Whole Medical Systems the Rehabilitation Setting (Traditional Chinese Medicine, Ayurvedic Medicine, Homeopathy, Naturopathy)

Elements of whole medical systems (WMSs) are re-emerging in a modern, patient-centered care model that leverages the benefits of evidence-based conventional medical practice with WMSs modalities. Many of these re-emerging modalities had their origins in traditional Chinese medicine, ayurvedic medicine, homeopathy, or naturopathy. To date, research has been conducted predominantly on multimodality treatment of experimental groups, drawing conclusions without a comparative control group or using modalities that are not actually WMSs.

Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans

OBJECTIVES

Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective.

RESEARCH DESIGN

In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information.

METHODS

A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record.

RESULTS

More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids.

CONCLUSION

VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives

Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.

Botulinum toxin type A for nonsurgical lateral release in patellofemoral pain syndrome: a case study

SETTING

Outpatient rehabilitation clinic.

PATIENT

A 37-year-old physically active male.

CASE DESCRIPTION

The patient presented with anterior left knee pain, exacerbated when climbing stairs, sitting, and running. Exam showed lateral tracking patellae and palpable crepitus. One hundred fifty units of botulinum toxin A was injected into his left vastus lateralis. He underwent a 12-week home exercise program targeting the vastus medialis (VM). ASSESSMENT/RESULTS: Visual analog scale decreased from 70 to 0 on a 150-mm scale, from initial until 8 weeks postinjection. Functional Index Questionnaire increased from 5 to 16 over the same period. Knee torque and surface electromyography findings showed increased activity of the VM during knee extension.

CONCLUSION

Botulinum injection into the vastus lateralis in conjunction with VM strengthening may provide more effective treatment of patellofemoral pain syndrome. Further study is needed to explore this novel treatment of patellofemoral pain syndrome.

Charcot shoulder joint associated with syringomyelia: a case report

A 36-year-old man with degenerative disease of the spine and cervical syringomyelia (syrinx) presented with new weakness and numbness in his left upper extremity. Examination revealed decreased range of motion (ROM), swelling, weakness, and diminished pinprick, vibratory, and proprioceptive sensation in the left upper extremity. Radiographic examination showed a severe destructive arthropathy; a biopsy ruled out malignancy. A culture was negative for infection, and a repeat magnetic resonance imaging (MRI) showed a patent syringo-peritoneal shunt with no change in syrinx size. He was diagnosed with a Charcot shoulder. Treatment consisted of nonsteroidal anti-inflammatory medication, passive motion exercises, and a protective sling. The patient with syringomyelia may experience sensory loss that prevents normal guarding, resulting in repetitive trauma and eventual joint destruction. Appropriate assessment, diagnostic work-up, and treatment are essential in the management of the Charcot joint. Patient education, including information on activities that may be harmful, must be included, as such knowledge may slow or prevent the impairment that comes with a Charcot joint.

Pain in Parkinson's disease: pathology to treatment, medication to deep brain stimulation

This article reviews the current literature on pain in Parkinson's disease to include the anatomy, pathology, and both basic and clinical science research. It explores treatment methods to include medication management as well as deep brain stimulation.

Sports and performing arts medicine. 2. Shoulder and elbow overuse injuries in sports

This self-directed learning module discusses classic topics and highlights new advances in this area. This article discusses upper-limb sports injuries as part of a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on shoulder and elbow pain in the athlete.

OVERALL ARTICLE OBJECTIVE

To discuss shoulder and elbow overuse injuries in sports.

Sports and performing arts medicine. 6. Issues relating to dancers

This self-directed study module highlights biomechanics unique to dance that predispose to common injuries of the lower extremity and discusses preventative strategies. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVE

To summarize lower-limb and back injuries commonly seen in dancers.

Sports and performing arts medicine. 3. Lower-limb injuries in endurance sports

This self-directed learning module highlights new advances in this topic area. It is part of the study guide on sports medicine and performing arts in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on (1) ankle pain in a runner, (2) heel pain in an adolescent, (3) anterior knee pain in a runner, (4) lateral knee pain in a cyclist, (5) shin splints in a runner, (6) buttock pain in a hiker, and (7) collapse of a marathoner from hyponatremia.

OVERALL ARTICLE OBJECTIVE

To summarize lower-limb injuries commonly seen in endurance sports.

Sports and performing arts medicine. 4. traumatic injuries in sports11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

This self-directed learning module focuses on injuries often seen in contact sports. It includes information on trauma to the cervical spine, wrist, shoulder, knee, ankle, foot, and chest and also discusses concussion in sport. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the etiology, differential diagnoses, treatment, and return-to-play criteria for traumatic sports injuries.

OVERALL ARTICLE OBJECTIVE

To summarize the approach to common traumatic sports injuries.

Sports and performing arts medicine. 1. general considerations for sports and performing arts medicine11A commercial party with a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit upon the author or one or more of the authors. Nadler is a consultant for Proctor & Gamble

This self-directed learning module highlights general considerations in sports and performing arts medicine. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVE

To discuss similarities and differences of injuries sustained in sports and performing arts using case vignettes.

Sports and performing arts medicine. 5. issues relating to musicians11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

This self-directed learning module discusses classic topics and highlights new advances in this topic area. This article, which discusses upper-limb injuries in musicians, is a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes to elaborate on issues relating to musicians.

OVERALL ARTICLE OBJECTIVE

To summarize overuse injury, nerve entrapment, and focal dystonia in instrumental musicians.

How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? a case report

Chest pain in a patient with acquired immune deficiency syndrome (AIDS) has a broad differential diagnosis including, but not limited to, coronary artery disease, gastroesophageal reflux, fungal esophagitis, and musculoskeletal pain. However, spontaneous pneumothorax must also be added to the list of possibilities. Spontaneous pneumothorax occurs 450 times more frequently in patients with AIDS versus the general population and is now the leading cause of nontraumatic pneumothorax in the urban population, to include both those with and without AIDS. Because many patients with human immunodeficiency virus (HIV) are young and typically devoid of comorbidity, the presentation of this pulmonary complication may be subtle. HIV-positive patients are receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for spontaneous pneumothorax to be an etiology of chest pain. We present a case exemplifying the need for rehabilitation professionals to maintain a broad-based approach when caring for patients with HIV and AIDS.

Benefits of an inpatient pulmonary rehabilitation program: a prospective analysis

OBJECTIVE

To examine the effect of an inpatient pulmonary rehabilitation program on functional outcome, supplemental oxygen use, quality of life (QOL), and rehospitalization.

DESIGN

A prospective study.

SETTING

Inpatient pulmonary rehabilitation unit.

PATIENTS

One hundred fifty-seven patients with moderate to severe chronic obstructive pulmonary disease (COPD) admitted to an inpatient pulmonary rehabilitation program over a 3-year period.

INTERVENTION

Comprehensive interdisciplinary inpatient pulmonary rehabilitation program with an average length of stay of 21 days.

MAIN OUTCOME MEASURES

Improvements in QOL questionnaire scores, COPD knowledge questionnaire scores, 6-minute walking test (with 3 ambulation categories: bed-bound, household ambulators, community ambulators), and supplemental oxygen use. Rehospitalization 1 year after completion of the program was also assessed and compared with hospital days for the year before the program.

RESULTS

On discharge from the program, 88% of individuals walked farther (p <.0001), and community ambulators doubled their walking distance, whereas bed-bound patients decreased 10-fold; supplemental oxygen use dropped 33% during the day (p <.0001) and 57% during the night (p <.0001); 82% showed improved QOL (p <.0001); 67% showed improved knowledge of COPD (p <.0001); and 67% of the sample spent less time in the hospital during the 12 months after program completion compared with the 12 months before admission (p <.001).

CONCLUSIONS

An inpatient pulmonary rehabilitation program leads to improved endurance and functional ambulation, decreased supplemental oxygen use, and fewer hospitalizations 1 year after discharge for patients with COPD.

Managed care. A product of market dynamics

The development of managed care is described as an unexpected product of competition between public and private purchasers of health care. Managed care is a series of purchasing techniques that employers have applied to reduce the cost of their employees' health benefits. Its most significant use has been as a device for bargaining with individual health care providers by encouraging or requiring employees to purchase health care services from a select set of providers. Selective contracting has broken a 40-year-old barrier to price competition among health care providers, who have responded to this negotiating tactic by forming or joining larger organizational units to strengthen their bargaining power. Although the so-called managed care revolution has reduced the rate of increase in health care costs by creating a more competitive price environment, it is simply a start toward a more effective health care market. It is very much a work in progress that will affect and be affected by both political and market changes occurring over the remainder of this century.

What do Hillary Rodham Clinton and Newt Gingrich have in common?

In a somewhat tongue-in-cheek style, this article tries to persuade conservatives that it might be in their best interests to consider broader health system reform alternatives in their quest to reduce the cost of federal health entitlements for a balanced budget by 2002. The conventional means for reducing the federal budget by $450 billion in 7 years will inflict much pain on many voters. The substitution of a new, more targeted entitlement, prospectively, for all Americans represents an alternative that provides much gain to many and only some pain to a few.

The struggle over health care controls continues

Although the struggle between advocates of competitive or regulatory controls for the health care market is abstract and ideological, when it comes to specific markets, it is very concrete and pragmatic. Some detailed implications of market strategy control for individual hospital managers are presented.

Does money spent on health care really improve U.S. health status?

Whether increased expenditures for health care substantially improve the overall health care of the U.S. population poses a critical question for the formulators of a national health policy. Concentrating exclusively on the impact of the Medicare program on the health status of the aged poor, the author examines HEW data and assesses the linkage between increased expenditures and improved health.