS scores, and use of leflunomide. Financial information: none Corresponding Author: Rita Nely Vilar Furtado, Universidade Federal de São Paulo, Rua Botucatu, 740 – 04023-900, São Paulo/SP – Brazil, Telephone contact/ Fax: 55-11-55764239, Email: rvfurtado@hotmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Time course and recovery of the movements of hyoid bone and thyroid cartilage during swallowing in a patient with sarcopenic dysphagia: a case report Sarcopenia is known to adversely affect swallowing function. In this report, we describe the treatment progress of an older patient with dysphagia caused by sarcopenia and the analysis results from videofluorographic examination images. An 89-year-old man who had been hospitalized for lumbar fracture experienced lower back pain, and thus had his oral intake reduced. After transfer to a rehabilitation hospital, he developed aspiration pneumonia and then sarcopenia with low nutrition and low activity. At the beginning of intervention, he aspirated food paste, but he recovered sufficiently to be able to ingest a normal meal via a nutritional approach combined with rehabilitation at the time of discharge. During this process, the maximum amounts of displacements and maximum moving velocities of his hyoid bone and thyroid cartilage during swallowing of moderately thick water were improved. Adequate nutrition intake and training for hyoid muscles are considered effective for the patient with sarcopenic dysphagia. It was concluded that measuring the maximum displacements and moving velocities of the hyoid bone and thyroid cartilage during swallowing in patients with sarcopenic dysphagia was an effective way to monitor their improvement. Correspondence : Enri Nakayama, Department of Dysphagia Rehabilitation/ Nihon University School of Dentistry/ 1-8-13, Kanda Surugadai, Chiyoda/ Tokyo/ 101-8310/ Japan. Tel: +81-3-3219-8198, FAX: +81-3-3219-8203, E-mail address: nakayama.enri@nihon-u.ac.jp Author Disclosures: Competing Interests: none (All authors) Funding or grants or equipment provided for the project from any source: This report was supported by Sato Fund and Dental Research Center, Nihon University School of Dentistry. (Enri Nakayama) Financial benefits to the authors: none (All authors) Details of any previous presentation of the research, manuscript, or abstract in any form: none (All authors) Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Luxatio erecta in a Frisbee player: Magnetic resonance imaging findings of a rare injury No abstract available