Dr. Kaplan’s Personal WebsiteApril 7
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Changes in post acute care rehabilitationApril 6
Below are listed the most common diagnostic and impairment groups in need of post acute care rehabilitation services.
Stroke
Stroke is the third leading cause of death and disability in the United States and the leading cause of serious long-term disability. Stroke can impact every facet of a person’s life, including cognition, speech, swallowing, behavior, ability to walk, mobility, daily activities, and bowel and bladder function, in addition to the psychological, fiscal, and family burden. It is common for these disabilities to occur in varying combinations and with varying severity. Comorbidities such as high blood pressure, heart disease and diabetes add to the complexity of care required by almost all stroke patients. Through an individualized program of care, the inpatient rehabilitation team works with the patient and caregivers to achieve optimal function and maximum quality of life following a stroke. The team approach, combined with early and intensive intervention, produces better outcomes related to recovery of function and also facilitate a coordinated transition to home.
Traumatic Brain Injury (TBI), and
Non-Traumatic Brain Injury (NTBI)
Persons with TBI are most often men in their teens, young adults, or over the age of 75 injured by firearms, falls, or motor vehicle collisions. Brain injury causes varying degrees of impairment in awareness, language, swallowing, memory, and ability to learn; loss of muscle strength; spasticity (painful, uncontrolled muscle spasms), loss of sensation, impairment in bladder, bowel and sexual function; increased risk for pressure sores, deep vein thrombosis (blood clots), and contractures (permanent joint deformities); and threats to personal identity, family role, vocation, and spiritual meaning. Given the breadth and depth of these impacts, patients with new-onset TBI require comprehensive and specialized TBI rehabilitation services that are only fully available in hospital-level rehabilitation programs. Skilled nursing facilities (SNFs) generally do not employ rehabilitation staff who possess TBI knowledge and treatment skills. Nor do most SNFs have daily access to the array of acute medical physicians and services these patients routinely require for safe and effective rehabilitation.
Typical causes of NTBI include infection, insufficient oxygenation, bleeding, and cancer. The loss of function and impact on life for persons with NTBI is just as severe as for persons with TBI. Thus the rehabilitation needs and appropriateness for inpatient rehabilitation care are the same for TBI and NTBI.
Traumatic Spinal Cord Injury (TSCI), and
Non-Traumatic Spinal Cord Injury (NTSCI)
Persons with TSCI are most often young adult men injured in a motor vehicle collision. In addition to nervous system injury pain, TSCI patients experience the same range of impairments as TBI and NTBI patients. Also in common with new-onset brain injuries, new TSCI patients require a broad range of specialized inpatient rehabilitation services provided by a multidisciplinary health team guided by daily physician coordination.
Persons with NTSCI tend to be older than those with TSCI. Nontraumatic causes include invasive cancer, narrowing of the spinal canal, and infection. While the onset of the disease is usually slower in these patients, the loss of function and impact on life is just as severe as persons with TSCI. Thus the rehabilitation needs and appropriateness for acute (hospital-level) rehabilitation care is the same as for TSCI.
Neurological Disorders
Patients in this group include those suffering from multiple sclerosis, Parkinson’s disease, polyneuropathy (widespread impairment of nerve sensation), cerebral palsy, and neuromuscular disorders. When patients in this impairment category have special needs, such as insensate skin, immobilization and positioning challenges, depression or pain, rehabilitation becomes a complicated process. Consequently, they require a comprehensive rehabilitation approach that coordinates an interdisciplinary team of therapists, nursing and physiatrists. Such a team is necessary because treatment plans need to be customized to each individual’s medical conditions and rehabilitation goals. Many patients suffer from spasticity, which requires treatments from physicians and therapists specially trained in managing this condition. When spasticity is properly managed, function can be restored to the limbs and daily independence maximized. Other patients have special cognitive and speech goals, which require the specially trained staff and equipment of an IRF. Finally, many of these patients require extensive life care management and discharge planning to facilitate their transition to home or another setting, where they will live more independently. Frequently, to facilitate a return to home, the following services are needed - extensive family teaching, home modification, and fitting and purchase of durable medical equipment, such as braces and wheelchairs.
Hip Fracture, and Replacement of Lower Extremity Joint
These two patient groups are treated with procedures to surgically implant artificial joints. As such, the subsequent rehab program is identical for both. Physicians prescribe the intensity of treatment based on the overall medical condition of the patient relative to functional loss, the patient’s need for medical supervision, and the ability of the patient to sustain daily, intensive therapy.
These patients typically have extensive multi-system co-morbidities that place them at risk for complications following surgery. Given the propensity toward and incidence of post-operative complications, the extent of medical oversight available in IRFs is clearly warranted. Complications after joint replacement that are addressed on a daily basis in an IRF include surgical wound management, surveillance for blood clot formation, management of coexisting medical problems temporarily destabilized by surgery, and pain management. For optimal recovery after major joint replacement, daily, specialized oversight and treatment are needed to avoid common complications and prevent readmissions to acute care facilities due to inadequate patient management.
The treatment method for hip and knee joint replacement is similar except the focus of range of motion is at the hip or the knee. The restoration of range of motion is even more critical for knee rather than hip replacement due to the greater risk of getting a blood clot which can be life threatening. The intensity of post-joint replacement therapy and the selection of the appropriate care setting are determined by the functional needs of the patient, combined with the patient’s ability to undergo daily, intensive therapy.
Other Orthopedic
Includes patients who have suffered an orthopedic injury that does not include a joint replacement, lower extremity fracture (hip, pelvis, femur shaft) or major multiple trauma where the patient’s function has been impaired and functional gain is expected through proper treatment. Common causes of other orthopedic cases include traumatic injury, cancer, and osteoporosis. The other orthopedic injury can be in the upper or lower extremity, including shoulder, arm, leg (anything but femur shaft), foot or ankle, which may or may not be coupled with one or more comorbidities affecting functional ability. The patient with another orthopedic diagnosis has been determined to need 24-hour nursing care and be able to tolerate at least three hours of therapy per day with an expectation during this period of regaining function. This type and severity of injury requires the management of treatment by a physician specializing in physical medicine and rehabilitation, commonly a physiatrist.
Lower Extremity Amputation, and
Other Amputation
The majority of amputation patients have significant and multiple comorbidities, the most serious of which are the complications related to diabetes. Patients who undergo amputations of the extremities require intensive rehabilitation to compensate for the loss of the amputated limb by using a prosthetic device. A typical rehabilitation program consists of wound healing, stump shaping, gait training and/or functional upper extremity activities as well as monitoring of cardiovascular status to ensure safe patient participation in typical rehabilitative efforts. A significant component of amputation treatment and therapy is the education of patient and caregivers on the care needed to manage the prosthesis and to prevent a second amputation.
Osteoarthritis
Rheumatoid and Other Arthritis (including Polyarthritis)
Patients treated for osteoarthritis and other forms of arthritis are commonly in their 70s. Many patients of this age have additional comorbidities and medical needs, which require daily medical management on a frequent basis, especially in light of the intense physical exercise and conditioning they undergo to rehabilitate the treated joint(s). The combination of post-acute care, medical management needs concerning the underlying arthritis debility, and related comorbidities are viewed by the field as medically appropriate for inpatient rehabilitation for patients suffering serious functional loss and with the capacity to withstand three hours or more of daily, intensive therapy.
Arthritis produces months and years of weakness and progressive debilitation caused by arthritic changes in multiple joints, increasing fatigue and immobility due to pain. The resulting sedentary lifestyle reduces cardiac and respiratory capacity and muscle strength. Therefore, intensive rehabilitation for arthritis patients recovering from one or more joint replacements consists of a two-pronged approach. The first approach is the strengthening and restoration of function to the replaced joint. The second and more intense rehab program is directed at strengthening and reconditioning the total patient after prolonged inactivity. Those patients with cardiac and respiratory comorbidities must recondition their bodies to regain the stamina and energy needed to increase activity allowed by a new joint, free from arthritis. For these reasons, an intensive, multidisciplinary approach is vital for this group of patients.
Cardiac
The following conditions are included within this category: post myocardial infarction, coronary artery bypass grafting, acute congestive heart failure and heart transplantation. Medical monitoring of these patients is critical for cardiac changes, fatigue, and internal fluid balances. Daily physician visits are required in conjunction with cardiac monitoring not only during exercise, but while performing routine activities including activities of daily living, transfer training, and ambulation. The rehabilitation plan of care and its progress are directed by the patient’s healing, as evidenced by daily monitoring. Adjustments to the rehab program may be needed on a daily basis based on a patient’s tolerance of these activities. In addition to the need for ongoing monitoring, an aggressive approach is often needed to limit the adverse physiological and psychological effects of cardiac illness, reduce the risk of death and enhance the patient’s vocational and functional status.
Pulmonary
In addition to close medical management, as described above, pulmonary patients require psychological intervention, stress control, and exercise reconditioning. Inpatient pulmonary rehabilitation programs have been shown to increase strength and endurance and lead to greater tolerance of dyspnea (shortness of breath) while allowing some patients to wean from continuous oxygen therapy. These types of conditions require the intensity in therapeutic approaches of a team oriented rehabilitation program in order to achieve positive outcomes.
Pain Syndromes
Chronic pain is generally caused by injury or diseases such as cancer, arthritis, sickle cell anemia, low back disorders, headaches, and nerve-related pain caused by disorders such as diabetes and fibromyalgia. People with chronic pain disorders generally have a relatively constant component of pain that is frequently superimposed by exacerbations, known as breakthrough pain. The impact of pain cannot be underestimated as it affects every aspect of life and results in significant decreased physical and mental functioning as well as social well-being. Due to the often unpredictable and variable nature of chronic pain and the need to provide a treatment plan directed at improving an individual’s ability to function that is not compromised by either drug side-effects and/or associated pain-related co-morbidities, a coordinated treatment approach is required by a team of specifically trained providers relative to pain control.
Major Multiple Trauma - No Brain or Spinal Cord Injury; and
Major Multiple Trauma - Brain or Spinal Cord Injury
Major multiple trauma (MMT) patients are people who have experienced serious injuries, which may include major multiple fractures or other major trauma. Many cases involve traumatic brain and/or spinal cord injury. In the case of these patients the extensive rehab care described for TBI and SCI is also commonly needed for MMT patients.
Guillain-Barre Syndrome
Guillain Barre Syndrome (GBS) is characterized by acute onset of weakness following a viral syndrome. Weakness and paresthesias (hyper sensations) typically start in the feet and ascend over days to weeks. Cases may involve complete paralysis, including respiratory muscles, leading to ventilator dependence. Swallowing and facial weakness are also common. Blood pressure, heart rate and heart rhythm abnormalities are present in most GBS patients. Often these patients are monitored in an ICU setting until their transfer to an inpatient rehabilitation setting.
The cardio-respiratory system must be serially monitored for signs of compromise and/or progression in weakness. These patients are also at higher risk for deep vein blood clots, pressure ulcers, and pneumonia due to immobility. Close nursing and physician oversight is important to reduce the risk of these complications. The rehabilitation for GBS patients includes positioning, range of motion exercises, splinting (both static and dynamic), conditioning, and pulmonary toilet.
Miscellaneous
As noted, the demand for some of the conditions that fall into no other group have grown due to technological gains and an aging population. This group should be carefully analyzed with such conditions removed from the miscellaneous category into other categories that are included within the parameters of a modernized 75% Rule. In particular, post-acute cancer and transplant rehabilitation continue to grow in prevalence and are providing effective restoration of function for affected patients.
Cancer
Surgical intervention, chemotherapy treatment, and radiation therapy services for the treatment of cancer have improved dramatically in the last two decades. As individual life expectancy has improved, the debilitating impact of these treatments on patient stamina and function has increased dramatically. Patients undergoing cancer treatment often have physical, emotional and social issues that affect their quality of life, regardless of the type of cancer. Inpatient cancer rehabilitation programs pick up where the clinical oncology team leaves off, focusing on improving physical function, managing pain, improving physical conditioning, endurance and exercise performance, and improving the patient’s overall quality of life.
The medical oversight needs of cancer patients requiring inpatient rehabilitation care are significant. The attending physiatrist works closely with the oncology team to ensure that medical issues are effectively managed in the inpatient rehabilitation environment. These patients require daily medical oversight to manage the multiple comorbidities and the many specialized medications they have been prescribed. Cancer rehabilitation is a complex process requiring an interdisciplinary collaboration among a broad array of providers and specialists. Regardless of an individual’s life expectancy, specialized cancer rehabilitation plays a vital role in improving the quality of life of individuals with cancer.
Transplants
Over the past 20 years, there has been a significant increase in the number of patients receiving organ transplants. The number of kidney, liver, heart and lung transplants has increased dramatically, saving thousands of lives. Given the shortage of organs in the United States, patients may wait for extended periods of time for a transplant which exacerbates the patients debilitation and weakness. Following surgical transplantation, many patients are challenged with significant debility requiring the expertise of an interdisciplinary rehabilitation team.
The medical oversight needs of transplant patients requiring inpatient rehabilitation care are significant. In the rehabilitation environment, medical and nursing staff and the other members of the interdisciplinary team have developed unique competencies related to the management and monitoring of medical status and anti-rejection monitoring and treatment. Given the medical fragility of these patients, daily oversight by a physician is critical as the patient works with the multi-faceted rehabilitation team to improve stamina and re-learn activities of daily living following the transplant. In addition to treatment of transplant-related needs, patients need significant assistance to improve physical conditioning, endurance, and exercise performance. Patients left with permanent impairments are especially dependent on the varied experts contributing to the inpatient rehabilitation team.
Burns
For children and adults with extensive burns, particularly those that cross joints, inpatient rehabilitation is an important phase in the healing process. Therapy must focus on wound healing and preventing complications such as infection and joint contractures. Proper positioning, splinting, and exercise are important in the care of these patients. Careful attention must be paid, however, to balancing the risk of disrupting burn healing due to stretching, and the risk of contracture. Proper pain management is necessary to maximize mobility and performance. Ambulation early in the rehabilitation course is encouraged to reduce the risks of deep vein thromboses, pressure ulcers, and pneumonia from immobility. Disfiguring scars must be discouraged with pressure garments. Hand deformities can severely limit the patient’s ability to perform activities of daily living so exercise, splint use, and proper management of exposed tendons are crucial to optimize hand function. Heterotopic ossification (abnormal bone and soft tissue regeneration) can result in progressive loss of motion and nerve damage - the risk of which increases with longer periods of immobility. The value of psychology and vocational counseling cannot be overstated in the rehabilitation of the burn patient.
April 6, 2006 at 2:17 pm | Uncategorized | No comment
Introduction to the practice parameters of physiatryApril 6
Profile of PM&R (Physiatry)
PM&R Scope of Practice
In the current medical environment, establishing parameters within which a specialist may practice is very important. The following modified AAPM&R document has been developed to define the appropriate practice for physicians who specialize in Physical Medicine and Rehabilitation (PM&R).
Using skills developed in ACGME-accredited training programs, PM&R specialists routinely diagnose and treat inpatients and outpatients with musculoskeletal and neuromuscular disorders, emphasizing function and rehabilitation. Physical medicine and rehabilitation specialists treat patients of all ages afflicted with painful and function-limiting musculoskeletal disorders of the spine, peripheral joints, and soft tissues such as sprains/strains, disc herniations, rheumatologic conditions and athletic injuries. PM&R specialists also diagnose and treat degenerative, developmental, acquired, and traumatic neuromuscular conditions of the upper and lower limbs, spinal cord, and brain. It is this unique blend of orthopedic, neuromuscular, pain, and rehabilitation training and experience that makes the PM&R specialist an ideal primary or secondary care physician for patients with occupational or sports-related musculoskeletal or neuromuscular injuries. This multidisciplinary training also makes the PM&R physician the most qualified specialist to lead the team of medical specialists and rehabilitation therapists involved in a patient’s rehabilitative care.
Physical medicine and rehabilitation specialists are specially trained to prescribe therapeutic exercise and other rehabilitation modalities. They are expert in the performance and interpretation of electrodiagnostic studies including electromyography, nerve conduction studies, and evoked potentials. PM&R specialists use routine laboratory and radiographic studies, but they are also trained in the interpretation of more sophisticated diagnostic studies that evaluate a patient’s musculoskeletal and neuromuscular systems such as CT, myelography, bone scan, and MRI. Many physical medicine and rehabilitation specialists are skilled in manual medicine. All physical medicine and rehabilitation residents are trained to perform injection techniques such as peripheral nerve blockade, trigger point injections, joint injections, and the injection of neurolytic agents and botulinum toxin. With specific training, many PM&R specialists routinely perform fluoroscopically directed spinal and large joint procedures such as interlaminar and transforaminal epidural injections, zygapophysial joint injections, radiofrequency denervation, sacroiliac joint intra-articular injections, sympathetic blockade, provocation discography, and other advanced interventional pain management techniques.
The American Academy of Physical Medicine and Rehabilitation asserts that all physical medicine and rehabilitation specialists who have completed a physical medicine and rehabilitation residency have adequate training to practice in the following areas:
1. inpatient and outpatient musculoskeletal and neuromuscular diagnosis and rehabilitation;
2. electrodiagnostic medicine;
3. medical and rehabilitative pain management;
4. injury prevention and wellness;
5. non-surgical spine medicine; and
6. sports medicine including athletes with disabilities.
In addition, the Academy further asserts that many physical medicine and rehabilitation specialists have the appropriate training to practice in the following areas:
1. interventional diagnostic and therapeutic spinal procedures; and
2. interventional pain management. *
* Most often achieved in fellowship training
In summary, physical medicine and rehabilitation is a diverse specialty allowing its members to seek and pursue special interests such as pain medicine, spine medicine, and sports medicine. Many PM&R specialists are integrally involved in university and private practice based spine centers, pain centers, and care of athletes from all levels of participation.
One pathway to success in outpatient rehabilitation is to establish an association in the public mind between Physical Medicine and Rehabilitation and certain medical problems. For example, the physiatrist could be identified as the specialist of choice for problems such as:
. back pain
. back, neck, arm, or leg pain which has been present longer than three weeks
. late effects of polio
. disorders of walking
. orthotics and prosthetics
. electromyography
. patients with functional deficits, difficulty doing the things they want to do
. returning the injured worker to productive activity
. making life easier for elderly people, and making care easier for the children of aging parents
. ongoing medical care or consultation on any patient with a disability, including stroke, spinal cord injury, brain injury, amputation, or progressive/degenerative neurologic disorder
. consultation on any patient who, despite the best of care, has persistent discomfort or physical impairment.
A multi-faceted education program promises to favorably affect outpatient referrals for medical rehabilitation. Patients need to know what physiatry can offer them. Insurance adjustors need to be educated that physiatrists lead efficient treatment teams with the goal of effective and efficient treatment. Referring physicians need to be educated in ways in which physiatrists can support their practices and make their professional lives easier.
The fundamental physiatric task of building effective treatment teams is getting harder every year. Each discipline involved in rehabilitation is seeking greater autonomy and a greater role in rehabilitation leadership. This trend can be expected to continue, fueled by human nature and economic incentives. If Physical Medicine and Rehabilitation is to be in a position of leadership in outpatient rehabilitation, physiatrists need to increase their volume of outpatient referrals.
Ideally, referrals would come from many sources. These sources include physicians, case managers, therapists, insurance companies and other third-party payers, recommendation of satisfied patients, and patient self-referral. Podiatrists, chiropractors, attorneys, and others refer occasional patients. Referral to outpatient physiatry services would be advanced by lowering barriers to referral. These barriers include lack of knowledge of physiatry and professional jealousy or ego. The physician who is able to solve these problems will be at an advantage in a competitive marketplace.
Physiatrists who are committed to giving service to physicians and patients will be at an advantage. The efficiently computerized office with helpful staff, appointments given within 2-3 days of the referral, consult notes reaching referring physicians within 2-3 days of the consult, and large doses of common courtesy and caring will be valued by patients and physicians in an age of greater complexity of life and work.
Material for Case Managers, Insurance Carriers, Hospital - Medical staff services/department
Suggested Delineation of Privileges
The purpose of this document is to provide a list of procedures performed by the physiatrist. This list is not meant to be all-inclusive but does include the kinds of procedures in physical medicine and rehabilitation that demand special degrees of skill and competence. This document is subject to revision from time to time as warranted by the evolution and technology of practice.
These are only suggested criteria that a hospital granting privileges in PM&R may consider when determining what criteria should be utilized in granting such privileges. All decisions relative to criteria governing the granting of privileges are individualized decisions that each hospital must make, taking into account factors relevant to the specific needs of the hospital.
Physical Examination:
A. Of pain-weakness-numbness syndromes (both neuromuscular and musculoskeletal) with a diagnostic plan and/or prescription for treatment, which may include the use of the physical agents and/or other interventions.
1. Including assessment of extent of injury and functional assessment with determination of impairment, intervention, disability, and impact on quality of life
B. Including evaluation, prescription and supervision of medical and comprehensive rehabilitation goals and treatment plans for:
1. Stroke syndromes
2. CNS degenerative diseases
3. CNS demyelinating diseases
4. Cranial nerve palsies and brainstem syndromes
5. Cerebral Palsy
6. Cognitive disorders
7. Traumatic brain and/or head injury
8. Communication and swallowing disorders including dysphagia and other related disorders
9. Spinal cord injuries and syndromes
10. Spina Bifida and /or myelomeningocoele disorders
11. Scoliotic disorders
12. Acute and chronic neuromusculoskeletal pain syndromes (including but not limited to acute low back, neck, and limb pain, and repetitive stress injuries
13. Cancer related disorders, impairments, and functional limitations
14. Acute and chronic pain and pain syndromes
15. Myopathies and muscular dystrophies
16. Weakness (including poor endurance)
17. Amputation (both congenital and acquired)
18. Disorders of the spine and extremities that interfere with an individual’s ability to function and quality of life
19. Impairments resulting from trauma, fracture, burns, and other medical and surgical illnesses and conditions
20. Peripheral nerve disorders
21. Pressure ulcers (decubitus)
22. Arthritis and related rheumatic conditions
23. Cardiac/circulatory diseases
24. Peripheral vascular disorders
25. Pulmonary disorders
26. Visual disorders
27. Injuries, illnesses, and undesirable symptoms requiring medical attention related to participation in sports and recreational/fitness related activities, performing arts, and occupational related activities
Performance of:
A. Physical medicine and rehabilitation department supervision
B. Rehabilitation unit administration and medical direction including administration and medical direction of comprehensive pain and functional restoration programs
C. Routine non-procedural medical care
D. Routine primary care procedures
E. Spinal cord rehabilitation (including neuromuscular, genito-urinary and other advanced techniques)
F. Prescription of medication
G. Venipuncture
H. Arterial puncture
I. Basic and advanced cardiac life support (American Heart Association)
J. Rehabilitation potential determination
K. Rehabilitation placement propriety and determination of appropriate level of care to meet patient functional needs (including, but not limited to, determination of qualification for comprehensive inpatient rehabilitation, subacute rehabilitation, home rehabilitation, or outpatient rehabilitation)
L. Prescription/administration/supervision of rehabilitation therapies including physical therapy, occupational therapy, speech/language pathology, massage, therapeutic exercise, (pre)vocational and habilitation services, athletic training and other restorative therapies
M. Prescription of prosthetic/orthotic and durable medical equipment
N. Prosthetic/orthotic and durable medical equipment checkout
O. Arthrocentesis: both aspiration and injection
1. joints (small, intermediate and major)
2. bursae
P. Manipulation/mobilization
1. peripheral
2. spinal
a. direct
b. indirect
3. cranial
Q. Serial casting
R. Soft tissue injection
1. ligament
2. tendon
3. sheath
4. muscle
5. fascial
6. prolotherapy
S. Chemolysis (Paralytic and Non-Paralytic)*
1. intramuscular (motor point)*
2. peripheral nerve*
3. cauda equina *
T. Anesthetic and/or motor blocks*
1. peripheral nerve *
2. myoneural junction*
3. sympathetic chain/ganglia*
4. caudal*
5. facet nerve/joint (may include the use of steroid)*
6. epidural (may include the use of steroid), including interlaminar (translaminar), transforaminal (selective spinal nerve or nerve root block).*
7. sacroiliac joint *
U. Interventional pain treatment including intrathecal medication administration and electrical stimulation (surface and implantable). Interventional means to treat spasticity including botulinum toxin injection and intrathecal pumps. *
V. Acupuncture *
W. Hyperbaric oxygen treatments
X. Hydrology
Y. Work determination status
Z. Impairment and disability evaluation
AA. Work hardening and simulation program direction
BB. Rehabilitation research
CC. Other
Performance and interpretation of:
A. Electrodiagnosis
1. electromyography
2. electroneurography (nerve conduction studies)
3. special procedures (i.e. repetitive stimulation, single fiber EMG, etc.)
B. Somatosensory evoked potentials *
1. non-operative (standard diagnostic)
C. Auditory evoked potentials *
D. Visual evoked potentials*
E. Intraoperative neurophysiologic studies*
1. SSEP
2. MEP (motor evoked potentials)
3. BAEP (brainstem auditory evoked potentials)
4. VEP (visual evoked potentials)
5. EMG
6. Electroneurography (NCS)
7. EEG
F. Urodynamic studies*
1. cystometrograms
2. sphincter EMG
3. urethral pressure profile
4. uroflow
G. Peripheral vascular testing *
H. Work physiology testing: treadmill and pulmonary ECG monitoring*
I. Muscle/muscle motor point biopsies*
J. Facet joint arthrogram*
K. Discography*
L. Small, intermediate or major joint arthrogram*
M. Gait laboratory studies*
N. Ergonomic studies*
O. Muscle strength testing
P. Range of motion evaluation
Q. Coordination testing
R. Radiological and lab procedures, including fluoroscopy
S. Dysphagia studies (performance of fiberoptic endoscopic evaluation of swallowing (FEES)) *
T. Assessments for impairments and functional limitations caused by osteoporosis
* Highly variable among graduates and often falls under the domain of other specialties!!
April 6, 2006 at 2:17 pm | Uncategorized | No comment
PM&R Pearls of Wisdom Review BookApril 6
April 6, 2006 at 2:17 pm | Uncategorized | No comment