House Staff Manual

Volume 1 MEDSTAR GEORGETOWN UNIVERSITY HOSPITAL MEDSTAR NATIONAL REHABILITATION HOSPITAL Physical Medicine & Rehabilitation Residency Training Program

CURRICULUM MANUAL

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Integrated Competency Based Curriculum

Adding Physiatrists who Care©

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A word from the residency program director

On behalf of the faculty, I welcome you to the MedStar National Rehabilitation Hospital and wish you every success. We believe that each house officer contributes directly to the MedStar NRH’s growth and prosperity, and we hope you will take pride in being a member of our team.

Postgraduate medical training is the basis for your future practice. It is the foundation on which you will build your approach to patient care. These years will be among your most challenging, rewarding and enjoyable.

The Graduate Medical Education Committee, the Residency Training Office, the administration and professional staff are committed to delivering a top-quality educational experience. Input from the house staff is welcomed and solicited on a continuous basis.

In 2002 the MedStar National Rehabilitation Hospital’s PM&R program merged with the MedStar Georgetown University Hospital to form the quintessential learning environment to produce our next generation of quality Physiatrist - physicians in the field of Physical Medicine & Rehabilitation. This curriculum has taken many hours of our dedicated faculty’s time to create. I believe this program to be one of the best in the country. It is my honor to serve as a mentor, leader and provider of education to our residents. Sincerely,

Curtis L. Whitehair, MD Program Director, MEDSTAR GUH - MEDSTAR NRH PM&R Residency Training Program

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What you will find in this guide

In this manual, you will get information on how our program is structured to deliver a high quality educational experience for the resident physician in our Physical Medicine & Rehabilitation training program.

• Domain Structures

• Progression of Responsibility

• Rotations

• Didactic Topics

• Assessment Tools

• Current Outcomes

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Table of Contents A word from the residency program director ...... 2

WHAT YOU WILL FIND IN THIS GUIDE ...... 3

TABLE OF CONTENTS ...... 4

INTRODUCTION ...... 17 Overall Educational Goals of the Program ...... 18 Curriculum Framework ...... 18 Progression of Learning and Responsibility ...... 20 PGY 2 Level (Care of Inpatients and Exposure to Ambulatory Care) ...... 20 PGY 3 Level (Care of Inpatients and Outpatient (Predominant), Pediatric Rehabilitation and Electrodiagnostic Studies) ...... 20 PGY 4 Level (Consultative Care, Electives/Selectives, Ambulatory Care, Electrodiagnostic Studies and Senior Inpatient Rotation) ...... 21 Criteria Used at All Training Levels to Assess Progression of Learning ...... 22

DOMAINS ...... 23 Electrodiagnostic Medicine ...... 24 Goals & Objectives – Beginners ...... 24 Patient Care ...... 24 Medical Knowledge ...... 24 ANATOMY & PHYSIOLOGY ...... 24 Instrumentation...... 25 Nerve conduction Studies (NCS) ...... 25 Needle Electromyography (EMG) ...... 26 Practice-Based Learning and Improvement ...... 26 Interpersonal and Communication Skills ...... 27 Professionalism ...... 27 System-Based Practice ...... 27 Goals & Objectives – Advanced ...... 27 Patient Care ...... 27 Medical Knowledge ...... 28 ANATOMY & PHYSIOLOGY ...... 28 Nerve Conduction studies (NCS) ...... 29 Electromyography(EMG) ...... 29 Practice-Based Learning and Improvement ...... 29 Interpersonal and Communication Skills ...... 30 Professionalism ...... 30 System-Based Practice ...... 30 Didactics Lectures ...... 30

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See Didactics – Chapter 4 ...... 30 SCI Rehabilitation ...... 31 Goals & Objectives ...... 31 Patient Care ...... 31 Medical Knowledge ...... 32 Practice-Based Learning and Improvement ...... 33 Interpersonal and Communication Skills ...... 34 Professionalism ...... 34 System-Based Practice ...... 35 Didactics Lectures ...... 35 See Didactics – Chapter 4 ...... 35 Neurorehabilitation ...... 36 Goals & Objectives ...... 36 Patient Care ...... 36 Medical Knowledge ...... 36 Practice Based Learning and Improvement ...... 37 Interpersonal and Communication Skills ...... 37 Professionalism ...... 38 Systems-Based Practice ...... 38 Didactics Lectures ...... 39 See Didactics – Chapter 4 ...... 39 Joint & Connective Tissue Rehabilitation ...... 40 Goals & Objectives ...... 40 Patient Care ...... 40 Medical Knowledge ...... 40 Practice Based Learning and Improvement ...... 41 Interpersonal and Communication Skills ...... 41 Professionalism ...... 41 Systems-Based Practice ...... 42 Didactics Lectures ...... 42 See Didactics – Chapter 4 ...... 42 Musculoskeletal, Sports and Occupational Medicine ...... 43 Goals & Objectives ...... 43 Patient Care ...... 43 Medical Knowledge ...... 44 Practice Based Learning and Improvement ...... 45 Interpersonal and Communication Skills ...... 45 Professionalism ...... 46 Systems-Based Practice ...... 46 Didactics Lectures ...... 46 See Didactics – Chapter 4 ...... 46 Pediatric Rehabilitation ...... 47 Patient Care ...... 47 Medical Knowledge ...... 47 Practice Based Learning and Improvement ...... 48 Interpersonal and Communication Skills ...... 49

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Professionalism ...... 49 Systems-Based Practice ...... 49 Didactics Lectures ...... 49 See Didactics – Chapter 4 ...... 49 Amputee Rehabilitation and Prosthetics & Orthotics ...... 50 Goals & Objectives ...... 50 Patient Care ...... 50 Medical Knowledge ...... 51 Practice-based Learning and Improvement...... 52 Interpersonal & Communication Skills ...... 53 Professionalism ...... 53 Systems-based Practice ...... 54 Didactics Lectures ...... 54 See Didactics – Chapter 4 ...... 54 Medical Rehabilitation ...... 55 Goals & Objectives ...... 55 Patient Care ...... 55 Medical Knowledge ...... 55 Practice-based Learning and Improvement...... 56 Interpersonal & Communication Skills ...... 56 Professionalism ...... 56 Systems-Based Practice ...... 56 Didactics Lectures ...... 57 See Didactics – Chapter 4 ...... 57 Rehabilitation Research ...... 58 Goals & Objectives ...... 58 Patient Care ...... 58 Medical Knowledge ...... 58 Practice-based Learning and Improvement...... 58 Interpersonal & Communication Skills ...... 58 Professionalism ...... 59 Systems-based Practice ...... 59 Didactics Lectures ...... 59 See Didactics – Chapter 4 ...... 59 Rehab Administration & Practice Management ...... 60 Goals & Objectives ...... 60 Patient Care ...... 60 Medical Knowledge ...... 60 Practice-based Learning and Improvement...... 60 Interpersonal & Communication Skills ...... 60 Professionalism ...... 61 Systems-based Practice ...... 61 Didactics Lectures ...... 62 See Didactics – Chapter 4 ...... 62 General Physical Medicine & Rehabilitation and Therapeutics ...... 63 Goals & Objectives ...... 63

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Patient Care ...... 63 Medical Knowledge ...... 63 Practice-based Learning and Improvement...... 64 Interpersonal & Communication Skills ...... 64 Professionalism ...... 64 Systems-based Practice ...... 65 Didactics Lectures ...... 65 See Didactics – Chapter 4 ...... 65 Humanities in Rehabilitation Medicine ...... 66 Goals ...... 66 Objectives ...... 66 Patient Care ...... 66 Medical Knowledge ...... 66 Practice Based Learning and Improvement ...... 67 Interpersonal and Communication Skills ...... 67 Professionalism ...... 67 Systems-Based Practice ...... 67 Didactics Lectures ...... 68 See Didactics – Chapter 4 ...... 68

ROTATIONS ...... 69 Spinal Cord Injury ...... 71 Spinal Cord Injury – PGY2 ...... 71 General Educational Objective ...... 71 Scope of Learning and Exposures ...... 71 Methods of Teaching ...... 72 Methods of Assessment ...... 74 Lines of Supervision ...... 74 Specific Competency – Based Goals & Objectives ...... 75 PATIENT CARE ...... 75 MEDICAL KNOWLEDGE ...... 78 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 79 INTERPERSONAL & COMMUNICATION SKILLS ...... 79 PROFESSIONALISM ...... 80 SYSTEMS-BASED PRACTICE ...... 80 Spinal Cord Injury – PGY3 ...... 85 General Educational Objective ...... 85 Scope of Learning and Exposures ...... 85 Methods of Teaching ...... 86 Methods of Assessment ...... 88 Lines of Supervision ...... 88 Specific Competency – Based Goals & Objectives ...... 88 PATIENT CARE ...... 88 MEDICAL KNOWLEDGE ...... 92 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 93 INTERPERSONAL & COMMUNICATION SKILLS ...... 93 PROFESSIONALISM ...... 93

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SYSTEMS-BASED PRACTICE ...... 94 Educational Resources ...... 95 Musculoskeletal Medicine ...... 99 Musculoskeletal Medicine – PGY2 ...... 99 General Educational Objective ...... 99 Scope of Learning and Exposures ...... 99 Methods of Teaching ...... 100 Methods of Assessment ...... 101 Lines of Supervision ...... 101 Specific Competency – Based Goals & Objectives ...... 101 PATIENT CARE ...... 101 MEDICAL KNOWLEDGE ...... 109 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 111 INTERPERSONAL & COMMUNICATION SKILLS ...... 112 PROFESSIONALISM ...... 112 SYSTEMS-BASED PRACTICE ...... 113 Educational Resources ...... 113 Musculoskeletal Medicine – PGY4 ...... 116 General Educational Objective ...... 116 Scope of Learning and Exposures ...... 116 Methods of Teaching ...... 117 Methods of Assessment ...... 118 Lines of Supervision ...... 118 Specific Competency – Based Goals & Objectives ...... 118 PATIENT CARE ...... 118 MEDICAL KNOWLEDGE ...... 125 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 127 INTERPERSONAL & COMMUNICATION SKILLS ...... 128 PROFESSIONALISM ...... 128 SYSTEMS-BASED PRACTICE ...... 129 Educational Resources ...... 129 Traumatic Brain Injury ...... 131 Traumatic Brain Injury – PGY2 ...... 131 General Educational Objective ...... 131 Scope of Learning and Exposures ...... 131 Methods of Teaching ...... 131 Methods of Assessment ...... 133 Lines of Supervision ...... 133 Specific Competency – Based Goals & Objectives ...... 133 PATIENT CARE ...... 133 MEDICAL KNOWLEDGE ...... 136 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 138 INTERPERSONAL & COMMUNICATION SKILLS ...... 139 PROFESSIONALISM ...... 139 SYSTEMS-BASED PRACTICE ...... 139 Educational Resources ...... 140 Traumatic Brain Injury – PGY4 ...... 141

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General Educational Objective ...... 141 Scope of Learning and Exposures ...... 141 Methods of Teaching ...... 141 Methods of Assessment ...... 143 Lines of Supervision ...... 143 Specific Competency – Based Goals & Objectives ...... 143 PATIENT CARE ...... 143 MEDICAL KNOWLEDGE ...... 146 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 148 INTERPERSONAL & COMMUNICATION SKILLS ...... 149 PROFESSIONALISM ...... 149 SYSTEMS-BASED PRACTICE ...... 149 Educational Resources ...... 150 Stroke Recovery ...... 151 Stroke Recovery – PGY2...... 151 General Educational Objective ...... 151 Scope of Learning and Exposures ...... 151 Methods of Assessment ...... 153 Lines of Supervision ...... 153 Specific Competency – Based Goals & Objectives ...... 153 PATIENT CARE ...... 153 MEDICAL KNOWLEDGE ...... 158 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 161 INTERPERSONAL & COMMUNICATION SKILLS ...... 162 PROFESSIONALISM ...... 162 SYSTEMS-BASED PRACTICE ...... 163 Stroke Recovery – PGY3...... 165 General Educational Objective ...... 165 Scope of Learning and Exposures ...... 165 Methods of Assessment ...... 167 Lines of Supervision ...... 167 Specific Competency – Based Goals & Objectives ...... 167 PATIENT CARE ...... 167 MEDICAL KNOWLEDGE ...... 172 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 175 INTERPERSONAL & COMMUNICATION SKILLS ...... 176 PROFESSIONALISM ...... 176 SYSTEMS-BASED PRACTICE ...... 177 Educational Resources ...... 177 Department of Veterans Affairs, Medical Center – Geriatrics ...... 179 General Educational Objective ...... 179 Scope of Learning and Exposures ...... 179 Methods of Teaching ...... 179 Methods of Assessment ...... 180 Lines of Supervision ...... 180 Specific Competency – Based Goals & Objectives ...... 180 PATIENT CARE ...... 181

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MEDICAL KNOWLEDGE ...... 184 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 185 INTERPERSONAL & COMMUNICATION SKILLS ...... 186 PROFESSIONALISM ...... 186 SYSTEMS-BASED PRACTICE ...... 187 Educational Resources ...... 187 Occupational Medicine & Electrodiagnostic Consultations ...... 188 Pediatric Rehabilitation ...... 189 General Educational Objective ...... 189 Scope of Learning and Exposures ...... 189 Methods of Teaching ...... 189 Methods of Assessment ...... 190 Lines of Supervision ...... 191 Specific Competency – Based Goals & Objectives ...... 191 PATIENT CARE ...... 191 MEDICAL KNOWLEDGE ...... 195 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 196 INTERPERSONAL & COMMUNICATION SKILLS ...... 197 PROFESSIONALISM ...... 197 SYSTEMS-BASED PRACTICE ...... 198 Radiology – Visiting Nurses Association – Nascott (P&O) ...... 200 General Educational Objective ...... 200 Scope of Learning and Exposures ...... 200 Methods of Teaching ...... 200 Methods of Assessment ...... 201 Lines of Supervision ...... 202 Specific Competency – Based Goals & Objectives ...... 202 PATIENT CARE ...... 202 MEDICAL KNOWLEDGE ...... 206 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 207 INTERPERSONAL & COMMUNICATION SKILLS ...... 207 PROFESSIONALISM ...... 208 SYSTEMS-BASED PRACTICE ...... 208 Educational Resources ...... 209 Outpatient Physician Center Specialty Clinics at NRH ...... 210 General Educational Objective ...... 210 Scope of Learning and Exposures ...... 210 Methods of Teaching ...... 211 Methods of Assessment ...... 212 Lines of Supervision ...... 213 Specific Competency – Based Goals & Objectives ...... 213 PATIENT CARE ...... 213 MEDICAL KNOWLEDGE ...... 218 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 221 INTERPERSONAL & COMMUNICATION SKILLS ...... 221 PROFESSIONALISM ...... 222

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SYSTEMS-BASED PRACTICE ...... 222 Educational Resources ...... 223 Pain Consultations ...... 224 Pain Consultations at Washington Hospital Center ...... 224 General Educational Objective ...... 224 Scope of Learning and Exposures ...... 224 Methods of Teaching ...... 225 Methods of Assessment ...... 226 Lines of Supervision ...... 226 Specific Competency – Based Goals & Objectives ...... 226 PATIENT CARE ...... 226 MEDICAL KNOWLEDGE ...... 229 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 230 INTERPERSONAL & COMMUNICATION SKILLS ...... 230 PROFESSIONALISM ...... 231 SYSTEMS-BASED PRACTICE ...... 231 Educational Resources ...... 231 Pain Consultations at George Washington University Medical Center ...... 233 General Educational Objective ...... 233 Scope of Learning and Exposures ...... 233 Methods of Teaching ...... 234 Methods of Assessment ...... 235 Lines of Supervision ...... 235 Specific Competency – Based Goals & Objectives ...... 235 PATIENT CARE ...... 235 MEDICAL KNOWLEDGE ...... 238 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 239 INTERPERSONAL & COMMUNICATION SKILLS ...... 239 PROFESSIONALISM ...... 240 SYSTEMS-BASED PRACTICE ...... 240 Educational Resources ...... 241 Outpatient Center - Bethesda NRH Regional Rehab ...... 242 General Educational Objective ...... 242 Scope of Learning and Exposures ...... 242 Methods of Teaching ...... 243 Methods of Assessment ...... 243 Lines of Supervision ...... 244 Specific Competency – Based Goals & Objectives ...... 244 PATIENT CARE ...... 244 MEDICAL KNOWLEDGE ...... 248 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 250 INTERPERSONAL & COMMUNICATION SKILLS ...... 250 PROFESSIONALISM ...... 250 SYSTEMS-BASED PRACTICE ...... 251 Educational Resources ...... 252 Electrodiagnostic Medicine ...... 253

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General Educational Objective ...... 253 Scope of Learning and Exposures ...... 253 Methods of Teaching ...... 254 Methods of Assessment ...... 255 Lines of Supervision ...... 255 Specific Competency – Based Goals & Objectives ...... 255 PATIENT CARELS ...... 255 MEDICAL KNOWLEDGE ...... 256 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 257 INTERPERSONAL & COMMUNICATION SKILLS ...... 257 PROFESSIONALISM ...... 258 SYSTEMS-BASED PRACTICE ...... 258 Educational Resources ...... 258 PM&R in Private Practice ...... 260 General Educational Objective ...... 260 Scope of Learning and Exposures ...... 260 Methods of Teaching ...... 261 Methods of Assessment ...... 261 Lines of Supervision ...... 262 Specific Competency – Based Goals & Objectives ...... 262 PATIENT CARE ...... 262 MEDICAL KNOWLEDGE ...... 265 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 267 INTERPERSONAL & COMMUNICATION SKILLS ...... 267 PROFESSIONALISM ...... 268 SYSTEMS-BASED PRACTICE ...... 268 Educational Resources ...... 269 Sports Medicine or Orthopedic Surgery ...... 271 General Educational Objective ...... 271 Scope of Learning and Exposures ...... 271 Methods of Teaching ...... 272 Methods of Assessment ...... 272 Lines of Supervision ...... 273 Specific Competency – Based Goals & Objectives ...... 273 PATIENT CARE ...... 273 MEDICAL KNOWLEDGE ...... 276 INTERPERSONAL & COMMUNICATION SKILLS ...... 278 PROFESSIONALISM ...... 278 SYSTEMS-BASED PRACTICE ...... 278 Educational Resources ...... 279 National Institutes of Health ...... 280 General Educational Objective ...... 280 Scope of Learning and Exposures ...... 280 Methods of Teaching ...... 280 Methods of Assessment ...... 281 Lines of Supervision ...... 281 Specific Competency – Based Goals & Objectives ...... 281

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PATIENT CARE ...... 282 MEDICAL KNOWLEDGE ...... 285 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 287 INTERPERSONAL & COMMUNICATION SKILLS ...... 288 PROFESSIONALISM ...... 288 SYSTEMS-BASED PRACTICE ...... 289 Educational Resources ...... 289 Rheumatology ...... 290 Rheumatology – WHC (Washington Hospital Center) ...... 290 General Educational Objective ...... 290 Scope of Learning and Exposures ...... 291 Methods of Teaching ...... 291 Methods of Assessment ...... 293 Lines of Supervision ...... 293 Specific Competency – Based Goals & Objectives ...... 293 PATIENT CARE ...... 294 MEDICAL KNOWLEDGE ...... 296 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 297 INTERPERSONAL & COMMUNICATION SKILLS ...... 297 PROFESSIONALISM ...... 298 SYSTEMS-BASED PRACTICE ...... 298 Educational Resources ...... 299 Rheumatology – GUH (Georgetown University Hospital) ...... 300 General Educational Objective ...... 300 Scope of Learning and Exposures ...... 300 Methods of Teaching ...... 301 Methods of Assessment ...... 302 Lines of Supervision ...... 302 Specific Competency – Based Goals & Objectives ...... 302 PATIENT CARE ...... 302 MEDICAL KNOWLEDGE ...... 305 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 306 INTERPERSONAL & COMMUNICATION SKILLS ...... 306 PROFESSIONALISM ...... 307 SYSTEMS-BASED PRACTICE ...... 307 Educational Resources ...... 308 Washington Hospital Center Consultations ...... 309 General Educational Objective ...... 309 Scope of Learning and Exposures ...... 309 Methods of Teaching ...... 309 Methods of Assessment ...... 310 Lines of Supervision ...... 310 Specific Competency – Based Goals & Objectives ...... 310 PATIENT CARE ...... 310 MEDICAL KNOWLEDGE ...... 316 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 318

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INTERPERSONAL & COMMUNICATION SKILLS ...... 319 PROFESSIONALISM ...... 319 SYSTEMS-BASED PRACTICE ...... 320 Educational Resources ...... 321 Electives...... 321 PGY2 ...... 321 PGY3 ...... 321 PGY4 ...... 322 PGY4 or Adult Neurology at WHC ...... 322 Adult Neurology at WHC ...... 322 General Educational Objective ...... 322 Scope of Learning and Exposures ...... 322 Methods of Teaching ...... 323 Methods of Assessment ...... 323 Lines of Supervision ...... 324 Specific Competency – Based Goals & Objectives ...... 324 PATIENT CARE ...... 324 MEDICAL KNOWLEDGE ...... 328 PRACTICE-BASED LEARNING & IMPROVEMENT ...... 330 INTERPERSONAL & COMMUNICATION SKILLS ...... 330 PROFESSIONALISM ...... 330 SYSTEMS-BASED PRACTICE ...... 331 Educational Resources ...... 331 OCOR (Outpatient Center for Orthopedic Rehabilitation) Physical Therapy ...... 332 Advanced Radiology ...... 332

DIDACTICS ...... 333 Engaging Our Learners through Interactive Pedagogies ...... 334 Audience Response System (ARS) ...... 334 Immediate Feedback – Assessment Tool (IF-AT)...... 334 Hands-on Workshops ...... 334 Objective Structured Clinical Examinations (OSCE)...... 334 Didactic Lecture Topics ...... 335 General Physical Medicine & Rehabilitation Therapeutics ...... 335 Electrodiagnostic Medicine ...... 335 Musculoskeletal, Sports and Occupational Medicine ...... 336 Amputee Rehabilitation and Prosthetics & Orthotics ...... 337 Spinal Cord Injury Rehabilitation ...... 337 Neurorehabilitation ...... 337 Humanities in Rehabilitation Medicine ...... 338 Medical Rehabilitation ...... 339 Rehabilitation Research ...... 339 Rehabilitation Administration and Practice Management ...... 339 Joint & Connective Tissue Rehabilitation ...... 340 Pediatric Rehabilitation ...... 340

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OTHER LEARNING OPPORTUNITIES ...... 341 Continuity clinic ...... 341 Clinic Design ...... 341 Clinic logistics ...... 341 Doctor Number assignment ...... 342 Resident’s responsibility ...... 342 Learning/Education ...... 342 Continuity Clinic Peer Lecture Schedule ...... 343 Research ...... 347 Educational Conferences and Workshops ...... 347

ASSESSMENT TOOLS ...... 348 Assessment System ...... 348 Resident Assessment ...... 349 OSCE ...... 349 Standardized Patients (SP) ...... 350 Guidelines for the Resident ...... 350 Feedback and Evaluation ...... 351 Competencies addressed ...... 352 Global Clinical Performance Rating ...... 352 Sample Global Assessment Evaluation: ...... 352 Competencies addressed ...... 352 Focused Evaluation / Observation of Patient Encounter...... 352 RO&CA ...... 352 Description ...... 352 Instructions for use ...... 353 Sample RO&CA ...... 353 Competencies addressed ...... 355 360-degree Evaluation ...... 355 Sample survey - 360o evaluation ...... 355 Competencies addressed ...... 356 Written Exams ...... 356 Unannounced quizzes ...... 356 Quarterly Exams ...... 357 Competencies addressed ...... 357 Case Logs ...... 357 Competencies addressed ...... 357 Portfolio ...... 357 Competencies addressed ...... 358 Curriculum Assessment ...... 358 Rotational Assessment ...... 359 Faculty Assessment ...... 359 Program Assessment ...... 359 Clinical Competency Committee ...... 359

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CURRENT OUTCOMES ...... 361 Contact Information ...... 361 ABPM&R – Written Boards ...... 362 5 year data ...... 362 ABPM&R – Oral Boards...... 363 5 year data ...... 363

APPENDIX ...... 364 REFERENCES Triple D 2004 (Compiled by Joel A DeLisa, MD, MS) Recommended reading list.- Association of Academic Physiatrist...... 364 Essential Articles in PM&R Training 1980 – 2003; Baylor College of Medicine - Association of Academic Physiatrist ...... 366

INDEX ...... 387

FIGURES AND TABLES ...... 390

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Chapter 1 Introduction elcome to the MedStar National Rehabilitation Hospital’s residency training program in Physical Medicine & Rehabilitation. The program proudly started in 1986 W and has graduated over 110 Physiatrist as of June 30, 2009.

Centered in the heart of Washington DC, the National Rehabilitation Hospital is ideally position to achieve its vision as the trusted leader in caring for people and advancing health. Our PM&R program currently consists of 4 residents for each of the PGY2 to PGY4 years.

The curriculum presented in this manual is a 3 dimensional design that fully supports an Integrated Competency Based Curriculum for the resident in Physical Medicine & Rehabilitation. The first dimension is the Resident him or herself. During all of the didactics and clinical scenarios, we are utilizing the latest technology in adult learning. The second dimension is our Domain structure. We have identified 12 domains that are the core of education for the PM&R resident. Every educational session (didactic lecture, workshop, examination, clinical rotation, etc.) is directly related to one of our domains. As with our domains, every educations session is also directly related to our third dimension which is one of the 6 Core ACGME Competencies (Patient Care, Medical Knowledge, Practice Based Learning, Professionalism, System Based Learning and Interpersonal Skills and Communication.)

This competency based curriculum takes advantage of the broad expertise of our faculty in the primary institution and affiliated hospitals and the unique and diverse educational resources available in Washington DC and Maryland area.

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Overall Educational Goals of the Program • To provide the resident with basic and advanced knowledge in physical medicine and rehabilitation to prepare for a career in academic/clinical practice • To provide the resident with clinical skills necessary to acquire competencies in the clinical practice of rehabilitation medicine • To encourage self-improvement by developing skills in communication, teaching and leadership • To mentor residents in a supportive environment that stimulates lifelong learning • To utilize opportunities and resources that would ensure that the resident is an integral part of the rehabilitation team and community

Curriculum Framework

The structural framework underlying the program curriculum revolves around the 5 “C” s: Compliance, Competencies, Content, Commitment and Change.

1. Compliance- We seek to continue to fulfill the ACGME Common and PMR and ABPMR requirements;

2. Competencies- The ACGME six core competencies are integrated in the development, implementation and evaluation of the curriculum. These are: • Medical Knowledge • Patient Care • Practice-based Learning and Improvement • Professionalism • Interpersonal and Communication Skills • Systems-based Practice

The competencies are emphasized in all learning sessions through awareness and delivery of competency-based education. In-service educational sessions on competencies occur throughout the year for faculty and residents.

3. Content – Core topics of PM&R that our residents need to know are identified and guided by one of our 12 Domains in the development of rotational Goals and Objectives and didactic learning sessions.

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4. Commitment- The best solutions emerge from the collective insight and wisdom of a diverse group of individuals who are willing to collaborate through active participation and hands on development of the curriculum.

5. Change- The program curriculum is dynamic and based on resident performance, evaluations of didactic sessions and clinical rotations and feedback from alumni, program needs and resources.

Figure 1 - 5 C's

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Progression of Learning and Responsibility

The careful reorganization of our rotation grid has allowed progression of resident learning and responsibility. In each of the three successive years of residency training, the responsibilities and expectations of the residents are increased. While there may be overlap among the years in terms of rehabilitation populations seen, the complexity of subspecialty care and rehabilitation management increases throughout training. In order for the resident to advance to the next academic level, the resident must demonstrate specific knowledge, skill, and performance as outlined below:

PGY 2 Level (Care of Inpatients and Exposure to Ambulatory Care) At the PGY 2 level, the resident has exposure in the direct clinical care of patients in various Adult Inpatient Rehabilitation Units which include SCI, Neurorehabilitation (Stroke and Brain Injury), Musculoskeletal Rehabilitation (Joint and Amputee) and Geriatric Rehabilitation. Exposure to Ambulatory Care (Continuity Clinic, Outpatient and EMG) is introduced. One elective month is offered.

At the completion of the PGY 2, the resident is expected to have demonstrated satisfactory achievement of all rotational educational objectives, as well as:

1. Direct and supervised clinical care of hospitalized patients (predominant) 2. Performance of a comprehensive physiatric history, physical and functional evaluation 3. Fundamental skills in the physiatric management of an inpatient rehabilitation unit 4. Formulation a general medical and rehabilitation problem list/differential diagnosis 5. Performance in dictation of a comprehensive discharge summary 6. Prescription of appropriate therapeutic measures 7. Participation in leading supervised team and family conferences 8. Participation in the supervision & training of medical students in basic information gathering, decision making & patient management 9. Acquisition of basic knowledge on performance of electrodiagnostic studies 10. Direct and supervised clinical care of outpatients

PGY 3 Level (Care of Inpatients and Outpatient (Predominant), Pediatric Rehabilitation and Electrodiagnostic Studies)

At the PGY-3 level, the resident has exposure to the direct care of both adult and pediatric populations. Rotations are predominantly in the ambulatory care setting. There is increased exposure to electrodiagnostic studies with a three month rotation at WRAMC. The resident has the opportunity to begin to explore his/her interests with additional elective time. Research opportunities are enhanced with exposure to the NIH rotation.

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At the completion of the PGY-3 year, the resident is expected to have the necessary knowledge, skills and attitudes to diagnose and manage the rehabilitation of patients on both an inpatient and outpatient basis.

At the completion of the PGY-3 year, the resident is expected to have demonstrated satisfactory achievement of all rotational educational objectives, as well as:

1. Compliance with all criteria for PGY-2 residents 2. Formulation of a comprehensive treatment plan for various types of patients, adult and pediatric, including appropriate intervention, goals and disposition of care 3. Ability to negotiate the various levels of care by making appropriate referrals & managing the discharge planning function 4. Substantial skill in supervising junior (PGY-2) and medical students 5. Demonstrate increased knowledge and skill in conducting electrodiagnostic studies 6. Substantial skill in leading team and family conferences

PGY 4 Level (Consultative Care, Electives/Selectives, Ambulatory Care, Electrodiagnostic Studies and Senior Inpatient Rotation)

At the end of the PGY-4 year, the resident will continue to have competence in all PGY-2 and PGY-3 objectives but with increasing responsibility for patient care and rehabilitation management, thus demonstrating advanced knowledge of differential diagnosis and patient therapeutic decisions.

At the completion of the PGY-4 year, the resident is expected to have demonstrated satisfactory achievement of all rotational educational objectives, as well as:

1. Compliance will all criteria for PGY 2 and PGY 3 residents 2. Skilled performance of electromyography, nerve conduction & other diagnostic studies (as evidenced by completion of a minimum of 200 studies) 3. Proficiency in writing therapeutic and diagnostic prescriptions for rehabilitation patients 4. Effective assessment of various aspects of the adult and pediatric rehabilitation management 5. Ability to act as a consulting physician with referring primary care &/or other specialty physicians 6. Substantial skill in supervising & training junior residents (PGY-2 & PGY-3) and medical students in continuity clinic and during inpatient and rotations 7. Presentation of scholarly project on Annual Resident Research Day 8. Independent responsibility for directing rehabilitation patient care management

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Criteria Used at All Training Levels to Assess Progression of Learning

The Competency Committee will also use the following evaluation tools in determining each resident’s competence and readiness to advance to the next level of training:

1. The resident must have attended a minimum of 75% of the didactic lectures 2. Global evaluations for each rotation shall be satisfactory 3. Semi-annual evaluations by the program director shall be satisfactory 4. 360 and peer evaluations shall be satisfactory 5. Rotation RO & CA evaluations shall be satisfactory 6. Peer evaluations shall be satisfactory 7. Quarterly examinations shall be satisfactory ( minimum of 65% passing grade) 8. Demonstration of progress and participation in a scholarly activity 9. General achievement in the Six Competencies (medical knowledge, patient care, interviewing & communication, professionalism, practice-based learning & improvement, systems-based practice) based on evaluation tools above 10. Compliance with other program, hospital and/or professional policy guidelines

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Chapter 2 Domains

he basis of our curriculum is built around 12 Domains that we have identified as the core structure for educating the Resident Physician in the discipline of Physical Medicine & T Rehabilitation. These domains oversee that the current Clinical Rotations as well as the PM&R Didactic Series provide the up to date information. Each domain has a Domain Chief which is a faculty attending and a current Resident Physician. Each lecture must also satisfy at least one of the ACGME 6 Core Competencies. The residents at the end of the lecture provide an evaluation of the lecture. The domain team meets at least quarterly to evaluate the lectures series as well as information from exam scores (PM&R residency quarterly exams and American Board of Physical Medicine & Rehabilitation – Self Assessment Exam – done yearly) that pertain to their domain.

Domains Electrodiagnostic Medicine Spinal Cord Injury Rehabilitation Neurorehabilitation Brain Disorders (Stroke and Traumatic Brain Injury) Joint and Connective Tissue Rehabilitation Musculoskeletal, Sports & Occupational Medicine Pediatric Rehabilitation General Physical Medicine & Rehabilitation and Therapeutics Humanities in Rehabilitation Medicine Amputee Rehabilitation, Prosthetics & Orthotics Medical Rehabilitation Rehabilitation Research Rehabilitation Administration & Practice Management Table 1 - Domains

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Electrodiagnostic Medicine

The Electrodiagnostic medicine consultation is the practice of medicine and as such is predicated on a thorough understanding of the basic science and clinical aspects of nerve and muscle physiology. In addition to the normal physiological function of these two primary tissues, the physician must also comprehend the manner in which nerve and muscle tissue reacts to various diseases. The practitioner must be aware of how the instrument detect and displays the recorded physiological potentials. Once these basic principles are mastered, the practitioner has taken the first step toward being able to perform and Electrodiagnostic medicine consultation.

Goals & Objectives – Beginners Patient Care Residents are expected to: • Perform a comprehensive electrodiagnostic evaluation of each patient and to provide a concise diagnosis and plan for further treatment • Describe the variety of conditions frequently encountered in electrodiagnostic medicine • Determine a logical approach of testing for each individual condition • Discuss the electrophysiology of common normal and abnormal findings encountered in Electromyography and Nerve conduction studies (EMG/NCS) • Develop an extensive knowledge base of neuromuscular anatomy • Familiarize oneself with the EMG/NCS machine and be able to troubleshoot common errors and problems encountered in EMG/NCS testing • Identify patient and family concerns associated with the testing process as well as the results • Define the patient safety issues with EMG/NCS including proper maintenance, inspection of the machine, and risk of blood borne pathogen exposure • Obtain appropriate informed consent for the procedure • Respect that the patient is experiencing an uncomfortable procedure • Complete an Electrodiagnostic Medicine Proctored Resident Observation & Competency Assessment (RO&CA)

Medical Knowledge Residents are expected to:

ANATOMY & PHYSIOLOGY . Define the components of the motor unit . Draw the Brachial Plexus, including the terminal nerves

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. List the nerve root level and peripheral nerve innervation of upper and lower extremity muscles . Describe the nerve root and peripheral nerve innervation of the skin in both the upper and lower extremity . Describe microanatomy of the axon-membrane and supporting structure . Compare the structure of myelinated and unmyelinated nerves . Identify the microanatomy of muscle, i.e., sarcomere, T-tubules, action, myosin, etc . Describe nerve and muscle membrane physiology such as potential and permeability . Compare impulse propagation in myelinated and unmyelinated nerves . Describe muscle contraction in microscopic terms, i.e., actin-myosin binding, ratcheting effect, sarcomere shortening . Describe the response of the peripheral nervous system to injury

INSTRUMENTATION . Describe the purpose of the EMG/NCV recording device . Identify the relative contraindications to electrodiagnosis . Identify the complications of electrodiagnosis . List the components of the EMG machine and their purpose . Discuss the concept of differential amplification and the purpose of G1 and G2 electrodes . Define sensitivity and gain . Describe the differences between monopolar and concentric needles in terms of recording area, noise and wave form characteristics . List at least three ways to reduce stimulus artifact . Give examples of high and low frequency responses commonly seen during Electrodiagnostic studies . Discuss the effects of inadequate or excessive stimulus intensity . List five causes of electrical interference and how to minimize them

NERVE CONDUCTION STUDIES (NCS) . Adjust various “Parameters” to record sensory, motor nerve conductions and motor unit potentials . Demonstrate the proper placement of recording, reference and ground electrodes; recognize proper stimulation sites; measure the latencies and calculate conduction velocities . State the various physiological factors, which can influence the electrodiagnostic results, e.g., age, body temperature, volume conduction, electrical interferences, and measurement error

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. Memorize normal values for distal latencies evoked response amplitudes and conduction velocities of different nerves . Measure sensory latencies and amplitudes of median, ulnar, radial, superficial peroneal, dorsal ulnar cutaneous nerve, and medial antebrachial cutaneous nerves. . Measure motor latencies, amplitude and conduction velocities of median, ulnar, radial, peroneal, tibial nerves, and musculocutaneous nerves . Distinguish between the late responses (H, F, A) waves, their etiology and clinical significance . Demonstrate the ability to perform H reflex and F wave studies and interpret the results. . Differentiate between axon loss and conduction block . Demonstrate the ability to perform and diagnose upper and lower extremity nerve entrapments and radiculopathies . Differentiate axonal versus demyelinating type of peripheral neuropathies . Demonstrate the ability to diagnose neurapraxia versus axonotmetic and neurotmetic nerve lesion in mononeuropathies

NEEDLE ELECTROMYOGRAPHY (EMG) . Analyze a normal motor unit potential’s morphology (shape, size, and phases) and recruitment pattern on needle EMG exam . Define the initial deflection, duration, amplitude, rate, rhythm, origin, and diagnostic significance of these potentials: miniature endplate potentials, end plate potentials, fibrillations, positive waves, fasciculations, myotonia, myokymia, complex repetitive discharges, pseudomyotonia, tremor and cramp discharges, 60 cycle interference and artifacts • Explain the reason why fibrillations and positive sharp waves are commonly seen in myopathy • Describe typical electromyographic findings in muscle disease • Describe the electromyographic findings in neurapraxia, axonotmesis, and neurotmesis over time in terms of spontaneous activity, recruitment, and motor unit action potential morphology • Know key muscles for cervical and lumbar radiculopathy

Practice-Based Learning and Improvement Residents are expected to: • Review the literature for electrodiagnostic medicine “Best Practices” for neuromuscular disorders • Disseminate these “Best Practices” to patients, consultants, and staff

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Interpersonal and Communication Skills Residents are expected to: • Interact with patients in a sensitive manner • Communicate on a given patient’s intellectual/educational level • Produce concise, accurate documentation of the consultation, electrodiagnostic findings, and recommendations • Complete all chart notes in a timely manner • Participate in teaching discussions

Professionalism Residents are expected to: • Promote respect, dignity, and compassion for patients • Accept responsibility for their own actions and decisions • Demonstrate reliability and punctuality • Understand and adhere to HIPPA regulations

System-Based Practice Residents are expected to: • Appreciate when electrodiagnostic medicine procedures are most appropriately rendered to maximize information gain and patient outcome • Appreciate when electrodiagnostic medicine procedures are/are not cost-effective for the patient and health care system • Understand where electrodiagnostic medicine testing “fits” in the continuum-of-care for persons with neurologic disorders

Goals & Objectives – Advanced

Patient Care Residents are expected to: • Review the objectives for the beginning rotation and to master what they have not learned • Perform 4 to 6 Electrodiagnostic medicine evaluations per day with limited faculty supervision • Determine a logical approach of testing for each individual condition • Characterize the electrophysiology of common normal and abnormal findings encountered in EMG/NCS • Build on their knowledge base of neuromuscular anatomy • Troubleshoot common errors and problems encountered in EMG/NCS testing

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• Identify patient and family concerns associated with the testing process as well as the results • Learn the patient safety issues with EMG/NCS including proper maintenance, inspection of the machine, and risk of blood borne pathogen exposure • Obtain appropriate informed consent for the procedure • Respect that the patient is experiencing an uncomfortable procedure • Communicate with tech support personnel when a machine is not functioning • Review inpatient and outpatient Electrodiagnostic medicine consults to determine medical necessity, and the best time frame to perform the exam • Develop enough speed to complete the exam in the allotted time frame

Medical Knowledge Residents are expected to:

ANATOMY & PHYSIOLOGY • Outline the events occurring at the neuromuscular junction • Review the course and muscles supplied by the facial, phrenic, suprascapular, axillary, and spinal accessory nerves • Review the anatomy of the lumbar and brachial plexus • Discuss myopathic and neuropathic biopsy findings • Describe anomalous innervation including the Martin-Gruber anastomosis and accessory deep peroneal nerve • List the most common forms of muscular dystrophy, motor neuron diseases (e.g., Amyotrophic Lateral Sclerosis (ALS), Spinal Muscular Atrophy (SMA), hereditary motor/sensory neuropathies(HMSN), and myopathies and be familiar with their genetics, incidences, ages of onset, evaluation (to include electrodiagnostic studies), treatment options, and recommendations and prognosis • Differentiate muscular dystrophy/congenital myopathy from kalemic and metabolic myopathies • Describe the findings of stiff man syndrome and other diseases of continuous muscle activity • Understand the anatomy of the blink reflex

• Describe the effect of changes in the high and low frequency filters on the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP) latencies and amplitudes • Describe the effect of changes in the high and low frequency filters on the motor unit action potential (MUAP)

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• Describe the technical difficulties of performing Electrodiagnostic testing in the ICU setting

NERVE CONDUCTION STUDIES (NCS) • Perform lateral femoral cutaneous, plantar, saphenous, spinal accessory, and suprascapular nerve studies • Demonstrate the ability to evaluate Neuromuscular junction disorders with repetitive stimulation testing • Evaluate and perform testing to diagnose patients with lumbar and brachial plexopathy • Evaluate an inpatient with generalized weakness or difficulty weaning off the ventilator • List the disease categories associated with axonal and demyelinating neuropathies • Identify common reasons for utilizing Somatosensory Evoked Potentials (SSEP). State the limitations and the pathophysiology behind their generation. Have a basic understanding of interpretation. • Interpret the blink reflex in a normal patient, and in a patient with trigeminal and facial nerve involvement • Describe the sensitivity and specificity of the various studies to diagnose median neuropathy • Describe the combined sensory index (CSI) for diagnosing median neuropathy

ELECTROMYOGRAPHY(EMG) • List the common forms of voluntary and spontaneous activity seen with muscle disease • Be familiar with and apply the grading systems available for documenting the extent of spontaneous activity • Describe the effects of muscle disease on MUAP morphology • Give the differential diagnosis of an abnormal interference pattern • Discuss single fiber electromyography (SFEMG) and its possible uses • Define jitter and fiber density based on SFEMG usage • Discuss when not to perform electromyography as part of the testing • State the indications for anal sphincter EMG and how to perform the exam

Practice-Based Learning and Improvement Residents are expected to: • Review the American Association of Neuromuscular and Electrodiagnostic Medicine’s (AANEM) Recommended Policy for Electrodiagnostic Medicine • Review AANEM practice parameters for Electrodiagnostic studies in carpal tunnel syndrome, ulnar neuropathy at the elbow, and peroneal neuropathy • Perform the minimum number of tests to establish an accurate diagnosis

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Professionalism Residents are expected to: • Promote respect, dignity, and compassion for patients • Accept responsibility for own actions and decisions • Demonstrate reliability and punctuality • Understand and adhere to HIPPA regulations • Serve as a role model for the more junior residents • Supervise and teach residents who are just learning electrodiagnosis

Didactics Lectures See Didactics – Chapter 4

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SCI Rehabilitation

Through thousands of years of human history, spinal cord injury (SCI) was considered a terminal medical condition. A number of factors, principally the discovery of modern antibiotics in an era of evolving societal attitudes toward persons with disability have allowed countless individuals the opportunity not only to survive their injury but to lead happy and productive lives.

Improvements in the acute treatment of SCI now allow even the most severely injured individuals to survive, placing a greater emphasis on the goal of improving quality of life. Persons with SCI no longer consider medical issues to be paramount in the existence; issues of community reintegration and socialization top the list of disability-related problems reports by this group. A person with a new injury regains health and confidence in his or her abilities, successful adjustment is promoted by a separation of the disabled person form the medical model of rehabilitation. The ultimate goal of medical treatment is to allow these individuals the opportunity to live a satisfying personal and vocational life that is not dominated by medical problems.

Goals & Objectives Patient Care The resident will be expected to: • Admit as the primary care provider all acute and some chronic spinal cord injury (SCI) inpatients. Residents are responsible for all administrative care related to their patient including but not limited to: • Daily progress notes, discharge summaries, team rounds summaries, daily patient medication orders, comprehensive therapy orders, family conference summaries • Diagnose physical, cognitive, and psychosocial impairments in rehabilitation patients with spinal cord injuries. • Perform a comprehensive musculoskeletal and neurological examination and ASIA examination on selected patients. • Perform daily examinations on SCI inpatients to prevent medical complications. • Create a differential diagnosis appropriate to the physical findings. • Perform tracheobronchial suctioning of a patient with tracheotomy tube. • Prescribe and understand how a paraplegic and tetraplegic person performs a bed-to- wheelchair transfer. • Assist a tetraplegic person with rolling from side to side. • Attend a urodynamic study of a patient. • Alter bladder management of a person with SCI based on urodynamic data.

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• Decide when a ventilator-dependent spinal cord injured individual is wean able, and defend your decision utilizing various clinical factors including level of injury, completeness of injury, and measurements of respiratory function. • Develop a wound care management plan for a patient with pressure ulcers. • Débride pressure ulcers competently; gain authorization to perform without supervision. • Assist a tetraplegic person in mat-to-wheelchair transfer, with the supervision of rehabilitation professional. • Correctly perform a rectal examination of a spinal cord injured individual, including assessment of reflex function, sensation, and voluntary motor function. • Recommend appropriate inpatient and outpatient rehabilitation plans based upon the level of spinal cord injury and co-morbid conditions. • Learn to order appropriate diagnostic tests and interpret the findings of the ordered tests. • Be knowledgeable about the different types of wheelchair seating, positioning, and orthotics to maximize functional activity.

Medical Knowledge The residents will be expected to: • Report trends in epidemiology of SCI concerning: • Incidence and prevalence • Age at injury • Gender and ethnicity • Etiology • Life expectancy and causes of death • Associated injuries • Apply learned anatomy and physiology as appropriate. • On various radiographic studies of the spine, identify: • vertebral body, posterior elements • the spinal canal and cord • intervertebral discs • facet joints • locations of important ligaments • Describe current pharmacologic treatment for acute spinal cord injury. • Identify reasons for surgical treatment of acute spinal injuries. • Define spasticity. Describe the Ashworth scale. • Know the tracts of the spinal cord (neuroanatomy). Become familiar and comfortable with using ASIA classification including recognized spinal cord injury syndromes.

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• Describe the risk factors of pressure ulceration, prevention procedures, the international classification, and the management principles of ulcerations. • Identify and treat specific disorders that are commonly seen in the SCI population setting, including but not limited to: • Autonomic dysreflexia, DVT and prophylaxis, decubitus, stress ulcers, pneumonia, UTI, ileus, heterotopic ossification, spasticity, depression, neurogenic bowel/bladder, pulmonary/cardiac/GI complications, sexual dysfunction, metabolic changes, obstructive uropathy with and without • stones, infertility, and ejaculatory dysfunction • Design a bowel routine for the spinal cord injured individual with: • Upper motor neuron bowel • Lower motor neuron bowel • Identify and manage depression and adjustment disorder with psychological assistance. • Describe the pathophysiology of autonomic dysreflexia. • Describe non-pharmacologic and pharmacologic treatment for autonomic dysreflexia. • Understand the kinesiology of upper extremity function and the use of muscle substitution patterns in retraining. • Describe the indications and contraindications of muscle and tendon transfers and other operative procedures to enhance function. • Identify the indications and usage of functional electrical stimulation (FES) in SCI. • Evaluate and manage outpatient SCI patients with: joint pain, spinal pain, entrapment neuropathies, renal stones, UTI, contractures, spasticity, depression, neuropathic and central pain, respiratory illness, cholesterol disorders, metabolic issues: • Learn the physiology and basic science behind these disorders • Determine appropriate goals for patients with specific levels and degrees of SCI • Learn the complications of a patient aging with SCI as it applies to inpatient admission and severe illness and outpatient care • Learn physiology of respiratory disorders associated with SCI • Apply assistive technology to the patient in the appropriate manner for level of SCI • Create a wheelchair prescription for a SCI patient • Write appropriately therapy orders for the SCI patients

Practice-Based Learning and Improvement Residents are expected to: • Evaluate their own exam skills and knowledge and incorporate feedback from others. • Investigate and apply evidence from scientific studies to enhance patient care throughout the rotation. • Use information technology (computers, journals, etc.) to access and manage patient information and support their own education and treatment decisions.

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• Participate in Mortality and Morbidity conference in a manner that critiques and evaluates your own performance and identifies key learning points. • Facilitate the education of junior residents and medical students who rotate on the SCI unit. • Attend and participate in conferences and rounds. • Provide in-service talks to allied health personnel. • Investigate the outcomes of their treatment decisions.

Interpersonal and Communication Skills Residents are expected to: • Elicit information using effective questioning and listening skills. • Demonstrate caring and respectful behaviors (verbal and non-verbal) with patients. • Establish trust and maintain rapport with patients and family. • Complete all chart notes and dictations in a timely manner. • Present material clearly and accurately to patients and family • Regularly visit the therapy areas to observe patients engaged in restorative activities. • Effectively communicate patient needs, verbally and in writing, to all multidisciplinary staff and other physicians involved with the patient. • Prescription writing: write inpatient therapy orders and prescribe home health or outpatient prescriptions that include the following essential elements: diagnosis, parts to be treated, procedures to be used with specifications of techniques and time, special instructions or precautions, home instructions for the patient, and number and frequency of treatments. • Utilize effective listening skills. • Participate in all relevant rounds and discussions. • Participate and eventually lead multidisciplinary rounds and family conferences. • Present their findings clearly and concisely to supervising faculty so that management can be discussed.

Professionalism Residents are expected to: • Show leadership and become proficient at organizing and leading a family meeting. • Lead a multidisciplinary team in the care of SCI patients. • Exemplify respect and compassion towards patients. • Show reliability, punctuality, integrity, and honesty. • Accept responsibility for own actions and decisions. • Apply sound ethical principles in practice, including patient confidentiality, Informed consent, and provision and withholding of care, and interactions with insurance or disability agencies.

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• Complete all required chart documentation including admission notes, progress notes and discharge summaries, admission and discharge ASIA exams. • Consider the effects of personal, social, or cultural factors in the disease process and patient management. • Demonstrate sensitivity to the patients who have different ages, social status, races, and genders.

System-Based Practice Residents are expected to: • Gain knowledge about vocational rehabilitation and community resources for persons with spinal cord injury and musculoskeletal injuries. • Collaborate and work effectively with other health professionals and maintain appropriate behaviors. • Assess how their decisions affect others – patients, family, and other health care professionals. • Integrate care of patients across hospital and community settings. • Recognize when tests are appropriate or may be under- or over-utilized. • Understand the cost of the treatments and diagnostic tests that are ordered. • Describe the relevance and utility of the Functional Independence Measure (FIM). • Gain familiarity and participate in completion of the Inpatient Rehabilitation Facility Patient Assessment instrument (IRF-PAI), including identification of impairment codes and co-morbidities. • Understand which physicians are involved in the treatment of patients with disabilities and what their role is. • Advocate for patients who need tests and treatments that might be inappropriately denied. • Describe Medicare and Medicaid requirements as it relates to documentation, elements of the exam, billing procedures, and codes. • Realize limitations on the ability of patients to pay for their medications, therapies, or equipment

Didactics Lectures See Didactics – Chapter 4

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Neurorehabilitation

Neurorehabilitation is a complex medical process which aims to aid recovery from a nervous system injury such as Traumatic Brain Injury, Spinal Cord Injury and Stroke, and to minimize and/or compensate for any functional alterations resulting from it. Neurorehabilitation is the specialty of neuroscience, which deals with the study and application of complex medical precess aiming at recovery from nervous injury and to compensate for any functional alterations therein.

In case of a serious disability the patient and his/her families’ abilities, life style and projects are suddenly shattered. In order to cope with this situation, the person and his/her family must establish and negotiate a “new way of living”, both with their changed body and as a changed individual within a wider community.

Thus, neurorehabilitation works with the skills and attitudes of the disabled person and his/her family and friends. It promotes his/her skills to work at the highest level of independence possible for him/her. It also encourages him/her to rebuild self-esteem and a positive mood. Thus, he/she can adapt to the new situation and become empowered for successful and committed community reintegration.

Goals & Objectives Patient Care Residents are expected to: • Perform a rehabilitation medicine focused history and physical. • Generate a comprehensive problem list. • Incorporate pertinent medical issues into therapy orders in order to precisely define patient precautions. • Select appropriate orthotics and durable medical equipment for patients with brain disorders. • Define short and long term goals for patients. • Demonstrate proficiency in performing a neurologic examination. • Observe a neuropsychological evaluation of one patient. • Observe a bedside swallow evaluation of one patient.

Medical Knowledge Residents are expected to: • Describe common neurosurgical disease processes, including aneurysms, tumors, arteriovenous malformations, and traumatic brain injuries and their prognoses. • Recognize when neuro-stimulants are appropriate, and how to choose an appropriate medication.

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• Determine how to evaluate a patient for returning to safe driving. • Diagnose and treat agitation by using environmental manipulation and medications. • Describe the role and duration of use of anti-epileptic medications in the acquired brain injury population. • Describe the Rancho Los Amigos cognitive scale and the GOAT and how they are used in patient assessment. • Outline the diagnosis and prognosis of traumatic brain injury using variables such as extent of injury, Glasgow coma scale, trauma scores, age, premorbid function, and somatosensory evoked potentials. • Outline the prognosis for right vs. left CVA, hemorrhagic vs. embolic stroke, and include factors such as age and co-morbidities that may affect outcome. • Develop a treatment plan for patients with brain disorders who have: . Mental status changes . Limited joint range of motion . Pain in an extremity . Spasticity . Bowel/bladder dysfunction . Fevers . Skin breakdown

• Identify candidates for neurolytic procedures and intrathecal baclofen. • Describe the therapeutic approaches (Bobath, Brunnstrom, Forced use, Proprioceptive neuromuscular facilitation) used with patients with neurological dysfunction. • Describe the clinical characteristics of the common aphasic syndromes.

Practice Based Learning and Improvement Residents are expected to: • Read pertinent articles from recent evidence-based medical literature on the assessment and/or treatment of brain injury and apply this knowledge to the current care of the patient. • Present a lecture to the attending and other residents on an aspect of interest to you in the assessment and/or treatment of brain injury. • Discuss with the attending and other residents the limitations in the current knowledge base about brain injury, and possible directions for future clinical research to improve knowledge in this area.

Interpersonal and Communication Skills Residents are expected to: • Communicate effectively with patients and families from a broad range of socio- economic and cultural backgrounds.

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• Communicate effectively with physicians, other health professionals, and health related agencies. • Work effectively as a member or leader of a health care team or other professional group. • Act in a consultative role to other physician and health professionals. • Maintain comprehensive, timely, and legible medical records. • Develop the skills to interview cognitively impaired patients. • Recognize how to implement safe techniques during an encounter with an agitated patient. • Perform an interview of the patient and family members with special attention to the psychosocial aspects of the patient and family unit. • Lead a family and team conference in a manner that optimizes the contributions of each team member and coordinates their individual roles.

Professionalism Residents are expected to: • Participate in rounds and discussions. • Respect patient privacy and autonomy. • Be on time to lectures and rounds. • Apply sound ethical principles in practice including patient confidentiality, informed consent and provisions of withholding care. • Demonstrate sensitivity to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. • Demonstrate sensitivity to the patient and family members, and respect the psychosocial impact of brain injury on the family unit. • Develop an attitude of interdisciplinary cooperation with physical, occupational therapies, and speech-language pathology, social work, psychology, and nursing. • Function as a team leader and teacher for the more junior residents.

Systems-Based Practice Residents are expected to: • Coordinate patient care within the health care system. • Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care. • Advocate for quality patient care and optimal patient care systems. • Participate in identifying system errors and implementing potential systems solutions. • Identify the resources in the community after discharge from hospital, including post- acute rehab facilities, vocational rehabilitation, group homes, and day programs. • State the criteria for state-funded vocational rehabilitation services.

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• Understand how complex social issues and limited resources can affect the patient’s rehabilitation and outcome.

Didactics Lectures See Didactics – Chapter 4

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Joint & Connective Tissue Rehabilitation

The rheumatic diseases are more than 100 diverse disorders affecting the musculoskeletal system. Some of them are common (e.g. osteoarthritis, regional pain syndromes, fibromyalgia, osteoporosis, rheumatoid arthritis, and gout), and many of them are rare (e.g. connective tissue disease and metabolic disorders of collagen). In many cases, there are no known cures, but a number of pharmacologic, surgical and rehabilitative intervention are known to impact the course of these illnesses and improve the quality of life of people with rheumatic diseases.

Goals & Objectives Patient Care Residents are expected to: • Perform a rehabilitation medicine focused history and physical. • Generate a comprehensive problem list. • Incorporate pertinent medical issues into therapy orders in order to precisely define patient precautions. • Select appropriate orthotics and durable medical equipment for patients with Joint and Connective Tissue disorders. • Define short and long term goals for patients. • Demonstrate proficiency in performing a joint examination.

Medical Knowledge Residents are expected to: • Describe common Rheumatological disease processes, including aneurysms, tumors, arteriovenous malformations, and traumatic brain injuries and their prognoses. • Recognize when neuro-stimulants are appropriate, and how to choose an appropriate medication. • Diagnose and treat common arthritic conditions with environmental manipulation and medications. • Describe the role and duration of use of NSAIDs and DMARD agents medications. • Outline the diagnosis and prognosis of Rheumatologic disorders • Develop a treatment plan for patients who have: . Rheumatoid Arthritis . Ankylosing Spondylitis and other Seronegative Arthropathies . Systemic Lupus Erythematous . Scleroderma and Progressive System Sclerosis . Osteoarthritis

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Practice Based Learning and Improvement Residents are expected to: • Read pertinent articles from recent evidence-based medical literature on the assessment and/or treatment of Rheumatology and apply this knowledge to the current care of the patient. • Present a lecture to the attending and other residents on an aspect of interest to you in the assessment and/or treatment of Joints and Connective Tissue • Discuss with the attending and other residents the limitations in the current knowledge base about Rheumatology, Joint & Connective Tissue disorders, and possible directions for future clinical research to improve knowledge in this area.

Interpersonal and Communication Skills Residents are expected to: • Communicate effectively with patients and families from a broad range of socio- economic and cultural backgrounds. • Communicate effectively with physicians, other health professionals, and health related agencies. • Work effectively as a member or leader of a health care team or other professional group. • Act in a consultative role to other physician and health professionals. • Maintain comprehensive, timely, and legible medical records. • Develop the skills to interview cognitively impaired patients. • Recognize how to implement safe techniques during an encounter with a patient. • Perform an interview of the patient and family members with special attention to the psychosocial aspects of the patient and family unit. • Lead a family and team conference in a manner that optimizes the contributions of each team member and coordinates their individual roles.

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• Develop an attitude of interdisciplinary cooperation with physical, occupational therapies, and speech-language pathology, social work, psychology, and nursing. • Function as a team leader and teacher for the more junior residents.

Didactics Lectures See Didactics – Chapter 4

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Musculoskeletal, Sports and Occupational Medicine

In many countries musculoskeletal symptoms and diseases are the most common cause of functional imitation in the adult population. Musculoskeletal medicine encompasses all injuries and illness that relate to the muscles and skeletal bones of the human body. In many cases it is considered conservative orthopedic treatment.

Sports medicine is an important area of practice for many physical medicine & rehabilitation specialist. Because of their training in anatomy, biomechanics, pathophysiology of musculoskeletal injury and functional rehabilitation, physiatrist are well prepared to care for individual who exercise to achieve health-related benefits and those who participate in recreational and competitive sports. The rehabilitation medicine model applies well to the fields of sports medicine, and occupational medicine, because the majority of injuries related to sports, exercise and occupational injury do not require surgical intervention and should be treated by aggressive conservative care. Sports and Occupational Medicine care should be delivered in an interdisciplinary team approach, which is one of the strengths of the specialist of PM&R.

The goal of rehabilitation is to return the individual to normal form and function. The injure athlete should achieved normal flexibility, strength and muscle balance, as well as neuromuscular coordination, before returning to participation in sports. The process of rehabilitation should start as early as possible after injury and minimize functional losses associate with acute or chronic recuing injury. Evaluation, management and rehabilitation for sports or occupational injuries require an accurate diagnosis, and specific treatment addressing not only the area of injury but the complete kinetic chain.

Goals & Objectives Patient Care Residents are expected to: • Perform a history and physical on the youth/adult who presents with a sports or activity related injury • Recognize how changes in training schedule/equipment/environment can lead to increased risk of injury • Develop a differential diagnosis for common problems including pain in the wrists, elbows, shoulders, hips, knees, ankle, foot, and spine based on the results of the history and physical • Evaluate and manage patients with common musculoskeletal problems in an outpatient clinic

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Medical Knowledge Residents are expected to: • Recognize and develop a treatment plan for the following sports-specific injuries: . Swimmers: shoulder injuries, shoulder multidirectional instability, mid back pain . Golf: golfer’s elbow, wrist injuries, low back pain . Tennis: tennis elbow, shoulder pain, lower extremity sprains and strains . Gymnasts: pars defects and spinal hyperextension injuries . Runners: overuse injuries including shin splints, stress fractures, tendonitis . Football: stingers, cervical spine injuries including transient quadriplegia, how to manage concussions and return to play guidelines, knee injuries, turf toe . Basketball: common knee, ankle, hand injuries . Baseball: medial collateral ligament sprains of the elbow, rotator cuff injuries, labral injuries

• Learn about injuries common in the geriatric athlete • Manage knee OA in the active older adult • Recognize the signs and symptoms of steroid use in athletes • Learn indications for and appropriate radiographic investigations of musculoskeletal injuries • Review imaging findings of common diagnoses including, arthritis, fractures, stress fractures, spondylolysis, spondylolisthesis, rotator cuff tear, labral tear, ACL tears, meniscus injuries, osteochondral defects • Learn common injection techniques • Learn injury specific precautions/restrictions • Learn the appropriate go/no-go return to play criteria of players within a given sport • Learn the acute care of injuries that may occur during competition and how to deal with those injuries on the athletic field • Recognize those injuries for which a minor delay in treatment would not be deleterious to the athlete • Demonstrate knowledge of sports equipment, particularly protective devices intended to allow the athlete to continue competition • Recognize symptoms of concussion in athletes, treatment, and return to play guidelines • Understand the psychological manifestations of athletic injuries • Understand the female athlete triad • Understand physical therapy modalities used in musculoskeletal medicine • Describe the pertinent clinical anatomy of the shoulder, elbow, wrist, knee, hip ankle and foot • Describe the anatomy and biomechanics of the shoulder • Understand the mechanics of the throwing motion

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• Understand the relationship between shoulder instability and impingement and rotator cuff tears • Describe the pathophysiology and treatment of stress fracture and compartment syndrome • Describe common surgical approaches to hip arthroplasty and the post operative precautions • Describe post hip arthroplasty nerve injuries • Describe common sequelae of a fall on an outstretched hand • Review the pathophysiology and treatment of common overuse injuries including: medial and lateral epicondylitis, Achilles tendonitis, iliotibial band syndrome, carpal tunnel syndrome, DeQuervain’s tenosynovitis, plantar fascitis, and shoulder impingement • Describe the function of an impairment rating • Review the Dictionary of Occupational Titles descriptions for work duties (heavy, medium, light, etc.) • Learn the pathophysiology of hand and finger deformities in rheumatoid arthritis

Practice Based Learning and Improvement Residents are expected to: . Assimilate evidence from scientific studies related to patient health issues in the sports medicine field • Develop skills to apply knowledge of study designs and statistical methods to appraisal of clinical studies • Utilize the library and Internet to perform literature searches upon which to base their treatment of patients

Interpersonal and Communication Skills Residents are expected to: • Work collaboratively and collegially with the other physicians and health care professionals involved in sports medicine (physical therapist, athletic trainers, coaches, nutritionists, nurse, and sports psychologist) • Communicate effectively with athletes, coaches, parents, and other appropriate individuals regarding the diagnosis and management of injuries and the impact on sport activity • Develop organized and succinct patient presentations to the supervising doctor • Write complete therapy orders (diagnosis, treatment plan/duration and precautions) • Discuss discharge from therapy once goals have been achieved • Communicate return to work issues with the injured worker

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Professionalism Residents are expected to: • Arrive on time for clinics • Maintain confidence in all interactions with patients, especially professional athletes with some measure of celebrity. Refrain from discussion of the athlete with friends, family, and colleagues. • Complete medical record duties in accordance with clinic guidelines • Demonstrate sensitivity to culture, age, gender, and disabilities

Systems-Based Practice Residents are expected to: • Educate Orthopedic and Family Practice physicians on the role of the Physical Medicine Specialist • Understand how physician decisions impact cost effectiveness and efficiency of patient care • Develop the concept of how a well run outpatient practice clinic should function • Understand the role of athletic trainers and physical therapists in caring for sports injuries • Obtain experience in the organizational and operational requirements associated with providing for the medical and health needs for professional, collegiate, and youth athletic teams in season and off-season • Recognize drug formulary and treatment limitations imposed by some health insurance plans • Become aware of public and private support organizations for persons with musculoskeletal disorders

Didactics Lectures See Didactics – Chapter 4

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Pediatric Rehabilitation

Assessment of an infant or a child requires that the examiner has the ability to attain a complete medical, developmental, and family history; has a flexible approach to the physical examination; and understand the unique interaction between a child and that child’s physical and psychosocial environment. Establishing a diagnostic label is important, but determining the child’s functional status is also important for the rehabilitation management of the child. Although the evaluation of children has many similarities to that of adults, it also has many distinctive features.

Patient Care Residents are expected to: • Perform a physical examination in infants and young children adapted to the child’s varying degree of ability to cooperate and follow commands. • Demonstrate performance of an age-appropriate neurological examination including techniques for the assessment of motor strength, coordination, balance, mobility, tone, cognition and speech. • Generate a comprehensive problem list. • Define short term and long term goals for pediatric patients. • Demonstrate proficiency in the performance of an age-appropriate developmental examination of a child. • Apply an appropriate clinical scale for assessment of tone such as the Modified Ashworth Scale or Tardieu scale. • Assess swallow and suck in small infants. • Understand principles of neurotoxin therapy in pediatric patients with spastic hypertonia. • Obtain informed consent from the patient’s parent or guardian. • Counsel parents on prognosis following an acute brain or spinal cord injury.

Medical Knowledge Residents are expected to:

• Identify treatment goals for inpatient pediatric rehabilitation admission. • Describe the pathophysiology and principles of medical treatment for the major pediatric rheumatologic disorders, including systemic lupus erythematosus, juvenile rheumatoid arthritis, and spondyloarthropathies. • Identify appropriate indications for outpatient versus inpatient treatment of brain injury.

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• Display basic science and clinical knowledge of pediatric problems which cause disabilities and handicaps in children. These include, but are not limited to, the following diagnoses and conditions: . Multiple trauma . Brain disorders: cerebral palsy, traumatic brain injury, and stroke . Spinal Dysraphism . Birth defects . Abnormal muscle tone: spasticity and dystonia . Amputations . Malignancies . Muscle disorders • Apply special treatment modalities used more commonly in pediatric than adult rehabilitation, such as serial and “inhibitive” casting, nerve and motor point blocks, and special orthotics devices and gait aids such as parapodium, swivel walkers, reciprocating gait orthoses, and posture controlled walkers. • Perform and interpret electrodiagnostic studies in pediatric population. • Understand the principles of management of musculoskeletal disorders including sports injury in the pediatric age group. • Outline the therapeutic principles and approaches to the patient with neuromuscular disease. • Explain the management principles of burns and wounds in children. • Identify growth plates on radiographs of the developing child. • Describe the common types of peripheral nerve injuries in children. • Outline the major types of limb deficiencies and amputations in this age group. • Prescribe prostheses for children with limb deficiency of various causes, with appropriate consideration of their size and developmental level. • Develop a treatment plan for a pediatric patient with neurogenic bladder and/or bowel.

Practice Based Learning and Improvement Residents are expected to: • Read and discuss articles from the current evidence-based pediatric literature on the assessment and/or treatment of brain injury and the application of these principles to a patient. • Give a lecture to the attending physiatrist and other residents or students on the management of spinal cord injury or its complications. • Attend a performance improvement meeting of the rehabilitation unit and understand principles of quality improvement in the pediatric hospital setting. Discuss the methods used in the current literature for analyzing rehabilitation outcomes.

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Interpersonal and Communication Skills Residents are expected to: • Communicate effectively with patients and families from a broad range of socio- economic and cultural backgrounds. • Communicate effectively with physicians, other health professionals, and health related agencies. • Work effectively as a team member or leader of a health care team or other professional group • Maintain comprehensive, timely, and legible medical records. • Develop the skills to interview cognitively impaired patients of different age groups. • Perform an interview of the patient and family members with special attention to the psychosocial aspects of the family unit.

Professionalism Residents are expected to: • Participate in rounds and discussions. • Respect patient privacy and autonomy. • Be on time for lectures and rounds. • Understand and apply the federal rules on patient confidentiality of health care information (HIPAA) and the ethical principles of informed consent. • Demonstrate an attitude of interdisciplinary cooperation with physical and occupational therapies, and speech-language pathology, social work, psychology, and nursing staff.

Systems-Based Practice Residents are expected to: • Discuss the psychosocial and behavioral aspects of rehabilitative management including family centered care, and to be familiar with the provision of school services for children with special needs. • Attend a team conference in which community resources are facilitated for children pending discharge from inpatient stay. • Advocate for quality patient care. • Identify the resources in the community available after discharge from hospital.

Didactics Lectures See Didactics – Chapter 4

49 Integrated Competency Based Curriculum 2012-2013

Amputee Rehabilitation and Prosthetics & Orthotics

Limb amputation remains one of the classic rehabilitation diagnoses amenable to intervention by a physiatrist. Rehabilitation and prosthetic interventions offer tremendous potential for improvement of amputee physical functioning, emotional well-being, and quality of life. Administering treatment to this population is profoundly rewarding. Despite advance in medicine, industry and technology, amputation remains a leading source of disability.

Goals & Objectives Patient Care Residents are expected to: • Perform a focused PM&R related History and Physical exam for patients with amputation and dysvascular disease, detailing skin or residual limb status and neurological issues which will affect the prosthesis prescription. • Prescribe adult and pediatric prosthetics and therapy with appropriate activity restrictions and precautions. This would include complete prosthetic prescriptions for: a young, otherwise healthy, transtibial, and transfemoral amputee and an older, dysvascular, transtibial, and transfemoral amputee • Prescribe a pre-amputation care plan and pre-prosthetic training program • Coordinate care with consultants (e.g., goal-directed therapy, orthotic/prosthetic prescriptions) • Prescribe functionally and neurologically appropriate orthoses, prostheses, and durable medical equipment • Screen patients to determine who is an appropriate candidate for a prosthetic device and the appropriate timing for prosthetic fitting • Evaluation, identification, and management of limb deficiency / amputation • Prescribe adult and pediatric orthoses for patients with neurological or musculoskeletal disorders • Perform an assessment / evaluation / “check out” of an orthosis, prosthesis, wheelchair, or other durable medical equipment • Prescribe a wheelchair / seating system for an adult and a pediatric patient with neurological or musculoskeletal disorders including hemiplegia, quadriplegia, or paraplegia • Understand, recognize, assess, and manage the following secondary problems of amputees: . Phantom sensation . Phantom pain . Choking phenomenon of the distal residual limb . Verrucous hyperplasia

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. Contractures • Depression and adjustment disorder following an amputation • Evaluate and manage skin problems utilizing various techniques of prevention and various modalities for managing edema and skin breakdown • Evaluate and manage additional amputation complications of the skin, bony overgrowth, and infection • Understand, recognize, assess, and manage prosthetic and pathologic gait deviations as they relate to prosthetic and orthotic setup and alignment • Identify important considerations in the rehabilitation evaluation and management of the geriatric amputee • Describe management of the foot in peripheral vascular disease and diabetes • For UE amputees, discuss the steps of prosthetic training and the body motion used to operate the prosthesis • Measure a patient for and instruct him/her in the use of a cane • Prescribe the appropriate orthotic or shoe modifications for various skeletal deformities of the insensate foot • Understand the differences between power wheelchairs and power scooters, including the benefits and limitations of each

Medical Knowledge Residents are expected to: • Learn to evaluate and prescribe assistive devices and technology, including: orthotics, prosthetics, wheelchairs and positioning, ADL aids, interfaces and environmental controls, augmentative/alternative communication, environmental accessibility, electrical stimulation, and dynamic splinting • Discuss the epidemiology & common causes of limb amputation • Discuss indications for amputation and the process of determining the amputation level, including hip disarticulation, AKA, BKA, and Symes, and review basic aspects of pre- and post-op surgical care • Discuss the various components of an upper extremity and lower extremity prosthesis and the indications/contraindications for the use of each component • Explain the purpose of a removable rigid dressing • Understand and outline the steps in the fabrication of a prosthesis • Explain the benefits of early prosthetic fitting and ambulation • Discuss the timing of prosthesis for congenital and acquired pediatric amputees • Discuss the differences between a pediatric and adult amputee • Discuss ambulatory prognosis based upon level of amputation • Discuss life expectancy and causes of death after amputation • Demonstrate knowledge of the rehabilitation management of edema

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• Evaluate and develop a differential diagnosis for a painful limb in the amputee • Describe the various phases of gait, indicate changes in joint angles, analyze forces and identify the active muscles • List the six major determinants of gait and know how they help decrease energy requirement • Learn the increased energy requirements to walk with different types of prosthesis • Learn how patient co-morbidities (stroke, diabetes, cardiovascular disease, diabetes, renal failure) will affect prosthetic choice • Describe indications for and specifics of drugs used for phantom pain • Discuss the various causes of foot drop • Evaluate various types of AFO's, KAFO's, and HKAFO's and their indications and contraindications • Discuss the implications of materials, components, and design in the prescription of various types of lower limb orthoses • Discuss the differences between static and dynamic bracing and the rationale for the use of each type • List six reasons for the use of orthotics • Explain the biomechanics of a single- and dual-chamber ankle joint in the AFO • List component parts of a standard commercial shoe and the significance of each part • Review the various types of mobility devices available for children • Discuss the effectiveness of immobilization (spinal orthotics, halo vest, SOMI, cervical collars, and TLSO) and discuss possible complications of these devices • Understand the principles of spinal stability • Discuss the various components of a wheelchair and the indications/contraindications for the use of each component • Explain the special considerations needed to appropriately prescribe a wheelchair for a pediatric patient • Discuss different types of canes, crutches, and walkers and know the advantages and disadvantages of each

Practice-based Learning and Improvement Residents are expected to: • Become proficient in the use of the hospital’s computer system in order to obtain medical records, lab results, imaging study results, and other ancillary notes • Critically review and analyze appropriate literature regarding prosthetics, orthotics, & medical devices • Prepare lectures for the didactic lecture series, to further enhance PM&R knowledge • Educate and supervise junior residents, rotators and medical students who are spending time on the rotation

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Interpersonal & Communication Skills Residents are expected to: • Explain basic residual limb management techniques to patients and families • Educate patients and families about possible complications associated with amputations (contractures, contralateral foot ulcers, etc.) • Appropriately convey medical and prognostic information to the patient, the patient's family, and allied health staff • Communicate with the orthotist / prosthetist regarding appropriate orthotic / prosthetic treatment plans • Develop effective presentation skills • Develop appropriate communication skills when working with medical/surgical consultants from other specialties • Develop rapport with patients and patients’ families • Develop skills in team management and leadership while working with the consult team members, pediatric team members and while participating in the various team and family conferences • Work as a part of the referral development team to enhance the efficiency of the admission process • Develop skills in team management and leadership • Identify and overcome obstacles to effective communication and care with the elderly rehabilitation patient • Identify and overcome obstacles to effective communication and care for non-English speaking patients and patients of differing cultures

Professionalism Residents are expected to: • Demonstrate professional and courteous communication to the patient, the patient's family, referring physicians and allied health staff • Demonstrate ability to serve non-English speaking and English speaking patients equally through the use of interpreters when needed • Recognize cultural / ethnic diversity and how that reflects differences in prosthetic and orthotic management • Demonstrate understanding of cultural, age, religion, and gender differences in patients • Understand and adhere to HIPPA regulations • Understand the ethical principles involved in managing children who have congenital disease or trauma • Demonstrate traits of reliability and punctuality • Demonstrate sensitivity to patients’ perception of disability

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Systems-based Practice Residents are expected to • Understand Medicare guidelines and K-code levels for prosthetic prescriptions • Advocate for all patients equally within the healthcare system • Determine appropriate discharge disposition for patients, including acute rehab, subacute rehab, ECF, home health, and outpatient therapy • Become familiar with discharge planning, educational and vocational planning, transitional planning, and adjustment to disability support • Become involved with administrative aspects of pediatric care, including principles of organizational behaviors and leadership, quality assurance, cost efficiency, knowledge of health care systems, community resources, and support services regulations pertaining to service provision (external reviews, inpatient services, outpatient services, home care, school based programs and capabilities), skills for effective advocacy, medical legal aspects (child protective services, guardianship, liability) • Review indications for radiographs, electrodiagnostic studies, vascular studies, CT, and MRI scans with patients and discuss the indications for invasive procedures • Understand management limitations and when to request appropriate medical/surgical consultations from other specialties • Coordinate care for patients and ensure a smooth transition at the time of discharge • Assess the efficacy of rehabilitation on maintaining achieved gains and reducing long- term costs • Understand vocational rehabilitation services available for amputees • Discuss vocational outcome and issues after amputation • Describe characteristics of appropriate home features and van features for wheelchair dependent individuals • Discuss and utilize community, healthcare, social, and financial resources that may be available to enhance function, care, and safety in the amputee rehabilitation patient

Didactics Lectures See Didactics – Chapter 4

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Medical Rehabilitation Disease management is shifting from inpatient to outpatient care, from invasive to noninvasive therapies from treatment to prevention. Certain medical conditions provide unique impairments or disabilities as well as potential challenges to the rehabilitation of patients with common injuries. This domain focuses on specific medical conditions and their impact on rehabilitation.

Goals & Objectives Patient Care Residents are expected to: • Perform a focused PM&R related History and Physical exam for patients with medical conditions, detailing skin or neurological issues which will affect the rehabilitation prescription. • Prescribe functionally and neurologically appropriate orthoses, prostheses, and durable medical equipment • Screen patients to determine who is an appropriate candidate for a orthotic and prosthetic devices • Evaluation, identification, and management of deficiencies in Activities of Daily Living due to medical conditions. • Understand, recognize, assess, and manage the following secondary problems from: . Pulmonary Disease . Cardiac Disease . Burns . Cancer Medical Knowledge Residents are expected to: • Learn to evaluate and prescribe assistive devices and technology, including: orthotics, prosthetics, wheelchairs and positioning, ADL aids, interfaces and environmental controls, augmentative/alternative communication, environmental accessibility, electrical stimulation, and dynamic splinting • Discuss the epidemiology & common causes of Pulmonary Disease • Discuss the epidemiology & common causes of Cardiac Disease • Discuss indications for amputation and the process of determining the amputation level, including hip disarticulation, AKA, BKA, and Symes, and review basic aspects of pre- and post-op surgical care • Discuss the various components of an upper extremity and lower extremity prosthesis and the indications/contraindications for the use of each component • Explain the purpose of End of Life and Palliative Care • Understand and outline the rehabilitation of: 55 Integrated Competency Based Curriculum 2012-2013

o Burns o Cardiac Disease o Cancer Rehabilitation . Exercise and Fatigue management . Chemotherapy sequela . Lymphedema

Practice-based Learning and Improvement Residents are expected to: • Critically review and analyze appropriate literature regarding Physical Medicine & Rehabilitation • Understand Research Proposals • Discuss relevance of clinical research • Educate and supervise junior residents, rotators and medical students who are spending time on elective rotations at NRH.

Interpersonal & Communication Skills Residents are expected to: • Communicate with the research professionals and colleagues • Develop effective presentation skills • Develop appropriate communication skills when working with office staff and administrative support • Work as a part of the research team • Develop skills in team management and leadership • Identify and overcome obstacles to effective communication

Systems-Based Practice Residents are expected to:

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• Discuss the psychosocial and behavioral aspects of rehabilitative management including family centered care. • Attend a team conference in which community resources are facilitated for patients pending discharge from inpatient stay. • Advocate for quality patient care. • Identify the resources in the community available after discharge from hospital.

Didactics Lectures See Didactics – Chapter 4

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Rehabilitation Research

Research is critical for improving the day-to-day practice of medicine. The skills of clinical research are core knowledge for the improvement of clinical cared and should be part of the repertoire for every physician, starting with the residency. Leaders in our field have argued strongly that a foundation of basic research skills should be included as part of residency training and incorporate into the lifelong learning of each physiatrist.

For physical medicine and rehabilitation to thrive as a specialty, we must develop a clear presence in medical schools, where academic physiatries are carrying out research and education in contact with peers in other specialties. Physiatric research must demonstrate that the treatments we offer are clinically effective and cost-effective, so they will be covered in an age of unrelenting fiscal restraint. Recent surveys demonstrate a need to increase the number of physiatrists who are engaged in research.

Goals & Objectives Patient Care Residents are expected to: • To deliver care using Tele-rehabilitation and technology • To translate evidence-based research to clinical practice and care of patients

Medical Knowledge Not applicable

Interpersonal & Communication Skills Residents are expected to: • Communicate with the research professionals and colleagues • Develop effective presentation skills • Develop appropriate communication skills when working with office staff and administrative support 58 Integrated Competency Based Curriculum 2012-2013

• Work as a part of the research team • Develop skills in team management and leadership • Identify and overcome obstacles to effective communication

Professionalism Residents are expected to: • Demonstrate professional and courteous communication to the patient, the patient's family, referring physicians and allied health staff • Recognize cultural / ethnic diversity and how that reflects differences in research • Understand and adhere to HIPPA regulations • Understand the ethical principles involved in managing protected health information • Demonstrate traits of reliability and punctuality • Demonstrate sensitivity to patients’ perception of disability

Systems-based Practice Residents are expected to: • Demonstrate ethical behavior during research • Understand the relevance of clinical research

Didactics Lectures See Didactics – Chapter 4

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Rehab Administration & Practice Management

Rehab Administration and Practice Management demands an orientation and mastery of professionalism, communication, critical thinking skills and leadership skills. The role requires proficiency and aptitude, which is critical to one’s success as well as the medical practice’s.

Operating a Rehabilitation Medical practice is not like managing a hospital, nursing home, or even a retail store. It requires a special set of technical and professional knowledge and skills that are unheard of in other professions. The diversity and variety of situations that occur in a Rehabilitation Medical practice make its managers and executives a unique breed.

Goals & Objectives Patient Care Residents are expected to: • Identify important non-medical considerations related to the delivery of medical carer that create barriers to the rehabilitation of a patient. • Understand National Patient Safety Goals • Understand the types and delivery of Post-Rehabilitation Care • Identify important and unique treatment plans for the worker’s compensation patient • Understand historical and current legislation and policies facing the care of the rehabilitation patient and it impact on plan of care

Medical Knowledge Not applicable

Practice-based Learning and Improvement Residents are expected to: • Become proficient in the use of the New Innovations software • Become proficient in the use of the hospital’s computer system in order to obtain medical records, lab results, imaging study results, and other ancillary notes • Critically review and analyze appropriate literature regarding practice-based learning • Educate and supervise junior residents, rotators and medical students who are spending time on elective rotations at NRH.

Interpersonal & Communication Skills Residents are expected to: • Explain basic practice management techniques to patients, families, and other health care professionals.

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• Communicate with the case managers and insurance adjustors • Develop effective presentation skills • Develop appropriate communication skills when working with office staff and administrative support • Work as a part of the referral development team to enhance the efficiency of the admission process • Develop skills in team management and leadership • Identify and overcome obstacles to effective communication

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• Understand management limitations and when to request appropriate medical/surgical consultations from other specialties • Coordinate care for patients and ensure a smooth transition at the time of discharge • Assess the efficacy of rehabilitation on maintaining achieved gains and reducing long- term costs • Discuss and utilize community, healthcare, social, and financial resources that may be available to enhance function, care, and safety in the amputee rehabilitation patient

Didactics Lectures See Didactics – Chapter 4

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General Physical Medicine & Rehabilitation and Therapeutics

Physiatrists are physicians who specialize in Physical Medicine and Rehabilitation and are trained to diagnose, treat, and direct a rehabilitation plan that provides the best possible outcomes for these patients. Physiatry not only employs the usual tools of medicine, but also uses physical agents and therapeutic exercise in the prevention, diagnosis, treatment and rehabilitation of disorders that produce pain, impairment and disability. This domain encompasses those areas that are essential to the therapeutics involved in developing a plan for rehabilitation regardless of the diagnosis or cause of disability.

Goals & Objectives Patient Care Residents are expected to: • Identify important medical considerations related to the delivery of medical care that create barriers to the rehabilitation of a patient • Manage patients with complex medical conditions • Understand how comorbidities modify the Rehabilitation Plan of Care for patients. • Understand infection control • Identify key components to a PM&R Therapy Prescription • Define discharge plan for post acute rehabilitation care • Prescribe environmental control units • Provide ostomy care • Understand the role of the Rehabilitation nurse

o Pain medications o NSAIDs o Antiepileptics o Cannabinoids o Neuro-pharmacologic agents

Practice-based Learning and Improvement Residents are expected to: • Become proficient in the use of the hospital’s computer system in order to obtain medical records, lab results, imaging study results, and other ancillary notes • Critically review and analyze appropriate literature regarding practice-based learning • Educate and supervise junior residents, rotators and medical students who are spending time on elective rotations at NRH.

Interpersonal & Communication Skills Residents are expected to: • Explain basic practice management techniques to patients, families, and other health care professionals. • Communicate with the case managers and insurance adjustors • Develop effective presentation skills • Develop appropriate communication skills when working with office staff and administrative support • Work as a part of the referral development team to enhance the efficiency of the admission process • Develop skills in team management and leadership • Identify and overcome obstacles to effective communication

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• Demonstrate traits of reliability and punctuality • Demonstrate sensitivity to patients’ perception of disability

Systems-based Practice Residents are expected to • Understand Medicare guidelines for admission to Inpatient Rehabilitation Facilities. • Advocate for all patients equally within the healthcare system • Determine appropriate discharge disposition for patients, including acute rehab, subacute rehab, ECF, home health, and outpatient therapy given their resources for payment of services • Become familiar with cost and logistics of the discharge plan, educational and vocational plan, transitional plan, and adjustment to disability support • Become involved with administrative aspects of Rehabilitation care, including principles of organizational behaviors and leadership, quality assurance, cost efficiency, knowledge of health care systems, community resources, and support services regulations pertaining to service provision (external reviews, inpatient services, outpatient services, home care, school based programs and capabilities), skills for effective advocacy, medical legal aspects (child protective services, guardianship, liability) • Understand management limitations and when to request appropriate medical/surgical consultations from other specialties • Coordinate care for patients and ensure a smooth transition at the time of discharge • Assess the efficacy of rehabilitation on maintaining achieved gains and reducing long- term costs • Discuss and utilize community, healthcare, social, and financial resources that may be available to enhance function, care, and safety in the amputee rehabilitation patient

Didactics Lectures See Didactics – Chapter 4

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Humanities in Rehabilitation Medicine

Humanities in Rehabilitation Medicine includes an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, and visual arts) and their application to medical education and practice. The humanities and arts provide insight into the human condition, suffering, personhood, our responsibility to each other, and offer a historical perspective on medical practice. Attention to literature and the arts help to develop and nurture skills of observation, analysis, empathy, and self-reflection -- skills that are essential for humane medical care. The social sciences help us to understand how bioscience and medicine take place within cultural and social contexts and how culture interacts with the individual experience of illness and the way medicine is practiced.

Goals

• To educate residents and medical students in the basic ethical and social questions confronting the contemporary physician, especially in the field of Physical Medicine & Rehabilitation • To acquaint the resident/student with works in the history of medicine, social medicine and literature as related to medicine • To integrate ethical and social concerns with the accompanying basic sciences curricula • To provide sustenance for residents/students with regard to the developing relationship between scientific, technological and humanistic learning in the making of a physician • To stress the complex interpersonal, social, legal and political factors in the physician- patient relationship; and to increase tolerance of differing values in order to reduce prejudice in health care delivery

Objectives

Patient Care Residents are expected to: • Demonstrate proficiency in the performance of delivering bad news. • Understand the role of care givers in the rehabilitation setting. • Respect cultural competency. • Understand the effect on patient care through spirituality in medicine.

Medical Knowledge Not applicable

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Practice Based Learning and Improvement Residents are expected to: • Learn strategies in dealing with stress and fatigue in Residency Training. • Discuss the epidemiology & common causes Physician Impairments • Explain the purpose of Connecting Art and Literature to Medical Education • Understand and outline the steps in Self-Reflection. • Describe indications for and specifics of drugs used for phantom pain • Understand “Doctors as Healers.”

Interpersonal and Communication Skills Residents are expected to: • Communicate effectively with difficult patients and families from a broad range of socio- economic and cultural backgrounds. • Communicate effectively with physicians, other health professionals, and health related agencies. • Work effectively as a team member or leader of a health care team or other professional group • Maintain comprehensive, timely, and legible medical records. • Develop the skills to interview cognitively impaired patients of different age groups. • Perform an interview of the patient and family members with special attention to the psychosocial aspects of the family unit.

Professionalism Residents are expected to: • Understand the Ethics of Professionalism • Recognize signs and symptoms of Physician Impairment • Respect patient privacy and autonomy. • Be on time for lectures and rounds. • Understand and apply the federal rules on patient confidentiality of health care information (HIPAA) and the ethical principles of informed consent. • Demonstrate an attitude of interdisciplinary cooperation with physical and occupational therapies, and speech-language pathology, social work, psychology, and nursing staff.

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• Understand Healthcare Disparities. • Attend a team conference in which community resources are facilitated for children pending discharge from inpatient stay. • Advocate for quality patient care. • Identify the resources in the community available after discharge from hospital.

Didactics Lectures See Didactics – Chapter 4

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GUH- NRH PM&R RESIDENCY

Chapter 3 Rotations

here are currently 22 resident PM&R clinical rotation as part of this curriculum. Each post graduate year level will consist of 12 months of clinical rotations. All of the inpatient clinical T rotations take place at the National Rehabilitation Hospital. The major affiliation sites include Washington Hospital Center, Walter Reed Army Medical Center, Children's National Medical Center, and Veterans Administration Medical Center, located in Washington DC, as well as National Institutes of Health –Rehabilitation Medicine Department, Concentra Medical Center in the DC – Maryland suburbs. These locations included inpatient consultations and outpatient ambulatory clinics.

Each rotation is governed by a Domain to ensure the integrated competency based program and oversee the intellectual properties taught. Each rotation is evaluated by the resident at the end of the rotation as well as the faculty assigned to that rotation.

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Rotation Grid PGY2 PGY3 PGY4 SCI ( IP) 2 1 MSK ( IP) 2 1 TBI (IP) 2 1 STROKE (IP) 2 1 VA/GERIATRICS (OP/IP) 1 OCC HEALTH/EMG (OP) 2 PEDS (OP/IP) 2 RAD/VNA/P&O (OP) 1 OPC (OP) 1 PAIN (CONSULT) or ELECTIVE PGY2/3 1 1 ELECTIVE PGY3 1 ELECTIVE PGY4 1 ELECTIVE PGY4 OR NEURO/WHC 1 (CONSULT) OPC BETHESDA (OP) 3 EMG/WRAMC (EMG) 3 PM&R in Private Practice 1 ORTHO/SM (OP) 1 NIH (OP) 2 RHEUMATOLOGY (OP) 1 WHC CONSULTS (CONSULTS) 1 Table 2 - Rotation Grid as of 4/14/2009

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Spinal Cord Injury

Spinal Cord Injury – PGY2

GMEC Approved on: October 3, 2012 Domain: Spinal Cord Injury Level: PGY2 Length: 2 months (3 months for the WRAMC residents) Type: Inpatient Rotation Director: Dr. Pamela Ballard Faculty: Dr. Pamela Ballard, Dr. Dallas Lea, Dr Suzanne Groah, and Dr Camilo Castillo

General Educational Objective The PGY2 resident manages the Inpatient Rehabilitation Spinal Cord Injury patient as measured by the resident physician’s participation in team conferences, daily patient rounding and assessments (such as ASIA, Neuro, MSK, Cardiovascular and Pulmonary), development to plan of care, admission history & physicals and discharge summaries.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the Spinal Cord 2. Common types of adult Spinal Cord Injury pathophysiology acquired by neurological disease, malignancy and through traumatic events causing Paraplegia or Tetraplegia a. Central Cord Syndrome b. Brown-Sequard syndrome c. Anterior Cord syndrome d. Conus Medullar syndrome e. Cauda Equina syndrome f. SCI through Traumatic events g. Multiple Sclerosis h. Transverse Myelitis i. Amyotrophic Lateral Sclerosis j. Guillain Barrie’ Syndrome 3. Management of common sequela of Spinal Cord Injury a. Heterotrophic Ossification b. Autonomic Dysreflexia c. Pulmonary complications d. DVT

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e. Metabolic Changes f. Hypotension 4. Procedure Skills a. ASIA Exam b. Halo Adjustments – if available on service

Methods of Teaching 1. Clinical Sites a. National Rehabilitation i. 2 West Unit 2. Clinical teaching a. PM&R Bedside Rounds b. Therapy Rounds: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the resident’s duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. Physical Therapy ii. Occupational Therapy iii. Speech Language Pathology iv. Recreational Therapy c. Team Conferences d. Family Conferences 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Held at Lunch time on Tuesday and Thursday during the first week of the rotation and every Tuesday after that 1. Interactive discussion 2. Question & Answer 3. Lecture topics below 4. Case discussion ii. Lectures.

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Week Topic 1 Introduction to Spinal Cord Injury Rotation 1 Spinal Cord: Anatomy, Physiology, and Pathophysiology Chapter 2 Epidemiology of Traumatic Spinal Cord Injury Chapter 5

2 Assessment and classification of Traumatic Spinal Cord injury Chapter 6 3 Predicting Outcomes Following Traumatic Spinal Cord Injury Chapter 8 Rehabilitation of Spinal Cord injury 4 Cardiovascular and Autonomic Dysfunctions After Spinal Cord injury Chapter 9 Respiratory Management of the Spinal Cord injury Patient Chapter 10 5 Gastrointestinal Disorders Chapter 11 Neurogenic Bladder Following Spinal Cord injury Chapter 13 6 Pressure Ulcers and Spinal Cord Chapter 14 Sexual Function and Fertility after Spinal Cord injury Chapter 23 7 Spasticity Chapter 15 Neuropathic pain after Spinal Cord Injury chapter 26 8 Metabolic Disorders (HO) Dual Diagnosis: Traumatic Brain Injury with Spinal cord injury Chapter 20 9 Test questions Make up Lecture and Article review 10 Test questions, Make up Lectures and Article review 11 Test questions, Make up lectures, and Article review. 12 Test questions, Make up lectures, and Article review

Table 3 - SCI Didactic Lectures (We will provide the weekly reading materials required to prepare each talk)

b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference

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iv. MedStar GUH - MedStar NRH Journal Club 5. Examination:

a. All NRH residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 2nd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY2 resident reports directly to the faculty attending and senior resident if on the rotation cycle. The PGY2 will be responsible to help supervise medical students. The medical student will report to the PGY2 as first line then the attending on service. The resident will work with and be supervised with each attending faculty for one month.

74 Integrated Competency Based Curriculum 2012-2013

Specific Competency – Based Goals & Objectives

SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES PATIENT CARE GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the SCI patient. OBJECTIVES: The resident is able to: Demonstrate basic knowledge in determining the mechanism of injury. Demonstrate basic knowledge in appreciating the pain of SCI. Demonstrate appropriate usage of the ASIA system of neurologic classification. Demonstrate the ability to recognize and appropriately grade spasticity in the SCI patient. Demonstrate the ability to recognize occult fractures in the SCI patient. Demonstrate the ability to recognize cardiopulmonary pathology in the SCI patient. Demonstrate the ability to detect GI pathology in the SCI patient. Demonstrate the ability to detect DVT's in the SCI patient. Demonstrate the ability to detect heterotopic ossification in the SCI patient. Demonstrate the ability to detect Osteoporosis in the SCI patient. Demonstrate the ability detect autonomic dysreflexia in the SCI patient. Demonstrate the ability to detect the cause of pain in the SCI patient. Demonstrate the ability to detect and classify pressure ulcers.

PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the SCI patient. OBJECTIVES: The resident is able to: Demonstrate understanding as to how the ASIA rating affects patient prognosis. Predict the expected functional outcome of a SCI patient based on the ASIA exam, including his/her potential degree of independence in ADL’s, ambulation and driving, based on level of injury. Demonstrate understanding of indications for UE reconstructive surgery. Exercise Prescription and Modalities

75 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the SCI patient. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for SCI patient which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity with Botox, Baclofen and Muscle relaxants. Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional procedures for SCI patients as well as perform appropriate ones as needed. OBJECTIVES: The resident is able to: Demonstrate hands-on understanding of Urodynamic studies. Demonstrate ability to read routine spinal films/MRI’s/CT scans and to diagnose by these studies vertebral fractures, spinal infarcts/contusion/hemorrhages, and the development of a spinal syrinx. Demonstrate knowledge of the indications for emergency decompressive spinal surgery. Demonstrate knowledge of post-operative complications of bone graft harvesting/application, and metal fixation devices used in spine stabilization surgery. Demonstrates ability to perform PVR scans and to catheterize both male and female patients. Electrodiagnostic Skills – N/A

Prosthetics/Orthotics/Medical Equipment

76 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES Demonstrate knowledge of the indications for the use of hand orthotics including: Universal cuff Tenodesis splint Demonstrate knowledge of adaptive ADL equipment appropriate to spinal cord injury. CLINICAL JUDGEMENT

77 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES Demonstrate the ability to treat autonomic dysreflexia. Demonstrate the ability to treat spasticity in the SCI patient with appropriate pharmacologic and therapeutic intervention. Demonstrate the ability to care for bowl/bladder abnormalities of the SCI patient. Demonstrate the ability to provide appropriate sexual information to the SCI patient regarding reproduction as well as techniques to enhance sexual pleasure. Demonstrate the ability to treat pressure ulcers. Understand the psychological adjustment required by the SCI patient and his/her significant other and can treat/refer appropriately for depression and other conditions that may interfere with the individual obtaining his/her highest possible functional level. Understand that the continuum of care of the SCI patient includes appropriate vocational/educational rehabilitation. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with SCI. OBJECTIVES: The resident is able to: Demonstrate knowledge of the epidemiology of SCI including incidence/ prevalence/age and gender distribution/etiology of injury/level of injuries/morbidity and mortality (early and late) Demonstrate understanding of the acute medical management of spinal cord injury, including pharmacotherapy. Demonstrate knowledge of: anatomy/neuroanatomy and physiology of bowel/bladder normal voiding and elimination anatomy/neuroanatomy and physiology of sexual functioning in the male and female PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with SCI. OBJECTIVES: The resident is able to: Understand the anatomy of the spinal cord and common neurologic syndromes.

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SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES Understanding the ASIA System of neurological classification of SCI. Demonstrate understanding the pathophysiology of the Cardiopulmonary system of the SCI patient. Demonstrate understanding the pathophysiology and pathology of the GI system of the spinal cord injury patient including gastric atony, GI bleeding, superior mesenteric artery syndrome and hypercalcemia. Demonstrate understanding the neuroanatomy and pathophysiology of heterotopic ossification and osteoporosis in spinal cord injury. Demonstrate understanding of the physiology of spasticity in spinal cord injury. Demonstrate understanding of the physiology of autonomic dysreflexia. Demonstrate understanding of the consequences of pain in the SCI patient and provide a differential diagnosis of same. Demonstrate understanding the medical and surgical intervention of pressure ulcers. PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able: To analyze practice experience and perform practice-based improvement activities using a systematic methodology. To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

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SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and significant others. Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals.

PROFESSIONALISM

PROFESSIONAL ATTITUDE

80 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY2 GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books/booklets

. Spinal Cord Medicine, Second Edition 2011, Steven Kirshblum. Denise Campagnolo. Chapters require for reading will be available at the WHC online Library

. International Standards for Neurological Classification of Spinal Cord Injury, American Spinal Injury Association, Revised 2011.

. Physical Medicine & Rehabilitation, Randall L Braddom MD MS.

. 2nd edition: • Chapter 55 - Spinal Cord Injuries Medicine 81 Integrated Competency Based Curriculum 2012-2013

• Chapter 15 - Upper Limb Orthotic Devices • Chapter 17 - Spinal Orthoses in Rehabilitation • Chapter 19 - Therapeutic Exercises • Chapter 22- Electrical Stimulation • Chapter 23 - Computer Assisted Devices and Environmental Control • Chapter 25 - Achieving Functional Independence • Chapter 27 - Management of Bladder Dysfunction • Chapter 28 - Neurogenic Bowel: Dysfunction and Management • Chapter 29 - Spasticity • Chapter 30 - Sexuality Issues in Persons with Disabilities • Chapter 31 - The Prevention and Management of Pressure Ulcers and Other Chronic Wounds • Chapter 34 - Deconditioning, Conditioning, and The Benefits of Exercise • Chapter 35 - Employment of Persons with Disabilities . 3rd edition: • Chapter 56 – Spinal Cord Injury • Chapter 15 - Upper Limb Orthotic Devices • Chapter 17 - Spinal Orthoses in Rehabilitation • Chapter 18 – Prescription of Wheelchairs and Seating Systems • Chapter 19 - Therapeutic Exercises • Chapter 22- Electrical Stimulation • Chapter 24 - The Roll of Assistive Technology in Rehabilitation • Chapter 29 - Management of Bladder Dysfunction • Chapter 30 - Neurogenic Bowel: Dysfunction and Management • Chapter 31 - Spasticity • Chapter 32 - Sexuality Issues in Persons with Disabilities • Chapter 33 - The Prevention and Management of Pressure Ulcers and Other Chronic Wounds • Chapter 34 - Deconditioning, Conditioning, and The Benefits of Exercise • Chapter 35 - Employment of Persons with Disabilities • Chapter 55 - Spinal Cord Injuries Medicine

. Recommended (Not Required)

. Rehabilitation Medicine: Principles and Practice, Third Edition: Editor-in-Chief, J.A. DeLisa:

82 Integrated Competency Based Curriculum 2012-2013

• Chapter 7 - Evaluation and Management of Daily Self Care Requirements; Chapter 9 - Psychological Aspects of Rehabilitation; Chapter 13 - Prescriptions, Referrals, Order Writing and the Rehabilitation Team Function; Chapter 25 - Spinal and Upper Extremity Orthotics; Chapter 28 - Therapeutic Exercise; Chapter 30 - Wheelchair Prescription and Adaptive Seating; Chapter 40 - Spasticity and Associated Abnormalities of Muscle Tone; Chapter 43 - Pressure Ulcers; Chapter 44 - Neurogenic Bladder and Bowel Dysfunction; Chapter 45 - Sexuality and Disability; Chapter 47 - Vocational Rehabilitation, Independent Living and Consumerism; Chapter 51 - Spinal Cord Injury and Spinal Cord Injury Medicine; Chapter 56 - Treatment of the Patient with Chronic Pain.

. Physical Medicine and Rehabilitation: The Complete Approach, Martin Grabois, M.D., et al, Editor:

• Chapter 2 - The Rehabilitation Team; Chapter 7 - Diagnostic Imaging for the Physiatrist: Urinary Tract Imaging and Interventional Radiologic Management of the Rehabilitation Patient; Chapter 8 - Neuro-Radiology; Chapter 11 - Functional Evaluation and Outcome Measurements; Chapter 29 - Upper Limb Orthoses; Chapter 36 - Adaptive Systems: Adaptive Seating and Assistive Technology; Chapter 37 - Wheeled Mobility; Chapter 40 - Competitive Employment for Person’s With Disabilities: Overcoming The Obstacles; Chapter 47 - Spasticity and Abnormalities of Muscle Tone; Chapter 50 - Prevention and Management of Pressure Ulcers; Chapter 51 - Neurogenic Bladder; Chapter 52 - Neurogenic Bowel; Chapter 53 - Heterotopic Ossification: Diagnosis and Management; Chapter 55 - Sexual Aspects of Physical Disability; Chapter 73 - Rehabilitation of Spinal Cord Injury; Chapter 98 - Ethnic And Minority Issues; Chapter 101 - Attitudinal Barriers Affecting Persons With Disabilities

All the SCI Rotation documents are uploaded on New Innovations. Please go to Resources and click Department Manuals from the Main page of the NewInnovations website and look for SCI Folder. You will find all the resources and references that can help you to enhance your SCI knowledge, including,

83 Integrated Competency Based Curriculum 2012-2013

1. PVA Clinical Practice guidelines for both SCI and MS 2. SCI Tips for the inpatient rotation 3. Weekly teaching schedule 4. SCI self assessment tool including one SAE sample exam 5. Motor Exam guide from ASIA website 6. Key sensory points guide from ASIA website 7. ASIA form and instructions 8. Autonomic Standards Form 9. List of useful and suggested readings on SCI research topics 10. Goals and objectives for SCI Inpatient Rotation

• Instep from the ASIA web site. CD-ROMs

. None Recommended.

84 Integrated Competency Based Curriculum 2012-2013

Spinal Cord Injury – PGY3 GMEC Approved on: October 3, 2012 Domain: Spinal Cord Injury Level: PGY3 Length: 1 month (3rd month for the WRAMC residents) Type: Inpatient Rotation Director: Dr. Pamela Ballard Faculty: Dr. Pamela Ballard; Dr. Dallas Lea; Dr. Suzanne Groah; and Dr Camilo Castillo

General Educational Objective The PGY3 resident manages the Inpatient Rehabilitation Spinal Cord Injury patient as measured by the resident physician’s ability to lead team and family conferences, independent daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries. The PGY3 is expected to provide guidance and direction for the PGY2 and medical students that are rotating on the same cycle.

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f. Hypotension 4. Procedure Skills a. ASIA Exam b. Halo Adjustments

Methods of Teaching 1. Clinical Sites a. National Rehabilitation i. 2 West Unit 2. Clinical teaching a. PM&R Bedside Rounds b. Therapy Rounds: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the resident’s duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. Physical Therapy ii. Occupational Therapy iii. Speech Language Pathology iv. Recreational Therapy c. Team Conferences d. Family Conferences 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Held each Tuesday at Lunch Time 1. Interactive discussion 2. Question & Answer 3. Lecture topics below 4. Case discussion ii. Lectures.

Week Topic 86 Integrated Competency Based Curriculum 2012-2013

1 Introduction to Spinal Cord Injury Rotation 1 Spinal Cord: Anatomy, Physiology, and Pathophysiology Chapter 2 Epidemiology of Traumatic Spinal Cord Injury Chapter 5

2 Assessment and classification of Traumatic Spinal Cord injury Chapter 6 3 Predicting Outcomes Following Traumatic Spinal Cord Injury Chapter 8 Rehabilitation of Spinal Cord injury 4 Cardiovascular and Autonomic Dysfunctions After Spinal Cord injury Chapter 9 Respiratory Manageemnt of the Spinal Cord injury Patient Chapter 10 5 Gastrointestinal Disorders Chapter 11 Neurogenic Bladder Following Spinal Cord injury Chapter 13 6 Pressure Ulcers and Spinal Cord Chapter 14 Sexual Function and Fertility after Spinal Cord injury Chapter 23 7 Spasticity Chapter 15 Neuropathic pain after Spinal Cord Injury chapter 26 8 Metabolic Disorders (HO) Dual Diagnosis: Traumatic Brain Injury with Spinal cord injury Chapter 20 9 Test questions,Make up lectures and Article review 10 Test questions, Make up lectures and Article review 11 Test questions, Make up lectures and Article review. 12 Test questions, Make up lectures and Article review 1.

Table 4 - SCI Didactic Lectures

b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination:

87 Integrated Competency Based Curriculum 2012-2013

a. All NRH residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Lines of Supervision The PGY3 resident reports directly to the faculty attending with minimal direct supervisor. The PGY4 will supervise PGY2 residents and rotating medical students. The medical student will report to the PGY2 as first line then the PGY3, then attending on service.

Specific Competency – Based Goals & Objectives

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES PATIENT CARE GENERAL SKILLS

88 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES Demonstrate the ability to recognize occult fractures in the SCI patient. Demonstrate the ability to recognize cardiopulmonary pathology in the SCI patient. Demonstrate the ability to detect GI pathology in the SCI patient. Demonstrate the ability to detect DVT's in the SCI patient. Demonstrate the ability to detect heterotopic ossification in the SCI patient. Demonstrate the ability to detect Osteoporosis in the SCI patient. Demonstrate the ability detect autonomic dysreflexia in the SCI patient. Demonstrate the ability to detect the cause of pain in the SCI patient. Demonstrate the ability to detect and classify pressure ulcers. PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the SCI patient. OBJECTIVES: The resident is able to: Demonstrate understanding as to how the ASIA rating affects patient prognosis. Predict the expected functional outcome of a SCI patient, including his/her potential degree of independence in ADL’s, ambulation and driving, based on level of injury. Demonstrate understanding of indications for UE reconstructive surgery. Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities OBJECTIVES:f h SCI The i resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for SCI patient which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity with baclofen, Botox and muscle relaxants Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional procedures for SCI patients as well as perform appropriate ones as needed. OBJECTIVES: The resident is able to:

89 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES Demonstrate hands-on understanding of Urodynamic studies. Demonstrate ability to read routine spinal films/MRI’s/CT scans and to diagnose by these studies vertebral fractures, spinal infarcts/contusion/hemorrhages, and the development of a spinal syrinx. Demonstrate knowledge of the indications for emergency decompressive spinal surgery. Demonstrate knowledge of post-operative complications of bone graft harvesting/application, and metal fixation devices used in spine stabilization surgery. Demonstrates ability to perform PVR scans and to catheterize both male and female patients. Electrodiagnostic Skills – N/A

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the SCI patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the indications for the use of halo-vest orthotics and test for proper fit. Demonstrate knowledge of the indications for the use of TLS orthotics and test for proper fit. Demonstrate knowledge of the indications for the use of hand orthotics including: Universal cuff Tenodesis splint Demonstrate knowledge of adaptive ADL equipment appropriate to spinal cord injury. CLINICAL JUDGEMENT

90 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome. PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe a program of pulmonary rehabilitation for the SCI patient as needed (including antibiotics/vaccinations/respiratory therapy/ventilation weaning). Demonstrate the ability to treat hypotension in the SCI patient both with physical modalities and pharmaceuticals. Demonstrate the ability to treat DVT and prescribe appropriate prophylaxis for same in the SCI patient. Demonstrate the ability to treat hypercalcemia in the SCI patient. Demonstrates the ability to treat GI bleeding, gastric atony, superior mesenteric artery syndrome and/or other gastric pathophysiology in the SCI patient. Demonstrate the ability to treat heterotopic ossification in the SCI patient. Demonstrate the ability to treat pain in the SCI patient. Demonstrate the ability to treat osteoporosis in the SCI patient. Demonstrate the ability to treat autonomic dysreflexia. Demonstrate the ability to treat spasticity in the SCI patient with appropriate pharmacologic and therapeutic intervention. Demonstrate the ability to care for bowl/bladder abnormalities of the SCI patient. Demonstrate the ability to provide appropriate sexual information to the SCI patient regarding reproduction as well as techniques to enhance sexual pleasure. Demonstrate the ability to treat pressure ulcers. Understand the psychological adjustment required by the SCI patient and his/her significant other and can treat/refer appropriately for depression and other conditions that may interfere with the individual obtaining his/her highest possible functional level. Understand that the continuum of care of the SCI patient includes appropriate vocational/educational rehabilitation.

91 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with SCI. OBJECTIVES: The resident is able to: Understand the anatomy of the spinal cord and common neurologic syndromes. Understanding the ASIA System of neurological classification of SCI. Demonstrate understanding the pathophysiology of the Cardiopulmonary system of the SCI patient. Demonstrate understanding the pathophysiology and pathology of the GI system of the spinal cord injury patient including gastric atony, GI bleeding, superior mesenteric artery syndrome and hypercalcemia. Demonstrate understanding the neuroanatomy and pathophysiology of heterotopic ossification and osteoporosis in spinal cord injury. Demonstrate understanding of the physiology of spasticity in spinal cord injury. Demonstrate understanding of the physiology of autonomic dysreflexia. Demonstrate understanding of the consequences of pain in the SCI patient and provide a differential diagnosis of same.

92 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES Demonstrate understanding the medical and surgical intervention of pressure ulcers. PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to: Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and significant others. Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals.

PROFESSIONALISM

93 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES PROFESSIONAL ATTITUDE

GOAL: The resident is able to see the patient beyond the disease. OBJECTIVES: The resident is able to: Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self-interest. SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity

94 Integrated Competency Based Curriculum 2012-2013

SPINAL CORD INJURY (SCI) - PGY3 GOALS AND OBJECTIVES Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources

• Text Books/booklets

. Spinal Cord Medicine, Second Edition 2011, Steven Kirshblum. Denise Campagnolo. Chapters require for reading will be available at the WHC online Library.

. International Standards for Neurological Classification of Spinal Cord Injury, American Spinal Injury Association, Revised 2011.

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. 2nd edition: • Chapter 55 - Spinal Cord Injuries Medicine • Chapter 15 - Upper Limb Orthotic Devices • Chapter 17 - Spinal Orthoses in Rehabilitation • Chapter 19 - Therapeutic Exercises • Chapter 22- Electrical Stimulation • Chapter 23 - Computer Assisted Devices and Environmental Control • Chapter 25 - Achieving Functional Independence • Chapter 27 - Management of Bladder Dysfunction • Chapter 28 - Neurogenic Bowel: Dysfunction and Management • Chapter 29 - Spasticity • Chapter 30 - Sexuality Issues in Persons with Disabilities • Chapter 31 - The Prevention and Management of Pressure Ulcers and Other Chronic Wounds

95 Integrated Competency Based Curriculum 2012-2013

• Chapter 34 - Deconditioning, Conditioning, and The Benefits of Exercise • Chapter 35 - Employment of Persons with Disabilities . 3rd edition: • Chapter 56 – Spinal Cord Injury • Chapter 15 - Upper Limb Orthotic Devices • Chapter 17 - Spinal Orthoses in Rehabilitation • Chapter 18 – Prescription of Wheelchairs and Seating Systems • Chapter 19 - Therapeutic Exercises • Chapter 22- Electrical Stimulation • Chapter 24 - The Roll of Assistive Technology in Rehabilitation • Chapter 29 - Management of Bladder Dysfunction • Chapter 30 - Neurogenic Bowel: Dysfunction and Management • Chapter 31 - Spasticity • Chapter 32 - Sexuality Issues in Persons with Disabilities • Chapter 33 - The Prevention and Management of Pressure Ulcers and Other Chronic Wounds • Chapter 34 - Deconditioning, Conditioning, and The Benefits of Exercise • Chapter 35 - Employment of Persons with Disabilities • Chapter 55 - Spinal Cord Injuries Medicine

. Recommended (Not Required)

. Rehabilitation Medicine: Principles and Practice, Third Edition: Editor-in-Chief, J.A. DeLisa:

96 Integrated Competency Based Curriculum 2012-2013

Chapter 51 - Spinal Cord Injury and Spinal Cord Injury Medicine; Chapter 56 - Treatment of the Patient with Chronic Pain.

. Physical Medicine and Rehabilitation: The Complete Approach, Martin Grabois, M.D., et al, Editor:

• Self directed learning modules

• InStep from the ASIA web site.

11. PVA Clinical Practice guidelines for both SCI and MS 12. SCI Tips for the inpatient rotation 13. Weekly teaching schedule

97 Integrated Competency Based Curriculum 2012-2013

14. SCI self assessment tool including one SAE sample exam 15. Motor Exam guide from ASIA website 16. Key sensory points guide from ASIA website 17. ASIA form and instructions 18. Autonomic Standards Form 19. List of useful and suggested readings on SCI research topics 20. Goals and objectives for SCI Inpatient Rotation

• Instep from the ASIA web site. CD-ROMs

. None Recommended.

98 Integrated Competency Based Curriculum 2012-2013

Musculoskeletal Medicine

Musculoskeletal Medicine – PGY2 GMEC Approved on: December 2, 2009 Domain: Musculoskeletal Level: PGY2 Length: 2 months Type: Inpatient Rotation Director: Dr. Howard Gilmer Faculty: Dr. Howard Gilmer and Dr. Robert Bunning

General Educational Objective The PGY2 resident manages the Musculoskeletal Inpatient Rehabilitation patient as measured by the resident physician’s participation in team conferences, daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries. Scope of Learning and Exposures 1. Basic Anatomy and Physiology of adult Musculoskeletal system 2. Common types of adult MSK pathophysiology a. Fractures i. Upper Extremities ii. Lower Extremities iii. Pelvis iv. Spine b. Limb Amputation c. Lumbar Spinal Surgery 3. Procedure Skills a. Joint Injections i. Shoulder ii. Knee iii. MCP iv. Elbow b. Joint Aspiration i. Knee – septic c. Wheel Chair prescriptions

99 Integrated Competency Based Curriculum 2012-2013

Methods of Teaching 1. Clinical Sites a. National Rehabilitation Hospital i. MSK Unit – most patients reside on the 2 East unit. 2. Clinical teaching a. PM&R Bedside Rounds b. Therapy Rounds: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the resident’s duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. Physical Therapy ii. Occupational Therapy iii. Recreational Therapy c. Team Conferences d. Family Conferences e. Ortho-Rheum-Physiatry Rounds i. 2nd Thursday of each month during PM&R didactic series 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Weekly Didactic Lectures on Tuesdays or occurs weekly but not on scheduled days. ii. Topic s: 1. Shoulder Exam 2. Knee Exam 3. Normal Gait 4. Abnormal Gait 5. Back Exam 6. Naming Prosthetics 7. Topics based on patient specific pathology. b. c. General Didactic while on this rotation include

100 Integrated Competency Based Curriculum 2012-2013

i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Specific Competency – Based Goals & Objectives

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

101 Integrated Competency Based Curriculum 2012-2013

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical upon the MSK patient. (The MSK patient includes those with rheumatic conditions, vascular disease, those who require joint OBJECTIVES: The resident is able to: Define claudication pain and illicit a history of same. Be able to illicit a history of the signs/symptoms indicative of loosening of arthroplastic cementing material. Describe the clinical features that suggest inflammatory versus non-inflammatory arthritis. Appropriately quantify morning stiffness. Appropriately describe pain in the patient with arthritis. Appropriately quantify fatigue in the patient with arthritis. Demonstrate the ability to perform a functional screen of the MSK patient including obtaining information related to ADLs, IADLs, vocation and avocational skills/desires. Demonstrate an physical exam of the signs and symptoms of peripheral vascular disease including trophic skin changes, dependent rubor, temperature abnormalities, abnormal pulses, bruits, etc. Demonstrate the ability to perform physical exam of individuals with chronic venous insufficiency. Demonstrate the ability to detect peripheral neuropathy. Demonstrate the ability to detect the common cutaneous manifestation of diabetic skin. Demonstrate the ability to detect the choke syndrome Demonstrate the ability to detect the common dermatological disorders found in the residual limb of an individual with an amputation. Demonstrate adequate understanding of the laboratory findings which suggest inflammatory versus non-inflammatory disease (including analysis of joint fluid). Demonstrate adequate proficiency in the use of a goniometer.

102 Integrated Competency Based Curriculum 2012-2013

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Demonstrate the ability to define and appropriately recognize the following conditions: MCP subluxation Ulnar deviation Joint effusion Occipital paresthesias Acute and Chronic Synovitis Trigger points

PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the MSK patient. OBJECTIVES: The resident is able to: Recognize and prescribe corrections for the common gait abnormalities of those with amputations. Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the MSK patient. OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the indications/contraindications of exercise in individuals with ischemic rest pain. Prescribe an active exercise program for patient with LE arteriosclerotic disease. Prescribe a program of intermittent compression for mobilization of fluid in the extremities. Prescribe a pre-prosthetic program for individuals with UE/LE amputations to include range of motion/strengthening/shaping/reduction of the residual limb. Be familiar to define the basic gait training program of a LE amputee. Prescribe a pre/postoperative arthroplasty program of muscle strengthening/range of motion/gait training for an individual with joint replacement of the LE.

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Demonstrate the ability to prescribe a total rehabilitation program for the patient with nonsurgical arthritis to include as appropriate the following components: Rest (local/systemic) Range of motion (passes/active assisted/active) Muscle strengthening (isometric/isotonic/isokinetic/eccentric/concentric as indicated) Endurance activities/aerobic activities Aquatic therapy /recreational exercise Prescribe appropriate modalities of heat/cold for the MSK patient (knowing Demonstrateidi i / the ability idi to i appropriately ) prescribe TENS. Therapeutic & Diagnostic Injections Procedures GOAL: The resident is able to understand the need for interventional procedures for MSK patients well as perform appropriate ones as designated. OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the indications for laboratory studies performed in the diagnosis of arteriosclerotic disease of the LE (including those which are both non-invasive and invasive). Define the indications/contraindications to: Angioplasty procedures Bypass surgery (limb salvage) Amputation CABG/MI precautions Identify the signs of joint loosening via plain x-ray in those patients who have undergone arthroplasty. Demonstrate appropriate techniques in the performance of joint aspirations/injections. Demonstrate the ability to interpret traditional common radiologic signs of arthritis in plain film. Demonstrate knowledge of the indications/contraindications of: Synovectomy Arthrodesis Osteotomy Arthroplasty

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Demonstrate knowledge of the common indications for tendon surgery in rheumatic arthritis. Electrodiagnostic Skills – N/A

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in MSK patient OBJECTIVES: The resident is able to: Prescribe appropriate shoe wear for protection of the diabetic foot. Discuss the procedures necessary to construct a preparatory and/or definitive prosthesis. Define the difference in between endo/exoskeletal prosthetic design. Demonstrate knowledge of the types of orthotic prescriptions available to those with partial foot amputations including: Spacers Spring shanks Rocker bottom soles Metatarsal pads Define the functional characteristics/advantages/disadvantages of the following: SACH foot Single axis/multi-axis feet Dynamic response/energy storing feet PTB socket (with/without ISNY component) Socket liners Total contact quadrilateral socket Ischial containment socket Transfemoral frame socket with flexible liner (ISNY) Single axis constant friction knee Safety knee Multi axial knee Hydraulic/pneumatic knee Canadian hip disarticulation prosthesis

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Hemipelvectomy prosthesis

Understand the indications/contraindications of the use of suspension devices for transtibial prostheses including: Supracondylar cuff Thigh corset with knee joint Y-strap Supracondylar medial wedge suspension 3-S suction suspension Neoprene sleeve suspension PTS socket design

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Understand the indications/contraindications of the use of suspension devices for the transfemoral prosthesis including: Suction socket 3-S suspension system Belt suspension Hypobaric sock Silesian belt TES belt Pelvic band and belt system Shoulder belt Understand the indications/contraindications and be able to appropriately prescribe the following: Resting hand splint Functional wrist splint Thumb post splint Ring splint Dynamic splint Double upright Klenzak splint KAFO (plus/minus dial lock) Swedish knee cage Understand the indications/contraindications and be able to appropriately prescribe shoe modifications including: Bevelled heel Wide toe box Metatarsal bar (internal/external) Rocker bottom shoe Understand the indications for short-leg patellar PTB brace

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Demonstrate understanding of the indications/contraindications and be able to appropriately prescribe spinal orthotics including: Jewitt brace/body jacket LS corset Soft surgical collar Philadelphia collar Demonstrate knowledge of the indications for the use cane/crutches/walkers in the MSK patient. Demonstrate knowledge of appropriate wheelchair and seating prescriptions for the MSK patient (including amputee patient and those with significant upper extremity arthritis/peripheral neuropathies. CLINICAL JUDGEMENT

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to educate patients as to the risk factors of atherosclerosis. Demonstrate the ability to educate patients as to an appropriate foot care program. Demonstrate the ability to prescribe a program adequate to manage ischemic leg pain (including the use of pharmaceutical and physical therapy agent). Demonstrate the ability to prescribe a complete program of care for the patient with lymphedema (including pharmaceuticals as needed as well as physical agents). Demonstrate the ability to prescribe a complete program of care for patients with chronic venous insufficiency/LE ulcers (including the use of pharmaceuticals as necessary and physical

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES therapeutic agents). Provide a prophylactic as well as an acute treatment program for DVT. Demonstrate the ability to prescribe a complete program of treatment for chronic arterial disease. Demonstrate the ability to prescribe a complete treatment program for foot ulcers. Prescribe a program of pharmaceutical relief of pain for neuropathy. Demonstrate the ability to prescribe a program for relief of phantom pain (including pharmaceutical and therapeutic modalities). Demonstrate the ability to prescribe a program to reduce the pain of neuromas. Demonstrate the ability to provide appropriate patient education for those who require total hip precautions. Understand the psychosocial adjustments required by patients who have undergone amputation. Understand the continuum of care for the amputee/arthroplasty patients may include appropriate vocational/educational rehabilitation. Prescribe appropriate adaptive devices for bathing/grooming/feeding/dressing/driving/kitchen work for the amputee patient. Education the arthritic patient in environmental changes to increase the bio-mechanical efficiency/safety of the home. Understand the continuum of care of the arthritis patient can include appropriate vocational/educational rehabilitation. Demonstrate the ability to provide appropriate sexual information to the arthritis patient regarding techniques/positions to enhance sexual pleasure while providing appropriate joint protection. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the MSK patient. OBJECTIVES: The resident is able to: Demonstrate understanding of the epidemiology of atherosclerotic disease Understand the phenomena of vascular steal

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Provide a differential diagnosis of intermittent claudication Define critical leg ischemia. Demonstrate knowledge of signs/symptoms/pathophysiology of : Raynaud’s Disease Buerger’s Disease (Thromboangiitis Obliterans) Lymphedema

Demonstrate knowledge of the anatomy of the vascular system of the lower extremity. Demonstrate knowledge of the etiology/pathophysiology of chronic venous insufficiency. Demonstrate knowledge of the pathophysiology of diabetic foot ulcers. Demonstrate knowledge of the incidence/prevalence/etiology/gender/age distribution of acquired amputation of the UE/LE. Demonstrate knowledge of the incidence/age/gender distribution of individuals requiring TKA/THA. Demonstrate awareness of non-pharmacologic and alternative medical care through modalities for the patient with arthritis including: Acupuncture Relaxation therapy Message therapy Diet PHYSIATRIC KNOWLEDGE GOAL: The resident is able to demonstrate physiatric knowledge of the MSK patient. OBJECTIVES: The resident is able to: Demonstrate appropriate knowledge of the risk factors leading to foot ulceration in the diabetic patient. Demonstrate knowledge of preferred levels of amputation in the UE/LE (including the anatomic issues on which these decisions are based). Demonstrate knowledge of the prognosis of individuals with LE amputation. Determine those individuals who have good/poor prognosis for prosthetic ambulation. Determine the appropriate timing of prosthetic fitting. Demonstrate knowledge of the advantages/disadvantages of: Partial foot amputation (including transmetatarsal, Lisfranc, Chopart, Boyd) amputation

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Symes amputation Transtibial amputation Knee disarticulation amputation Transfibular amputation Hip Disarticulation Define the patients who need hip disarticulation prosthesis. Define phantom pain and its differential diagnosis. Define the choke syndrome. Define the TKA line and its functional consequences. Demonstrate knowledge of the indications/contraindications for THA/TKA/hemi-arthroplasty. Demonstrate knowledge of the indications/contraindications of cementing materials used in arthroplasty surgery including: PMMA Porous Coated/Boney Ingrowth Demonstrate adequate knowledge of signs/symptoms/etiology/incidence of post-arthroplasty complications including: Aseptic loosening Thromboembolic disease Pulmonary Embolism PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able: To analyze practice experience and perform practice-based improvement activities using a To analyzei and hdlassimilate evidence of “best practices” from scientific studies related to their Applyi knowledge ’ h l h of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education.

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing OBJECTIVES:f i l d The lresident is able to: Assume responsibility and act responsibly. Demonstrate commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, informed consent, and business practices. Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal, professional, organizational and social level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Physical Medicine and Rehabilitation, 3rd Edition, Randall L Braddom, M.D. Editor:

• Chapter 5 - Gait Analysis: Technology and Clinical Applications;

• Chapter 7 – Neurologic and Musculoskeletal Imaging Studies

• Chapter 8 - Quality and Outcome Measurements;

113 Integrated Competency Based Curriculum 2012-2013

• Chapter 13 - Upper Limb Amputee Rehabilitation and Prosthetic Restoration;

• Chapter 14 – Rehabilitation of People with Lower Limb Amputation;

• Chapter 15 - Upper Limb Orthotic Devices;

• Chapter 16 - Lower Limb Orthoses;

• Chapter 19 - Therapeutic Exercises;

• Chapter 21 – Physical Agent Modalities

• Chapter 25 – Peripheral Joint and Soft Tissue and Spinal Injection Techniques;

• Chapter 27 - Achieving Functional Independence;

• Chapter 32 - Sexuality Issues in Persons with Disabilities;

• Chapter 36 - Employment of Persons With Disabilities;

• Chapter 37 - Rehabilitation of Patients with Rheumatic Disorders;

• Chapter 48 - Rehabilitation of Patients with Neuropathies;

• Chapter 57 – Lower Limb Peripheral Vascular Diseases

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

114 Integrated Competency Based Curriculum 2012-2013

. None Recommended.

115 Integrated Competency Based Curriculum 2012-2013

Musculoskeletal Medicine – PGY4 GMEC Approved on: December 2, 2009 Domain: Musculoskeletal Level: PGY4 Length: 1 month Type: Inpatient Rotation Director: Dr. Howard Gilmer Faculty: Dr. Howard Gilmer and Dr. Robert Bunning

General Educational Objective The PGY4 resident manages the Musculoskeletal Inpatient Rehabilitation patient as measured by the resident physician’s ability to lead team and family conferences, independent daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries. The PGY4 is expected to provide guidance and direction for the PGY2 and medical students that are rotating on the same cycle.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of adult Musculoskeletal system 2. Common types of adult MSK pathophysiology a. Fractures i. Upper Extremities ii. Lower Extremities iii. Pelvis iv. Spine b. Limb Amputation c. Lumbar Spinal Surgery 3. Procedure Skills a. Joint Injections i. Shoulder ii. Knee iii. MCP iv. Elbow b. Joint Aspiration i. Knee – septic c. Wheel Chair prescriptions

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117 Integrated Competency Based Curriculum 2012-2013

ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Lines of Supervision The PGY4 resident reports directly to the faculty attending with minimal direct supervisor. The PGY4 will supervise PGY2 residents and rotating medical students. The medical student will report to the PGY2 as first line then the PGY4, then attending on service.

Specific Competency – Based Goals & Objectives

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical upon the MSK patient. (The MSK patient includes those with vascular disease, those who require joint placement and amputations, and those with significant neuropathies)

118 Integrated Competency Based Curriculum 2012-2013

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Define claudication pain and illicit a history of same. Be able to illicit a history of the signs/symptoms indicative of loosening of arthroplastic cementing material. Describe the clinical features that suggest inflammatory versus non-inflammatory arthritis. Appropriately quantify morning stiffness. Appropriately describe pain in the patient with arthritis. Appropriately quantify fatigue in the patient with arthritis. Demonstrate the ability to perform a functional screen of the MSK patient including obtaining information related to ADLs, IADLs, vocation and avocational skills/desires. Demonstrate an physical exam of the signs and symptoms of peripheral vascular disease including trophic skin changes, dependent rubor, temperature abnormalities, abnormal pulses, bruits, etc. Demonstrate the ability to perform physical exam of individuals with chronic venous insufficiency. Demonstrate the ability to detect peripheral neuropathy. Demonstrate the ability to detect the common cutaneous manifestation of diabetic skin. Demonstrate the ability to detect the choke syndrome Demonstrate the ability to detect the common dermatological disorders found in the residual limb of an individual with an amputation. Demonstrate adequate understanding of the laboratory findings which suggest inflammatory versus non-inflammatory disease (including analysis of joint fluid). Demonstrate adequate proficiency in the use of a goniometer. Demonstrate the ability to define and appropriately recognize the following conditions: MCP subluxation Ulnar deviation Joint effusion Occipital paresthesias Acute and Chronic Synovitis Trigger points

119 Integrated Competency Based Curriculum 2012-2013

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the MSK patient. OBJECTIVES: The resident is able to: Recognize and prescribe corrections for the common gait abnormalities of those with amputations. Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the MSK patient. OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the indications/contraindications of exercise in individuals with ischemic rest pain. Prescribe an active exercise program for patient with LE arteriosclerotic disease. Prescribe a program of intermittent compression for mobilization of fluid in the extremities. Prescribe a pre-prosthetic program for individuals with UE/LE amputations to include range of motion/strengthening/shaping/reduction of the residual limb. Be familiar to define the basic gait training program of a LE amputee. Prescribe a pre/postoperative arthroplasty program of muscle strengthening/range of motion/gait training for an individual with joint replacement of the LE. Demonstrate the ability to prescribe a total rehabilitation program for the patient with nonsurgical arthritis to include as appropriate the following components: Rest (local/systemic) Range of motion (passes/active assisted/active) Muscle strengthening (isometric/isotonic/isokinetic/eccentric/concentric as indicated) Endurance activities/aerobic activities Aquatic therapy /recreational exercise Prescribe appropriate modalities of heat/cold for the MSK patient (knowing Demonstratei di i / the ability i di to i appropriately ) prescribe TENS. Therapeutic & Diagnostic Injections Procedures GOAL: The resident is able to understand the need for interventional procedures for MSK patients well as perform appropriate ones as designated.

120 Integrated Competency Based Curriculum 2012-2013

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the indications for laboratory studies performed in the diagnosis of arteriosclerotic disease of the LE (including those which are both non-invasive and invasive). Define the indications/contraindications to: Angioplasty procedures Bypass surgery (limb salvage) Amputation CABG/MI precautions Identify the signs of joint loosening via plain x-ray in those patients who have undergone arthroplasty. Demonstrate appropriate techniques in the performance of joint aspirations/injections. Demonstrate the ability to interpret traditional common radiologic signs of arthritis in plain film. Demonstrate knowledge of the indications/contraindications of: Synovectomy Arthrodesis Osteotomy Arthroplasty Electrodiagnostic Skills – N/A

Prosthetics/Orthotics/Medical Equipment

121 Integrated Competency Based Curriculum 2012-2013

MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Demonstrate knowledge of the types of orthotic prescriptions available to those with partial foot amputations including: Spacers Spring shanks Rocker bottom soles Metatarsal pads Define the functional characteristics/advantages/disadvantages of the following: SACH foot Single axis/multi-axis feet Dynamic response/energy storing feet PTB socket (with/without ISNY component) Socket liners Total contact quadrilateral socket Ischial containment socket Transfemoral frame socket with flexible liner (ISNY) Single axis constant friction knee Safety knee Multi axial knee Hydraulic/pneumatic knee Canadian hip disarticulation prosthesis Hemipelvectomy prosthesis Understand the indications/contraindications of the use of suspension devices for transtibial prostheses including: Supracondylar cuff Thigh corset with knee joint Y-strap Supracondylar medial wedge suspension 3-S suction suspension Neoprene sleeve suspension PTS socket design

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GENERAL KNOWLEDGE

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Symes amputation Transtibial amputation Knee disarticulation amputation Transfibular amputation Hip Disarticulation Define the patients who need a hip disarticulation prosthesis. Define phantom pain and its differential diagnosis. Define the choke syndrome. Define the TKA line and its functional consequences. Demonstrate knowledge of the indications/contraindications for THA/TKA/hemi-arthroplasty. Demonstrate knowledge of the indications/contraindications of cementing materials used in arthroplasty surgery including: PMMA Porous Coated/Boney Ingrowth Demonstrate adequate knowledge of signs/symptoms/etiology/incidence of post-arthroplasty complications including: Aseptic loosening Thromboembolic disease Pulmonary Embolism PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able: To analyze practice experience and perform practice-based improvement activities using a To analyzei and hdlassimilate evidence of “best practices” from scientific studies related to their Applyi knowledge ’ h l h of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education.

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MUSCULOSKELETAL (MSK) GOALS AND OBJECTIVES Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

PROFESSIONAL ATTITUDE

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Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Physical Medicine and Rehabilitation, 3rd Edition, Randall L Braddom, M.D. Editor:

• Chapter 5 - Gait Analysis: Technology and Clinical Applications;

• Chapter 7 – Neurologic and Musculoskeletal Imaging Studies

• Chapter 8 - Quality and Outcome Measurements;

129 Integrated Competency Based Curriculum 2012-2013

• Chapter 13 - Upper Limb Amputee Rehabilitation and Prosthetic Restoration;

• Chapter 14 – Rehabilitation of People with Lower Limb Amputation;

• Chapter 15 - Upper Limb Orthotic Devices;

• Chapter 16 - Lower Limb Orthoses;

• Chapter 19 - Therapeutic Exercises;

• Chapter 21 – Physical Agent Modalities

• Chapter 25 – Peripheral Joint and Soft Tissue and Spinal Injection Techniques;

• Chapter 27 - Achieving Functional Independence;

• Chapter 32 - Sexuality Issues in Persons with Disabilities;

• Chapter 36 - Employment of Persons With Disabilities;

• Chapter 48 - Rehabilitation of Patients with Neuropathies;

• Chapter 57 – Lower Limb Peripheral Vascular Diseases

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

130 Integrated Competency Based Curriculum 2012-2013

Traumatic Brain Injury

Traumatic Brain Injury – PGY2 GMEC Approved on: December 2, 2009 Domain: Neurorehabilitation Level: PGY2 Length: 2 months Type: Inpatient/Outpatient/Consults Rotation Director: Dr. Michael Yochelson Faculty: Dr. Michael Yochelson and Dr. Kritis Dasgupta

General Educational Objective The PGY2 resident manages the Traumatic Brain Injury Inpatient Rehabilitation patient as measured by the resident physician’s participation in team conferences, daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the Brain. 2. Common types of adult Brain Injury pathophysiology a. Traumatic brain injury b. Anoxic brain injury c. Non-traumatic CNS bleeds (e.g. subarachnoid hemorrhage, subdural hemorrhage, intraparenchymal hemorrhage d. Brain tumors (primary and metastatic) e. Encephalopathies (infectious, metabolic) f. Vasculitis 3. Procedure Skills a. Complete neurological examination, including cognitive evaluation b. Intrathecal baclofen pump screening trials (to include lumbar puncture) c. Management (programming) of intrathecal baclofen pumps

Methods of Teaching 1. Clinical Sites a. National Rehabilitation i. 3 East Unit 2. Clinical teaching

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a. PM&R Bedside Rounds b. Therapy Rounds: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the resident’s duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. Physical Therapy ii. Occupational Therapy iii. Speech Language Pathology iv. Recreational Therapy c. Team Conferences d. Family Conferences e. Weekly Didactic Lectures i. Tuesday 10:00am – 11:00am, Dr. Kritis Dasgupta ii. Wednesday 10:00am – 11:00am, Dr. Michael Yochelson 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. The Neurological Examination ii. Depression after brain injury iii. Managing agitation after brain injury iv. Managing spasticity in brain injury v. Managing heterotopic ossification in brain injury vi. Use of neuro-stimulants in brain injury vii. Sleep dysfunction and fatigue after brain injury viii. Medical management of cognitive dysfunction ix. Endocrine dysfunction after brain injury x. Spectrum of care (acute inpatient rehab, subacute rehab, day programs, outpatient therapy, home therapy) and resources available in the long term care and rehabilitation of the brain injured patient xi. Education on various scales used in the assessment and management of the brain injured patient (e.g., GOAT, Rancho Los Amigos Cognitive Scale) b. General Didactic while on this rotation include

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Lines of Supervision The PGY2 resident reports directly to the faculty attending and fellow or senior resident if on the rotation cycle. The PGY2 will be responsible to help supervise medical students. The medical student will report to the PGY2 as first line then the attending on service.

Specific Competency – Based Goals & Objectives

TRAUMATIC BRAIN INJURY (TBI) – PGY2 GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the TBI patient.

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OBJECTIVES: The resident is able to:

Demonstrate proficiency in determining the mechanism of injury.

Demonstrate proficiency in establishing the length of coma/post traumatic amnesia. Demonstrate appropriate usage and interpretation of the following scales: GOAT Rancho Los Amigos scale FIM scale

Demonstrate an appropriate assessment and differential diagnosis of a: Comatose patient Patient in a vegetative state Mild traumatic brain injured patient Agitated patient

Examine the brain injured patient for: Ocular injury Spasticity DVT

Assess the nutritional status of the patient and perform a screening examination for dysphasia. Assess the endocrinologic condition of the patient for: DI SIADH Gynecomastia Galactorrhea

Assess the patient for movement disorders including tremors/parkinsonism/Bradykinesia. Demonstrate the ability to recognize and appropriately grade Spasticity in the TBI patient. Recognize the signs/symptoms of the following disorders: Arousal/attention disorders Memory impairment Impairment of the executive functioning capability

Demonstrate the ability to detect language disorders in TBI. Demonstrate the ability to detect neuro-behavioral disorders in TBI patients including depression, reduced initiation, reduced awareness, agitated/aggressive/disinhibited behavior. Demonstrate the ability to detect the signs/symptoms of hydrocephalus. Demonstrate the ability to perform an appropriate cognitive screening on the TBI patient. Demonstrate the ability to detect decorticate versus decerebrate posturing in the TBI patient. Demonstrate the ability to detect swallowing dysfunction in the TBI patient. Demonstrate the ability to detect homonymous hemianopsia versus hemineglect in the TBI patient. Demonstrate the ability to heterotopic ossification in the TBI patient.

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PHYSIATRIC SKILLS

Functional Evaluation

GOAL: The resident is able to perform a functional examination of the TBI patient.

OBJECTIVES: The resident is able to:

Understand use/limitation of the GLASGOW Outcome score. Understand use/limitation of the Rancho Los Amigos cognitive scale. Predict the expected functional outcome of the TBI patient based on prognostic factors. Understand the various indications for the various discharge options available to the TBI patient including nursing home discharge (short term rehabilitative care) vs. chronic long term care, residential behavioral management programs, and supervised group homes. Understand the role of the case manager in the selection of the community resources available. Understand the impact which TBI has upon the patient and his/her social support system. Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the TBI patient.

OBJECTIVES: The resident is able to:

Prescribe and implement a coma stimulation program. Demonstrate the ability to prescribe and monitor an appropriate exercise program for TBI patient which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity

Therapeutic & Diagnostic Injections/ Procedures

GOAL: The resident is able to understand the need for interventional procedures for TBI patients well as perform appropriate ones as designated. OBJECTIVES: The resident is able to:

Demonstrate the ability to read neuro imaging studies (CT/MRI) and successfully denote fractures, hematomas, intra-cerebral hematomas, cerebral edema, mass effects, tumors, hydrocephalus, etc. Understand the pros/cons of MRI/CT imaging in the TBI patient and demonstrate the appropriate ordering of these tests. Understand the appropriate indications for ordering an EEG in the TBI patient. Demonstrate hands-on understanding of MBS study. Electrodiagnostic Skills Prosthetics/Orthotics/ Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in TBI patient. OBJECTIVES: The resident is able to:

135 Integrated Competency Based Curriculum 2012-2013

Demonstrate knowledge of appropriate wheelchair and seating prescriptions for the TBI patient. Demonstrate knowledge of adaptive ADL equipment appropriate to TBI patient. Demonstrate knowledge of the indications for the use of canes/crutches/walkers in the TBI patient. Demonstrate knowledge of the indications for the appropriate use of hand orthotics in the TBI patient including Universal cuff. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient.

OBJECTIVES: The resident is able to:

Regularly integrate medical knowledge with clinical data and generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an appropriate management plan Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome. PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate.

OBJECTIVES: The resident is able to:

Demonstrate the ability to prescribe an appropriate program of environmental/psychological/pharmaceutical intervention for the: Agitated patient Mild TBI patient Patient with post traumatic amnesia

Demonstrate the ability to prevent ocular injury in the TBI patient. Demonstrate the ability to treat hypo/hypertension in the TBI patient with appropriate drugs and physical agents. Demonstrate the ability to treat Heterotopic ossification in the TBI patient. Demonstrate the ability to treat spasticity in the TBI patient with appropriate pharmacologic and therapeutic intervention. Demonstrate the ability to treat seizures and prescribe seizure prophylaxis in the TBI patient. Demonstrate the ability to treat movement disorders in the TBI patient with appropriate pharmacologic and therapeutic intervention. Demonstrate the ability to care for bowel/bladder abnormalities of the TBI patient. Demonstrate the ability to prescribe appropriate diet intervention and feeding alternatives for patients with dysphagia. Demonstrate the ability to appropriately treat the endocrinologic disorders of DI and SIADH. Demonstrate the ability to pharmacological treat disorders of arousal/attention, reduced initiation. Demonstrate the ability to appropriately treat the language disorders of the TBI patient. Demonstrate the ability to treat neuro behavioral disorders of the TBI patient using pharmacologic/behavioral/environmental therapy. Understand the psychological adjustment required by the TBI patient and his/her significant other and treat/refer appropriately for depression and other conditions that may interfere with the individual obtaining his/her highest possible function. Understand that the continuum of care of the TBI patient includes appropriate vocational/education rehabilitation.

MEDICAL KNOWLEDGE

136 Integrated Competency Based Curriculum 2012-2013

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with TBI.

OBJECTIVES: The resident is able to:

Define the features of: Closed head injury Open head injury Penetrating head injury Anoxic brain injury Toxic/metabolic brain injury Vegetative state Minimally conscious state Severe TBI Moderate TBI Mild TBI

Define the clinical features of locked in syndrome.

Define the clinical features of akinetic mutism

Define and contrast the difference between increased intracranial pressure and cerebral perfusion pressure and demonstrate knowledge of the consequences of both as well as their treatment. Define the pathophysiology of TBI including: Diffuse axonal injury Cerebral contusion

Demonstrate an understanding of the incidence/prevalence/survival rate of TBI. Demonstrate an understanding of the social and economic impact of brain injury. Demonstrate an understanding of the age/gender distribution of brain injury. Demonstrate an understanding of the etiology/risk factors of TBI. Demonstrate knowledge of the prognostic indicators in TBI. Demonstrate knowledge of the prognostic indicators for coma. Demonstrate understand of the anatomy/neuroanatomy/physiology of normal voiding and bowel elimination. PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with TBI.

OBJECTIVES: The resident is able to:

137 Integrated Competency Based Curriculum 2012-2013

Demonstrate appropriate knowledge of the: WESTMEAD scale GOAT GLASGOW Outcome scale Disability Rating scale Rancho Los Amigos levels of cognitive function scale Functional Independent Measures (FIM)

Demonstrate knowledge of possible mechanisms of recovery in TBI. Demonstrate understanding of the phases of recovery in TBI. Demonstrate understanding of the physiology and anatomy of swallowing disorders in TBI. Demonstrate understanding of movement disorders which occur as a result of TBI including: Spasticity Parkinsonism/Bradykinesia/Tremors Provide the definition to the following cognitive impairment: Impairment of executive functioning Arousal disorder Attention disorder

Demonstrate understanding of the language disorders in TBI. Demonstrate understanding of the visuospatial perception and construction impairments of TBI. Demonstrate an understanding of the neuro behavioral consequences of TBI as well as their relationship to cognitive disorders. Demonstrate knowledge of the anatomic/physiologic basis of the common medical conditions which are associated with brain injury including: Post traumatic seizures Undetected fractures Post traumatic hydrocephalus Autonomic dysfunction (hyper/hypotension, temperature instability) Cranial nerve damage Ocular injury (including corneal damage) Heterotopic ossification Spasticity DVT Endocrine disorders such DI/SIADH

PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices.

OBJECTIVES: The resident is able:

138 Integrated Competency Based Curriculum 2012-2013

To analyze practice experience and perform practice-based improvement activities using a systematic methodology.

To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status.

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

Use information technology to manage information, access on-line medical information, and support their didactic education.

Facilitate the learning of students and other healthcare professionals.

INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team.

OBJECTIVES: The resident is able to:

Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and significant others. Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

OBJECTIVES: The resident is able to:

Assume responsibility and act responsibly. Demonstrate commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, informed consent, and business practices. Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to:

139 Integrated Competency Based Curriculum 2012-2013

demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. https://docs.google.com/leaf?id=0B4faOywZhlHUN2FlNTYwM2MtODM2MS00MTczLTlh YzYtMGIwZmJiMDA1YmJj&hl=en

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. CD with reading material is given to the resident at the start of the rotation.

140 Integrated Competency Based Curriculum 2012-2013

Traumatic Brain Injury – PGY4 GMEC Approved on: December 2, 2009 Domain: Neurorehabilitation Level: PGY4 Length: 1 month Type: Inpatient/Outpatient/Consults Rotation Director: Dr. Michael Yochelson Faculty: Dr. Michael Yochelson and Dr. Kritis Dasgupta

General Educational Objective The PGY4 resident manages the Traumatic Brain Injury Inpatient Rehabilitation patient as measured by the resident physician’s ability to lead team and family conferences, independent daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries. The PGY4 is expected to provide guidance and direction for the PGY2 and medical students that are rotating on the same cycle.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the Brain. 2. Basic Anatomy and Physiology of the Brain. 3. Common types of adult Brain Injury pathophysiology a. Traumatic brain injury b. Anoxic brain injury c. Non-traumatic CNS bleeds (e.g. subarachnoid hemorrhage, subdural hemorrhage, intraparenchymal hemorrhage d. Brain tumors (primary and metastatic) e. Encephalopathies (infectious, metabolic) f. Vasculitis

Methods of Teaching 1. Clinical Sites a. National Rehabilitation i. 3 East Unit 2. Clinical teaching a. PM&R Bedside Rounds b. Therapy Rounds: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the resident’s

141 Integrated Competency Based Curriculum 2012-2013

duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. Physical Therapy ii. Occupational Therapy iii. Speech Language Pathology iv. Recreational Therapy c. Team Conferences d. Family Conferences e. Weekly Didactic Lectures i. Tuesday 10:00am – 11:00am, Dr. Kritis Dasgupta ii. Wednesday 10:00am – 11:00am, Dr. Michael Yochelson 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics b. Specific Rotation Didactics i. The Neurological Examination ii. Depression after brain injury iii. Managing agitation after brain injury iv. Managing spasticity in brain injury v. Managing heterotopic ossification in brain injury vi. Use of neuro-stimulants in brain injury vii. Sleep dysfunction and fatigue after brain injury viii. Medical management of cognitive dysfunction ix. Endocrine dysfunction after brain injury x. Spectrum of care (acute inpatient rehab, subacute rehab, day programs, outpatient therapy, home therapy) and resources available in the long term care and rehabilitation of the brain injured patient xi. Education on various scales used in the assessment and management of the brain injured patient (e.g., GOAT, Rancho Los Amigos Cognitive Scale) c. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series

142 Integrated Competency Based Curriculum 2012-2013

iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Lines of Supervision

The PGY4 resident reports directly to the faculty attending or fellow if on service with minimal direct supervisor. The PGY4 will supervise PGY2 residents and rotating medical students. The medical student will report to the PGY2 as first line then the PGY4, then attending on service.

Specific Competency – Based Goals & Objectives

TRAUMATIC BRAIN INJURY (TBI) - PGY4 GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the TBI patient.

143 Integrated Competency Based Curriculum 2012-2013

OBJECTIVES: The resident is able to:

Demonstrate proficiency in determining the mechanism of injury.

Demonstrate proficiency in establishing the length of coma/post traumatic amnesia. Demonstrate appropriate usage and interpretation of the following scales: GOAT Rancho Los Amigos scale FIM scale

Demonstrate an appropriate assessment and differential diagnosis of a: Comatose patient Patient in a vegetative state Mild traumatic brain injured patient Agitated patient

Examine the brain injured patient for: Ocular injury Spasticity DVT

Assess the nutritional status of the patient and perform a screening examination for dysphasia. Assess the endocrinologic condition of the patient for: DI SIADH Gynecomastia Galactorrhea

144 Integrated Competency Based Curriculum 2012-2013

PHYSIATRIC SKILLS

Functional Evaluation

GOAL: The resident is able to perform a functional examination of the TBI patient.

OBJECTIVES: The resident is able to:

Therapeutic & Diagnostic Injections/ Procedures

GOAL: The resident is able to understand the need for interventional procedures for TBI patients well as perform appropriate ones as designated. OBJECTIVES: The resident is able to:

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in TBI patient. OBJECTIVES: The resident is able to:

145 Integrated Competency Based Curriculum 2012-2013

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to provide patient care that is effective and appropriate.

OBJECTIVES: The resident is able to:

Demonstrate the ability to prescribe an appropriate program of environmental/psychological/pharmaceutical intervention for the: Agitated patient Mild TBI patient Patient with post traumatic amnesia

MEDICAL KNOWLEDGE

146 Integrated Competency Based Curriculum 2012-2013

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with TBI.

OBJECTIVES: The resident is able to:

Define the clinical features of locked in syndrome.

Define the clinical features of akinetic mutism

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with TBI.

OBJECTIVES: The resident is able to:

147 Integrated Competency Based Curriculum 2012-2013

Demonstrate appropriate knowledge of the: WESTMEAD scale GOAT GLASGOW Outcome scale Disability Rating scale Rancho Los Amigos levels of cognitive function scale Functional Independent Measures (FIM)

PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices.

OBJECTIVES: The resident is able:

148 Integrated Competency Based Curriculum 2012-2013

To analyze practice experience and perform practice-based improvement activities using a systematic methodology.

To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status.

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

Use information technology to manage information, access on-line medical information, and support their didactic education.

Facilitate the learning of students and other healthcare professionals.

INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team.

OBJECTIVES: The resident is able to:

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to:

149 Integrated Competency Based Curriculum 2012-2013

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. https://docs.google.com/leaf?id=0B4faOywZhlHUN2FlNTYwM2MtODM2MS00MTczLTlh YzYtMGIwZmJiMDA1YmJj&hl=en

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. CD with reading material is given to the resident at the start of the rotation.

150 Integrated Competency Based Curriculum 2012-2013

Stroke Recovery

Stroke Recovery – PGY2 GMEC Approved on: December 2, 2009 Domain: Neurorehabilitation Level: PGY2 Length: 2 months Type: Inpatient Rotation Director: Dr. Brendan Conroy Faculty: Dr. Brendan Conroy and Dr. Sandeep Simlote

General Educational Objective The PGY2 resident manages the Inpatient Rehabilitation Stroke patient as measured by the resident physician’s participation in team conferences, daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the brain, shoulder and gait physiology.

2. Common types of adult Stroke pathophysiology a. Ischemic i. Thrombotic ii. Embolic b. Hemorrhagic i. Subarachnoid ii. Intracerebral (intraparenchymal)

3. Procedure Skills a. Neurologic Exam b. Mini Mental Status Exam

4. Clinical Sites a. National Rehabilitation Hospital

5. Clinical teaching a. PM&R Bedside Rounds b. Therapy Rounds: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the resident’s

151 Integrated Competency Based Curriculum 2012-2013

duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. The resident should have exposure at minimum to the following therapist: 1. Physical Therapy 2. Occupational Therapy 3. Speech Language Pathology 4. Recreational Therapy ii. The residents should learn the basics of: 1. Transfer Training 2. Pre-gait 3. Gait Training 4. Basic ROM 5. Wheel Chair Clinic c. Team Conferences d. Family Conferences e. Weekly Didactic Lectures i. Tuesdays 6. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. d. Evaluation 7. Didactic Conferences a. Specific Rotation Didactics i. Monthly Neuro Continue Education Conference b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 8. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

152 Integrated Competency Based Curriculum 2012-2013

Specific Competency – Based Goals & Objectives

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the CVA patient. OBJECTIVES: The resident is able to:

153 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Relate the anatomy of the cranial system to the signs/symptoms of the following common stroke syndromes: ICA syndrome MCA syndrome (including Pseudobulbar Palsy) ACA syndrome PCA syndrome Brainstem syndromes (including Lateral Medullary syndrome, Locked in Syndrome, and Weber Syndrome) Lacunar stroke syndromes Pure motor stroke Pure sensory stroke Dysarthria-clumsy hand syndrome Demonstrate adequate ability to obtain a history which would indicate the possible etiology of pain in the hemiparetic arm Assess the stroke patient in his/her: Higher mental functions Communication skills Level of motor/sensory impairment Cranial nerve impairment Balance/coordination/posture/gait Demonstrate adequate performance of a bedside test for dysphagia. Demonstrate adequate performance of a bedside test of communication disorders and differentiate between: Dysarthria versus apraxia of speech Aphasia versus dysarthria Dementia versus aphasia Demonstrate the ability to detect DVT in the CVA patient. Demonstrate the ability to detect neurobehavioral disorders in CVA patients including depression, reduced initiation, reduced awareness, agitation/aggressive/disinhibited behavior. Demonstrate the ability to detect homonymous hemianopsia versus hemineglect in the CVA patients.

154 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Demonstrate the ability to perform an appropriate cognitive screen on the CVA patient. Demonstrate the ability to rank the CVA patient appropriately in the Brunnstrom stages of motor recovery. Differentiate through physical examination the following causes of pain in the hemiparetic arm: RSD Shoulder subluxation Shoulder contracture Brachial plexus injury Impingement syndrome Rotator cuff lesion Peripheral neuropathy Cervical radiculopathy Demonstrate adequate ability to assess spasticity in the CVA patient as well as use the Ashworth Scale (if applicable). PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the CVA patient. OBJECTIVES: The resident is able to: Compare and contrast commonly used evaluations of aphasia: Boston Diagnostic Aphasia exam Western Aphasia Battery Porch Index of Communication Abilities Functional Communication Profile Compare and contrast commonly used evaluation scales of self management including: Barthel Index FIM PULSES Profile Katz Index Independence in ADL Exercise Prescription and Modalities

155 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the CVA patient. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for the CVA patient which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional procedures for CVA patients well as perform appropriate ones as needed. OBJECTIVES: The resident is able to: Demonstrate the ability to read neuro imaging studies (CT/MRI) and successfully denote the presence of ischemia, SAH, cerebral hematoma, cerebral edema, mass effects, etc. Understand the pros/cons of MRI/CT imaging in the CVA patient and demonstrate the appropriate ordering of these tests. Demonstrate hands-on understanding of MBS study. Demonstrate hands-on understanding of Cystometrogram Study. Understand the indications of the use of conventional echocardiogram versus TEE studies in the stroke patient. Demonstrate the ability to perform PVR scans on stroke patients, and understand how to use the test in clinical practice. Electrodiagnostic Skills

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the CVA patient. OBJECTIVES: The resident is able to:

156 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Understand the difference between: Restorative training Compensatory training Assistive technology Demonstrate knowledge of adaptive ADL equipment appropriate to the CVA patient. Demonstrate knowledge of appropriate wheelchair and seating prescriptions for CVA patients. Demonstrate knowledge of appropriate prescription of AFOs for the CVA patient. Demonstrate knowledge of the indications for the use of cane/walkers in the CVA patient. CLINICAL JUDGEMENT

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to treat spasticity in the CVA patient with appropriate pharmacologic and therapeutic interventions. Demonstrate the ability to treat seizures and prescribe seizure prophylaxis in the CVA patient. Demonstrate the ability to care for bowel/bladder abnormalities of the CVA patient. Demonstrate the ability to prescribe appropriate diet intervention and feeding alternatives for patients with dysphagia. Demonstrate the ability to provide a preventative as well as an acute treatment programs

157 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES for DVT. Educate the patient in appropriate compensatory techniques for dysphagia, including the use of dietary and mechanical maneuvers. Educate the patient in the various risk factors pertain to CVA and prescribe a program of risk prevention. Discuss the concepts of learned non-use/forced use and biofeedback as they pertain to the rehabilitation of patients with CVA. Demonstrate the ability to appropriately treat the language disorders of the CVA patient. Demonstrate the ability to pharmacologically treat disorders of arousal/attention/reduced initiation. Demonstrate the ability to treat neural behavioral disorders of the CVA patient using pharmacologic/behavioral/environmental therapy. Understand the psychological adjustment required by the CVA patient and his/her significant other and treat/refer appropriately for depression and other conditions that may interfere with the individual obtaining his/her highest possible function. Understand that the continuum of care of the CVA patient may include appropriate vocational/educational rehabilitation. Demonstrate the ability to provide appropriate sexual information to the CVA patient regarding techniques to enhance sexual participation and pleasure. Demonstrate the ability to diagnose and treat the causes of pain in the hemiplegic side of the body. MEDICAL KNOWLEDGE GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with CVA. OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the epidemiology of CVA including incidence/prevalence/age distribution/survival rate/race distribution. Demonstrate understanding of the definitions of TIA and RIND and discuss their Demonstratel i hi understanding CVA of the incidence/pathophysiology/and clinical presentation of the various types of stroke including : Thrombotic

158 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Embolic Lacunar SAH Intraparenchymal hemorrhage Provide a differential diagnosis of stroke in the young adult and child as compared with that in the older adult. Demonstrate knowledge of the following in the CVA patient: Anatomy/neuroanatomy and physiology of bowel/bladder normal voiding and elimination. Anatomy/neuroanatomy and physiology of sexual functioning in the male and female. PHYSIATRIC KNOWLEDGE GOAL: The resident is able to demonstrate adequate physiatric knowledge of the patient with CVA. OBJECTIVES: The resident is able to: Demonstrate understanding of risk factors of stroke in : Asymptomatic patients Symptomatic patients Patients with previous history of CVA Demonstrate understanding of the risk factors of stroke including: High blood pressure Smoking Increased cholesterol levels Diabetes Alcohol Abuse Obesity Heart disease/Arrhythmias Chronic disease Increased blood viscosity Understand the process whereby an individual with stroke is evaluated for acute rehabilitation.

159 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Understanding the usual period for potential recovery for: Hemiparetic arm Aphasia Visual impairment Dysphagia Define the following terms: Aphasia Alexia Agraphia Prosody Perceptual deficit (versus hemisensory loss versus homonymous hemianopsia) Apraxia (including dressing apraxia/constructional apraxia/ideomotor apraxia) Dysarthria Neglect Dysphagia Agnosia Understand those factors that most commonly predict ADL abilities status post CVA. Provide definitions of the following terminology used to describe Aphasia: Agrammatism Anomia Circumlocution Echolalia Empty speech Paraphasias Telegraphic speech Jargon versus neologism

160 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Define the anatomy as well as the language characteristics of the following types of communication disorders: Broca’s aphasia Global aphasia Anomia Wernicke’s aphasia Transcortical motor aphasia Transcortical sensory aphasia Conduction aphasia Demonstrate understanding of the communication disorders resulting from an injury of the right hemisphere. Understand the physiology of the swallowing mechanism as well as the incidence and recovery of dysphagia in the stroke patient. Demonstrate knowledge of both flexion and extension synergy pattern. Demonstrate understanding of the physiology of spasticity. Demonstrate understanding of the concept of the ischemic penumbra and diaschisis. Demonstrate knowledge of the acute care management of the CVA patient. Demonstrate knowledge of potential predictors of functional outcomes status post CVA. Understand the functional recovery of the hemiparetic arm. Provide a differential diagnosis of pain in the hemiparetic/hemiplegic side of the body PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able to: Analyze practice experience and perform practice-based improvement activities using a Analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly

161 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals.

INTERPERSONAL & COMMUNICATION SKILLS GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to: Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and significant others. Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

GOAL: The resident is able to see the patient beyond the disease. OBJECTIVES: The resident is able to:

162 Integrated Competency Based Curriculum 2012-2013

STROKE RECOVERY – PGY2 GOALS AND OBJECTIVES Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

rd nd • Physical Medicine & Rehabilitation, 3 edition 2007 (as of July 1, 2009) 2 edition 2000 prior, Randall L Braddom MD MS.

. Chapter 50 - Rehabilitation of Stroke Syndromes . Chapter 4 - Psychological Perspectives on Rehabilitation: Contemporary Assessment and Intervention Strategies

. Chapter 5 – Gait Analysis

163 Integrated Competency Based Curriculum 2012-2013

. Chapter 16 - Lower Limb Orthoses . Chapter 28 - Rehabilitation of Patients With Swallowing Disorders . Chapter 29 – Management of Bladder Dysfunction . Chapter 30 – Neurogenic Bowel: Dysfunction and Rehabilitation . Chapter 31 - Spasticity Management . Chapter 32 - Sexuality Issues in Persons with Disabilities . Chapter 48 - Rehabilitation of Patients with Neuropathies . Chapter 60 - Geriatric Rehabilitation

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

164 Integrated Competency Based Curriculum 2012-2013

Stroke Recovery – PGY3 GMEC Approved on: December 2, 2009 Domain: Neurorehabilitation Level: PGY3 Length: 1 month Type: Inpatient Rotation Director: Dr. Brendan Conroy Faculty: Dr. Brendan Conroy and Dr. Sandeep Simlote

General Educational Objective The PGY3 resident manages the Inpatient Rehabilitation Stroke patient as measured by the resident physician’s ability to lead team and family conferences, independent daily patient rounding and assessments, development to plan of care, admission history & physicals and discharge summaries. The PGY3 is expected to provide guidance and direction for the PGY2 and medical students that are rotating on the same cycle.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the brain, shoulder and gait physiology.

2. Common types of adult Stroke pathophysiology a. Ischemic i. Thrombotic ii. Embolic b. Hemorrhagic i. Subarachnoid ii. Intracerebral (intraparenchymal)

3. Procedure Skills a. Neurologic Exam b. Mini Mental Status Exam

4. Clinical Sites a. National Rehabilitation Hospital

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duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. The resident should have exposure at minimum to the following therapist: 1. Physical Therapy 2. Occupational Therapy 3. Speech Language Pathology 4. Recreational Therapy ii. The residents should learn the basics of: 1. Transfer Training 2. Pre-gait 3. Gait Training 4. Basic ROM 5. Wheel Chair Clinic c. Team Conferences d. Family Conferences e. Weekly Didactic Lectures i. Tuesdays 6. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. d. Evaluation 7. Didactic Conferences a. Specific Rotation Didactics i. Monthly Neuro Continue Education Conference b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 8. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

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Specific Competency – Based Goals & Objectives

STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the CVA patient. OBJECTIVES: The resident is able to:

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Relate the anatomy of the cranial system to the signs/symptoms of the following common stroke syndromes: ICA syndrome MCA syndrome (including Pseudobulbar Palsy) ACA syndrome PCA syndrome Brainstem syndromes (including Lateral Medullary syndrome, Locked in Syndrome, and Weber Syndrome) Lacunar stroke syndromes Pure motor stroke Pure sensory stroke Dysarthria-clumsy hand syndrome Demonstrate adequate ability to obtain a history which would indicate the possible etiology of pain in the hemiparetic arm Assess the stroke patient in his/her: Higher mental functions Communication skills Level of motor/sensory impairment Cranial nerve impairment Balance/coordination/posture/gait Demonstrate adequate performance of a bedside test for dysphagia. Demonstrate adequate performance of a bedside test of communication disorders and differentiate between: Dysarthria versus apraxia of speech Aphasia versus dysarthria Dementia versus aphasia Demonstrate the ability to detect DVT in the CVA patient. Demonstrate the ability to detect neurobehavioral disorders in CVA patients including depression, reduced initiation, reduced awareness, agitation/aggressive/disinhibited behavior. Demonstrate the ability to detect homonymous hemianopsia versus hemineglect in the CVA patients.

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Demonstrate the ability to perform an appropriate cognitive screen on the CVA patient. Demonstrate the ability to rank the CVA patient appropriately in the Brunnstrom stages of motor recovery. Differentiate through physical examination the following causes of pain in the hemiparetic arm: RSD Shoulder subluxation Shoulder contracture Brachial plexus injury Impingement syndrome Rotator cuff lesion Peripheral neuropathy Cervical radiculopathy Demonstrate adequate ability to assess spasticity in the CVA patient as well as use the Ashworth Scale (if applicable). PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the CVA patient. OBJECTIVES: The resident is able to: Compare and contrast commonly used evaluations of aphasia: Boston Diagnostic Aphasia exam Western Aphasia Battery Porch Index of Communication Abilities Functional Communication Profile Compare and contrast commonly used evaluation scales of self management including: Barthel Index FIM PULSES Profile Katz Index Independence in ADL Exercise Prescription and Modalities

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the CVA patient. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for the CVA patient which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional procedures for CVA patients well as perform appropriate ones as needed. OBJECTIVES: The resident is able to: Demonstrate the ability to read neuro imaging studies (CT/MRI) and successfully denote the presence of ischemia, SAH, cerebral hematoma, cerebral edema, mass effects, etc. Understand the pros/cons of MRI/CT imaging in the CVA patient and demonstrate the appropriate ordering of these tests. Demonstrate hands-on understanding of MBS study. Demonstrate hands-on understanding of Cystometrogram Study. Understand the indications of the use of conventional echocardiogram versus TEE studies in the stroke patient. Demonstrate the ability to perform PVR scans on stroke patients, and understand how to use the test in clinical practice. Electrodiagnostic Skills

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the CVA patient. OBJECTIVES: The resident is able to:

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Understand the difference between: Restorative training Compensatory training Assistive technology Demonstrate knowledge of adaptive ADL equipment appropriate to the CVA patient. Demonstrate knowledge of appropriate wheelchair and seating prescriptions for CVA patients. Demonstrate knowledge of appropriate prescription of AFOs for the CVA patient. Demonstrate knowledge of the indications for the use of cane/walkers in the CVA patient. CLINICAL JUDGEMENT

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES for DVT. Educate the patient in appropriate compensatory techniques for dysphagia, including the use of dietary and mechanical maneuvers. Educate the patient in the various risk factors pertain to CVA and prescribe a program of risk prevention. Discuss the concepts of learned non-use/forced use and biofeedback as they pertain to the rehabilitation of patients with CVA. Demonstrate the ability to appropriately treat the language disorders of the CVA patient. Demonstrate the ability to pharmacologically treat disorders of arousal/attention/reduced initiation. Demonstrate the ability to treat neural behavioral disorders of the CVA patient using pharmacologic/behavioral/environmental therapy. Understand the psychological adjustment required by the CVA patient and his/her significant other and treat/refer appropriately for depression and other conditions that may interfere with the individual obtaining his/her highest possible function. Understand that the continuum of care of the CVA patient may include appropriate vocational/educational rehabilitation. Demonstrate the ability to provide appropriate sexual information to the CVA patient regarding techniques to enhance sexual participation and pleasure. Demonstrate the ability to diagnose and treat the causes of pain in the hemiplegic side of the body. MEDICAL KNOWLEDGE GENERAL KNOWLEDGE

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Embolic Lacunar SAH Intraparenchymal hemorrhage Provide a differential diagnosis of stroke in the young adult and child as compared with that in the older adult. Demonstrate knowledge of the following in the CVA patient: Anatomy/neuroanatomy and physiology of bowel/bladder normal voiding and elimination. Anatomy/neuroanatomy and physiology of sexual functioning in the male and female. PHYSIATRIC KNOWLEDGE GOAL: The resident is able to demonstrate adequate physiatric knowledge of the patient with CVA. OBJECTIVES: The resident is able to: Demonstrate understanding of risk factors of stroke in : Asymptomatic patients Symptomatic patients Patients with previous history of CVA Demonstrate understanding of the risk factors of stroke including: High blood pressure Smoking Increased cholesterol levels Diabetes Alcohol Abuse Obesity Heart disease/Arrhythmias Chronic disease Increased blood viscosity Understand the process whereby an individual with stroke is evaluated for acute rehabilitation.

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Understanding the usual period for potential recovery for: Hemiparetic arm Aphasia Visual impairment Dysphagia Define the following terms: Aphasia Alexia Agraphia Prosody Perceptual deficit (versus hemisensory loss versus homonymous hemianopsia) Apraxia (including dressing apraxia/constructional apraxia/ideomotor apraxia) Dysarthria Neglect Dysphagia Agnosia Understand those factors that most commonly predict ADL abilities status post CVA. Provide definitions of the following terminology used to describe Aphasia: Agrammatism Anomia Circumlocution Echolalia Empty speech Paraphasias Telegraphic speech Jargon versus neologism

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Define the anatomy as well as the language characteristics of the following types of communication disorders: Broca’s aphasia Global aphasia Anomia Wernicke’s aphasia Transcortical motor aphasia Transcortical sensory aphasia Conduction aphasia Demonstrate understanding of the communication disorders resulting from an injury of the right hemisphere. Understand the physiology of the swallowing mechanism as well as the incidence and recovery of dysphagia in the stroke patient. Demonstrate knowledge of both flexion and extension synergy pattern. Demonstrate understanding of the physiology of spasticity. Demonstrate understanding of the concept of the ischemic penumbra and diaschisis. Demonstrate knowledge of the acute care management of the CVA patient. Demonstrate knowledge of potential predictors of functional outcomes status post CVA. Understand the functional recovery of the hemiparetic arm. Provide a differential diagnosis of pain in the hemiparetic/hemiplegic side of the body PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able to: Analyze practice experience and perform practice-based improvement activities using a Analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals.

PROFESSIONAL ATTITUDE

GOAL: The resident is able to see the patient beyond the disease. OBJECTIVES: The resident is able to:

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STROKE RECOVERY – PGY3 GOALS AND OBJECTIVES Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

rd nd • Physical Medicine & Rehabilitation, 3 edition 2007 (as of July 1, 2009) 2 edition 2000 prior, Randall L Braddom MD MS.

. Chapter 50 - Rehabilitation of Stroke Syndromes . Chapter 4 - Psychological Perspectives on Rehabilitation: Contemporary Assessment and Intervention Strategies

. Chapter 5 – Gait Analysis

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• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

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Department of Veterans Affairs, Medical Center – Geriatrics GMEC Approved on: November 4, 2009 Domain: General Physical Medicine & Rehabilitation and Therapeutics Level: PGY2 Length: 1 month Type: Inpatient Consults and Outpatient Clinic Rotation Director: Dr. Nickie Lepcha Faculty: Dr. Nickie Lepcha

General Educational Objective The PGY2 resident will provide outpatient care with attending supervision and round on a consult service as measured by attending faculty evaluation. The resident will understand the epidemiology and sequela of geriatric diseases and disorders. The resident will become proficient with the management of the geriatric patient.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the Geriatric Patient 2. Common types of geriatric pathophysiology causing a. Hearing loss b. Abnormal Gait c. Fictional Decline d. Deconditioning e. Falls and Home safety f. Claudication g. Osteoporosis h. Visual impairments i. Motor Neuron Disease 3. Procedure Skills

Methods of Teaching 1. Clinical Sites a. Washington DC VA Medical Center 2. Clinical teaching a. Ambulatory Clinic b. Ward Rounding 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions.

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b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Lines of Supervision The PGY2 resident reports directly to the Dr. Nickie Lepcha with direct supervision of exam and procedures.

Specific Competency – Based Goals & Objectives Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the geriatric patient. OBJECTIVES: The resident is able to: Obtain a history differentiating vascular vs. neurogenic claudication pain. Obtain a history of the signs/symptoms indicative of loosening arthroplastic cementing material. Obtain the historical features that suggest inflammatory vs. non inflammatory arthritis. Obtain a history that would identify: Functional decline Cognitive decline Depression, anxiety, and other alterations of mood Available social support Available economic support PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the geriatric patient. OBJECTIVES: The resident is able to: Perform a physical exam that will enable the physician to assess the patient’s ability to perform in a safe manner: ADL’s IADL’s Recreational/vocational activities Ambulation activities Perform a physical exam that will enable the physician to assess the patient’s ability to express his/her needs/wants/emotions Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the geriatric patient.

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the indications/contraindications of exercise in individuals with ischemic rest pain. Demonstrate adequate knowledge of the indications/contraindications/administration of hot packs, ultrasound treatment, Paraffin baths, E-stimulation, and the use of ice. Prescribe a pre-prosthetic program for individuals with lower extremity amputations to include range of motion/strengthening/shaping/reduction of the residual limb. Be able to define the basic gait training program of a lower extremity amputee. Prescribe a post-operative arthroplasty program of muscle strengthening/range of motion/gait training for an individual with a joint replacement of the lower extremity (including appropriate precautions). Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional procedures for geriatric patients as well as perform appropriate ones as designated. OBJECTIVES: The resident is able to: Identify the signs of joint loosening via plain X-rays in those patients who have undergone arthroplasty. Demonstrate appropriate techniques in the performance of joint aspirations/injections. Demonstrate the ability to interpret traditional common radiologic signs of arthritis, osteoporosis, and Paget’s Disease in plain film examinations. Demonstrate familiarity with the Geriatrics Depression Scale. Electrodiagnostic Skills Prosthetics/Orthotics/Medical Equipment GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the geriatric patient. OBJECTIVES: The resident is able to: Understand the indications/contraindications and be able to appropriately prescribe shoe modifications including: Bevelled heel Wide toe box Rocker bottom shoe/metatarsal bar

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES Bal vs. blucher shoe

Demonstrate knowledge of the indications and contraindications for the use of cane/crutches/walkers in the geriatric patient. Demonstrate knowledge of appropriate wheel chair/seating prescriptions for the geriatric patient CLINICAL JUDGEMENT GOAL: The resident is able to demonstrate the ability to provide high standards of care OBJECTIVES: The resident is able to: Regularly integrate medical knowledge with clinical data and generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an Use diagnostici and therapeutic l procedures judiciously to achieve a quality outcome. PATIENT CARE GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Prescribe a prophylactic as well as an acute treatment program for DVT. Demonstrate the ability to prescribe a complete treatment program for foot ulcers/distal neuropathy. Prescribe appropriate adaptive devices in order for the geriatric patient to complete ADL’s/IADL’s at his/her highest functional level. Demonstrate the ability to provide a comprehensive treatment program to the patient in a subacute rehab facility who has experienced: CVA Joint arthroplasty Hip fracture Medical deconditioning Falls Osteoporosis Pain

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES Demonstrate the ability to design a home safety program to prevent falls. Demonstrate the ability to design an exercise program to minimize disability in the elderly. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE GOAL: The resident is able to demonstrate medical knowledge of the geriatric patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the financial impact of the aging population’s healthcare on this country. Demonstrate knowledge of biology and physiology of aging. Demonstrate knowledge of the demographics of aging. Demonstrate knowledge of the pharmacokinetic and pharmacodynamic changes associated with medication prescriptions of the elderly. Demonstrate knowledge of the risk of polypharmacy in the elderly. Demonstrate knowledge of the common impairments induced by drugs in the elderly, including those induced by the following medication groups: Anti seizure medications Anti psychotic medications Antidepressants Anti Parkinson’s medications Analgesics Antihistamines Cardiovascular medications Demonstrate knowledge of the signs and symptoms of Paget’s disease. Demonstrate recognition of the signs and symptoms of the following common disorders in the elderly: Sleep disorders Disorders of mood (including depression and anxiety) Pain disorders “Reversible dementia” (including delirium) Hypotension

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES PHYSIATRIC KNOWLEDGE GOAL: The resident is able to demonstrate physiatric knowledge of the geriatric patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the epidemiology of cerebral vascular disease (CVA’s) in the elderly population. Demonstrate knowledge of the epidemiology of amputations/joint replacements in the elderly population. Demonstrate knowledge of the differential diagnosis of cognitive impairment in the elderly population. Demonstrate knowledge of the differential diagnosis of dysphagia in the elderly population. Demonstrate knowledge of the epidemiology/financial impact as well the clinical characteristics of the following: Falls Incontinence Neuropathies Demonstrate knowledge of the epidemiology and clinical characteristics of osteoporosis. Demonstrate knowledge of the effects of deconditioning in the elderly population. Demonstrate knowledge of the epidemiology of spinal cord injury in the elderly population. Demonstrate knowledge of the normal aging changes that predispose the elderly to: Falls Cognitive impairments Incontinence Neuropathies PRACTICE-BASED LEARNING & IMPROVEMENT

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

PROFESSIONAL ATTITUDE

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Veterans Affairs GERIATRICS REHABILITATION ROTATION GOALS AND OBJECTIVES their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand the means by which rehabilitation programs are evaluated; including having basic knowledge of the standards used by CARF & JCAHO. Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system.

Educational Resources • Text Books

187 Integrated Competency Based Curriculum 2012-2013

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Chapter 59 – Principles of Geriatric Rehabilitation

• Articles

. Recommended from current literature during the rotation.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

Occupational Medicine & Electrodiagnostic Consultations This will be offered starting 2011.

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Pediatric Rehabilitation GMEC Approved on: December 2, 2009 Domain: Pediatrics Level: PGY3 Length: 2 months Type: Inpatient/Outpatient/Consults Rotation Director: Dr. Sally Evans Faculty: Dr. Sally Evans, Dr. Olga Morozova and Dr. Marion Kay McAlpine.

General Educational Objective The PGY3 resident will able to demonstrate the ability to take an appropriate physiatric history from either the pediatric patient and/or the appropriate care taker and perform a physiatric physical exam upon the pediatric patient as measured by the ability to establish or confirm a medical diagnosis as well as to obtain knowledge of the child’s developmental/functional status.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of pediatric patient. 2. Common types of pediatric pathophysiology a. Congenital Deformities b. Cerebral Palsy c. Hereditary Neuromuscular Disease and Dystrophy

Methods of Teaching 1. Clinical Sites a. Children’s National Medical Center – outpatient center and consultations 1 month b. National Center for Children’s Rehabilitation at NRH – inpatient 1 month 2. Clinical teaching a. Inpatient daily bedside rounds at NCCR b. Outpatient clinic evaluations at CNMC c. Inpatient consultations at CNMC d. Multidisciplinary Clinic participation i. Muscular Dystrophy ii. Spina Bifida iii. Congenital Anomalies iv. Spasticity e. Therapy Rounds at NCCR: Each week the resident and faculty attending will decided on that weeks dedicated time for therapy rounds. The time will be recorded in the

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resident’s duty hours with a specific duty type of NRH Therapy (a clinic designated duty type). The resident will participate in one patient’s therapy for any of the following. The resident should have exposure at minimum to the following therapist: i. The resident should have exposure at minimum to the following therapist: 1. Physical Therapy 2. Occupational Therapy 3. Speech Language Pathology 4. Recreational Therapy f. 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Determined at the beginning of each rotation. b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

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7. The Program Director will assess the progress of the 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision

The PGY3 resident reports directly to the faculty attending covering the service for the day. There will be direct supervision with procedures.

Specific Competency – Based Goals & Objectives PEDIATRIC ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from either the pediatric patient and/or the appropriate care taker and perform a physiatric physical exam upon the pediatric patient in order to establish or confirm a medical diagnosis as well as to obtain knowledge of the child’s developmental/functional status. OBJECTIVES: The resident is able to: Obtain a history pertinent to the illness/injury of the child which includes a demonstration of the understanding of: Pertinent maternal/paternal factors relating to the patient including: Age/health of parents before and after birth of child Pertinent maternal factors during gestation (i.e. illnesses, medications, toxic exposures, prenatal care, type/difficulty of delivery) Neonatal history (including Apgar scores, and history of feeding) The growth and development history of the child including: The child’s assimilation of postural reflexes and developmental milestones The child’s attainment of motor skills The child’s attainment of visual/auditory skills The child’s attainment of language skills The child’s attainment of cognitive, behavioral, and psychosocial skills Demonstrate the ability to detect myopathic disease in the pediatrics patient. Demonstrate the ability to detect PNS vs. CNS disease in the pediatrics patient.

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PEDIATRIC ROTATION GOALS AND OBJECTIVES Demonstrate the ability to detect orthopedic disease in the pediatrics patient (including an appreciation of Barlow’s sign, Galeazzi’s sign, and Ortolani’s sign). PHYSIATRIC SKILLS

Functional Evaluations GOAL: The resident is able to perform a meaningful examination of the pediatrics patient. OBJECTIVES: The resident is able to: Demonstrate proficiency in the age appropriate pediatric physical exam including: A neuromuscular exam which tests the child’s reflexes, tone, strength, and coordination Inspection and palpation of bones, measurement of active/passive joint ROM and assessment of stance and gait A sensory exam that will screen for visual/auditory impairment An assessment of the developmental skills of feeding/swallowing An assessment of speech and voice disorders through evaluation of respiration/phonation/articulation as well as dysarthria/apraxia Demonstrate the ability to clinically assess pain in the pediatric population Exercise Prescription and Modalities

GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the pediatrics patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the evidenced based as well as theoretical basis of prescribing the major therapeutic interventions that are appropriate for children including: Traditional exercises to promote strength coordination range of motion and endurance PNF, Rood Method, NDT, Brunnstrom exercises to promote increased function Therapeutic exercises to prevent contracture formation Therapeutic exercises/positioning techniques for hyper/hypotonicity

Demonstrate knowledge of the indications for biofeedback and electrical stimulation Demonstrate knowledge of the therapeutic and psychosocial benefits of adapted sports and recreation Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the need for interventional and diagnostic procedures for the pediatric patient.

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PEDIATRIC ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Demonstrate the ability to use plain film to associate bone age with general maturation characteristics of the child. Demonstrate the methods to measure scoliosis in appropriate children (including the COBB method). Demonstrate knowledge of the Salter’s classification of epiphyseal injuries. Demonstrate knowledge (and skill as appropriate) of chemo-denervation and intramuscular neurolytic techniques performed in order to treat spasticity. Electrodiagnostic Skills

GOAL: The resident is able to demonstrate knowledge of the normal and abnormal neurophysiologic data related to the electrodiagnostic exam of the pediatric patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the normative neurophysiologic data related to the maturation of pediatric peripheral nerves and muscles. Demonstrate familiarity with the electrophysiologic evaluation of the: Floppy baby Infant in respiratory distress Infant with plexus/nerve root injury Childhood neuromuscular junction disorders Childhood myopathies/peripheral neuropathies

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the pediatric patient. OBJECTIVES: The resident is able to: Prescribe age/function appropriate upper extremity orthotics/prosthetics to those parts of the anatomy that require same. Prescribe age/function appropriate lower extremity orthotics/prosthetics to those parts of the anatomy that requires same including: RGO’s and HGO’s Pavlik harness and static hip abduction orthoses Twister cables and hip abduction orthoses (for the older child) Prescribe age/function appropriate spinal orthotics to provide the support of parts of the anatomy

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PEDIATRIC ROTATION GOALS AND OBJECTIVES that require same including: Parapodium, standing frames, swivel walkers Milwaukee brace (CTLSO’s)/TLSO body jacket (for scoliosis and kyphosis) Prescribe age/function appropriate DME to offer mobility assistance to the pediatric patient. Demonstrate knowledge of age appropriate car seats/seat restraints. Demonstrate knowledge of age/function appropriate augmentative communication devices. CLINICAL JUDGEMENT GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient. OBJECTIVES: The resident is able to:

PATIENT CARE GOAL: The resident is able to demonstrate physiatric knowledge and skill related towards the pediatric patient with a neuromusculoskeletal diagnosis. OBJECTIVES: The resident is able to: Demonstrate knowledge of the pertinent characteristics of the following diseases, including signs/symptoms, differential diagnoses, diagnostic work-up, treatment options and means to prevent further sequela/degeneration (as appropriate): Cerebral Palsy Brain Injury (including brain tumors and concussions) Arnold Chiari Malformations Spinal Cord Injury (including those from tumors, trauma, SCIWORA, tethered cord, diastematomyelia, syringomyelia, transverse myelitis, AVM’s) Spasticity Limb Deficiencies Rheumatic disease (including JRA, AS and other seronegative spondyloarthropathies, juvenile dermatomyositis, SLE, Henoch-Schönlein Purpura, RSD) Arthrogryposis Osteogenesis imperfect Disorders of motor neuron (including spinal muscular atrophy I, II, II, ALS, and

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PEDIATRIC ROTATION GOALS AND OBJECTIVES poliomyelitis) Disorders of neuromuscular transmission (including myasthenia gravis) Neuropathic disease (including HMSN I, II, III, Roussy-Levy Syndrome, Refsum Disease, Fabry Disease, and Lead Poisoning) Myopathic disease (including malignant hyperthermia, congenital muscle fiber-type disproportion, nemaline rod myopathy, and central core myopathy) Guillain-Barré Disease Muscular dystrophy (including Duchenne’s, Becker’s, Emery-Dreifuss, Limb Girdle, Congenital, and Facioscapulohumeral) Myotonic dystrophy (including both congenital and acquired forms) Nutritional rickets Disorders of bone and joint including those of: Foot (including metatarsus adductus, calcaneovalgus foot, and club foot) Torsional deformities of the tibia and femur Genu varum/valgum (bowleggedness and knock-knees) Knee (including idiopathic adolescent anterior knee pain and Osgood-Schlatter Disease) Disorders of the hip (including developmental dysplasia of the hip, Legg-Calve- Perthes Disease, acute transient synovitis, and slipped capital femoral epiphysis, femoral version abnormalities) Spine (including scoliosis/kyphosis, and discitis) Neck (including torticollis, Klippel-Feil, and atlantoaxial instability) Upper limb (including Sprengel’s deformity and Nursemaid’s elbow) Demonstrate the ability to appropriately suspect those injuries that suggest child abuse. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE GOAL: The resident is able to demonstrate medical knowledge of the common diagnostic conditions of the pediatrics patient with a neuromusculoskeletal condition. OBJECTIVES: The resident is able to: Demonstrate knowledge of the general differentiating characteristics of neuropathies and myopathies including those that are physical as well as electrical. Demonstrate knowledge of the growth and development of a child in the following stages of life:

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PEDIATRIC ROTATION GOALS AND OBJECTIVES Newborn Age 1 Pre-school years Early school years Adolescence Demonstrate knowledge of the characteristics of autistic disorder Demonstrate knowledge of the nature of the epiphysis, diaphysis, and metaphysis. PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the pediatrics patient.

OBJECTIVES: The resident is able to:

Demonstrate an understanding of the anatomy/physiology of spasticity Understand the appropriate evaluation of the pediatrics patient who is experiencing back pain and demonstrate appreciation of the “danger signs” in this disorder Demonstrate understanding of the American Academy of Neurology Demonstrate the correlation between the risk of osteopenia and the female adolescent athlete Demonstrate an understanding of the prevention and treatment of heat injuries PRACTICE-BASED LEARNING & IMPROVEMENT

To analyze practice experience and perform practice-based improvement activities using a systematic methodology. To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education.

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PEDIATRIC ROTATION GOALS AND OBJECTIVES Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

PROFESSIONAL ATTITUDE

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PEDIATRIC ROTATION GOALS AND OBJECTIVES SYSTEMS-BASED PRACTICE

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal, professional, organizational, social level). Understand how the healthcare system affects their own practice (at the personal, professional, organizational, social level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources: • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

198 Integrated Competency Based Curriculum 2012-2013

. None Recommended.

• CD-ROMs

. None Recommended.

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Radiology – Visiting Nurses Association – Nascott (P&O) GMEC Approved on: November 4, 2009 Domain: General Physical Medicine & Rehabilitation and Therapeutics Level: PGY2 Length: 1 month Type: Outpatient Rotation Director: MEDSTAR GUH - MEDSTAR NRH PM&R Residency Training Program, Program Director Faculty: WHC- Radiology - Dr. James Jelinek and various radiologists under his direction. VNA – Various Home Physical or Occupational Therapist, (contact: Nadine Hosten, Rehab Operative Director 202-538-8607) Nascott - Shawn Kholer, CO, Jennifer Gatson, CO, Erin King, BOCP, David Fenton, CP, Dwayne Mills, C.Ped, and Rick Croat, C.Ped

General Educational Objective The PGY2 resident will be exposed to basic Radiology, Prosthetic & Orthotic and home physical/occupational therapy. This knowledge will be measured by clinical discussion with each healthcare provider and their written exam.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of the human body. 2. Common types of adult pathophysiology a. Amputations 1. Lower extremity 2. Upper extremity b. Foot & Ankle deformities c. Brain disorders d. Spine disorders e. Limb disorders 3. Procedure Skills None provide during this rotation

Methods of Teaching 1. Clinical Sites a. Washington Hospital Center i. Department of Radiology b. National Rehabilitation Hospital – Outpatient Physician Center i. Nascott 200 Integrated Competency Based Curriculum 2012-2013

c. Individual Patient’s homes i. Visiting Nurses Association

Contact Information: Nadine Hosten 202-538-8607 Title: Rehab Opertative Director DC Office -Medstar Health 2. Clinical teaching a. Radiology Rounds b. Outpatient Clinic Visit with O&P professionals c. Home clinical visits with therapist 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step- by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. None during this rotation b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

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7. The Program Director will assess the progress of the 4th year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY2 resident reports directly to the health care provider they are assigned to that day.

Specific Competency – Based Goals & Objectives Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical upon the MSK patient with an amputation and/or who demonstrates a significant neuropathy and/or who requires an orthotic/prosthetic device.

OBJECTIVES: The resident is able to:

Demonstrate the ability to detect the choke syndrome. Demonstrate the ability to detect the common dermatologic disorders found in the residual limb of an individual with an amputation. PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the MSK patient who has experienced an amputation, significant neuropathy, and/or who requires an orthotic.

OBJECTIVES: The resident is able to: Recognize and prescribe corrections for the common gait abnormalities of those with amputations and those with common gait abnormalities such as: Drop foot gait Gluteus medius gait Gluteus maximus gait Quadriceps weakness gait

Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the patient who has an amputation, significant neuropathy, or who requires an orthotic.

OBJECTIVES: The resident is able to:

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Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES Prescribe a pre-prosthetic program for individuals with UE/LE amputations to include range of motion/strengthening/shaping/reduction of the residual limb. Be able to define the basic gait training program of a LE amputee patient. Therapeutic & Diagnostic Injections Procedures GOAL: The resident is able to understand the need for interventional procedures for MSK patients well as perform appropriate ones as designated.

OBJECTIVES: The resident is able to: Be able to define those areas in prosthetics/orthotics that are causing the patient pain through the use of appropriate techniques (libstick/clay ball/etc.) Electrodiagnostic Skills N/A

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the patient who has an amputation, significant neuropathy, or who requires an orthotic.

OBJECTIVES: The resident is able to:

Prescribe appropriate shoe wear for protection of the diabetic foot. Discuss the procedures necessary to construct a preparatory and/or definitive prosthesis. Define the difference in between endo/exoskeletal prosthetic design. Demonstrate knowledge of the types of orthotic prescriptions available to those with partial foot amputations including: Spacers Spring shanks Rocker bottom soles Metatarsal pads

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Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES Define the functional characteristics/advantages/disadvantages of the following: SACH foot Single axis/multi-axis feet Dynamic response/energy storing feet PTB socket (with/without ISNY component) Socket liners Total contact quadrilateral socket Ischial containment socket Transfemoral frame socket with flexible liner (ISNY) Single axis constant friction knee Safety knee Multi axial knee Hydraulic/pneumatic knee Canadian hip disarticulation prosthesis Hemipelvectomy prosthesis

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Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES Understand the indications/contraindications of the use of suspension devices for the transfemoral prosthesis including: Suction socket 3-S suspension system Belt suspension Hypobaric sock Silesian belt TES belt Pelvic band and belt system Shoulder belt

Understand the indications/contraindications and be able to appropriately prescribe the following: Resting hand splint Functional wrist splint Thumb post splint Ring splint Dynamic splint Double upright Klenzak splint KAFO (plus/minus dial lock) Swedish knee cage

Understand the indications/contraindications and be able to appropriately prescribe shoe modifications including: Bevelled heel Wide toe box Metatarsal bar (internal/external) Rocker bottom shoe Understand the indications for short-leg patellar PTB brace

Demonstrate understanding of the indications/contraindications and be able to appropriately prescribe spinal orthotics including: Jewitt brace/body jacket LS corset Soft surgical collar Philadelphia collar

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Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES Demonstrate knowledge of the indications for the use cane/crutches/walkers in the MSK patient. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient.

OBJECTIVES: The resident is able to:

PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate.

OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe a program for relief of phantom pain (including pharmaceutical and therapeutic modalities). Demonstrate the ability to prescribe a program to reduce the pain of neuromas. Understand the psychosocial adjustments required by patients who have undergone amputation. Understand the continuum of care for the amputee/arthroplasty patients may include appropriate vocational/educational rehabilitation. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the MSK patient.

OBJECTIVES: The resident is able to:

Demonstrate knowledge of the incidence/prevalence/etiology/gender/age distribution of acquired amputation of the UE/LE.

PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the MSK patient.

OBJECTIVES: The resident is able to:

Demonstrate knowledge of preferred levels of amputation in the UE/LE (including the anatomic issues on which these decisions are based). Demonstrate knowledge of the prognosis of individuals with LE amputation.

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Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES Determine those individuals who have good/poor prognosis for prosthetic ambulation. Determine the appropriate timing of prosthetic fitting. Demonstrate knowledge of the advantages/disadvantages of: Partial foot amputation (including transmetatarsal, Lisfranc, Chopart, Boyd) amputation Symes amputation Transtibial amputation Knee disarticulation amputation Transfibular amputation Hip Disarticulation

Define the patients who need a hip disarticulation prosthesis. Define phantom pain and its differential diagnosis. Define the choke syndrome. Define the TKA line and its functional consequences in each phase of gait for those who are able bodied and those with LE amputations. PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices.

OBJECTIVES: The resident is able:

To analyze practice experience and perform practice-based improvement activities using a systematic methodology.

To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status.

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

Use information technology to manage information, access on-line medical information, and support their didactic education.

Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

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Radiology /VNA/Nascott (P&O) GOALS AND OBJECTIVES Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to:

Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

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Educational Resources • Text Books

rd nd . Physical Medicine & Rehabilitation, 3 edition 2007 (as of July 1, 2009) 2 edition 2000 prior, Randall L Braddom MD MS.

. Sanders GT. Lower Limb Amputations: A Guide to Rehabilitation. Philadelphia, FA Davis, 1986.

. Tan JC. Practical Manual of Physical Medicine and Rehabilitation. St Louis, Mosby, 1998.

. Delisa JA, Gans BM eds. Rehabilitation Medicine: Principals and Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2004.

. Orthotics. Phys Med Rehabil: State of the Art Reviews 1(1), Hanley & Belfus, 1987.

. Moore WS, Malone JM, eds. Lower Extremity Amputation. Philadelphia: Saunders, 1989.

. Prosthetics. Phys Med Rehabil: State of the Art Reviews 8(1), Hanley & Belfus, 1994.

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

209 Integrated Competency Based Curriculum 2012-2013

Outpatient Physician Center Specialty Clinics at NRH GMEC Approved on: November 4, 2009 Domain: MSK, Sports and Occupational Medicine Level: PGY2 Length: 1 month Type: Outpatient Rotation Director: Dr. Curtis Whitehair Faculty: Dr.Curtis Whitehair, Dr. Fatehme Milani, Dr. Victor Ibriham, Dr. Judith Galser, Dr. Brendan Conry, Dr. Pamela Ballard, Dr. Sandeep Simlote, Dr. Kritis Desgupta, Dr. Michael Yochelson, Dr. John N. Aseff, Dr. Rafael Convit, Dr. Nabil Khawand, Dr. Lauro Halstead, Dr. Howard Gilmer, Dr. Robert Bunning and Ginger Walls, PT.

General Educational Objective The PGY2 resident will be exposed to speciality clinics that provide the card for persons with disabilities. As a PGY2 they should understand the impact and need for specialty care. This rotation will allow them to learn about multiple areas of special skills and treatment. The goal is not be proficient in these areas as much as understanding what resources are available for their patients. Several of the specialty clinic will be part of their continued curriculum and they may have rotation some of the specialty areas.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of multiple musculoskeletal and neurologic systems. 2. Various types of adult pathophysiology are seen in the Outpatient Physician Center a. Spasticity b. Neurogenic Bowel c. Neurogenic Bladder d. Pressure Ulcers e. Cardiac Disease and Debilitation f. Amputations g. Stroke h. Pain i. Neuropathic ii. Somatic iii. Nociceptive i. Spine degeneration and traumatic problems i. Radiculopathy

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ii. Spondylosis iii. Spondylolisthesis iv. Degenerative Stenosis v. Facet Syndromes vi. Sacroiliac Dysfunction

j. Spinal Cord Injury k. Traumatic Brain Injury l. Post Polio Syndrome m. Rheumatologic conditions n. Musculoskeletal conditions requiring orthotics and bracing o. Lymphedema p. Cancer Related Fatigue and sequela 3. Procedure Skills a. Joint Injections i. Shoulder ii. Knee iii. MCP iv. Elbow b. Carpal Tunnel Injections c. Trigger Point Injections d. Botulinum Injections e. Wound Debridement f. Urology – catheter placement

Methods of Teaching 1. Clinical Sites a. All of the specialty clinics occur at the National Rehabilitation Hospital – Outpatient Physician Center. They are virtual clinics that occur on different scheduled days: i. Cardiac Rehab Clinic ii. Oncology Rehab Clinic iii. Urology Clinic iv. Plastic Surgery Clinic

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v. Stroke Outpatient vi. Rheumatology Clinic vii. Musculoskeletal Clinic viii. Spasticity Clinic ix. Spinal Cord Injury Outpatient x. Traumatic Brain Injury Outpatient xi. Post Polio Clinic xii. Electrodiagnostic Clinic 2. Clinical teaching a. Residents will observation of specialist b. Residents may exam and document H&P on certain patients that expand the resident’s patient care management experience. 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation.

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2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 2nd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY2 resident reports directly to the faculty attending of the specialty clinic. As they may progress though the skill’s learning process they will require less supervision in performing procedures, however, at the PGY2 level it is expected that all procedures will be under direct observation.

Specific Competency – Based Goals & Objectives

OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate focused history from and perform a focused physical exam upon the ambulatory PM&R patient. OBJECTIVES: The resident is able to: Obtain a patient history pertinent to the impairment/disability/handicap of the patient. Perform a physical exam pertinent to the impairment/disability/handicap of the patient. Use the information obtained on the history and physical exam with a goal of providing a prioritized differential diagnosis. PHYSIATRIC SKILLS

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OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES Functional Evaluations GOAL: The resident is able to demonstrate understanding of the functional examination of the ambulatory PM&R patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the functional impairment in patients with cancer including those secondary to: Nutritional deficiencies Pain Fatigue Neuropsychological abnormalities Lymphedema Metastatic boney involvement Demonstrate knowledge of the functional changes that occur with progressive/static weakness of the muscles of the limbs/trunk. Determine the physical/societal barriers that prevent a patient from obtaining his/her highest potential degree of independence in ADL’s, ambulation, and driving (based on level/severity of injuries) and the means by which they can be overcome if possible. Exercise Prescription and Modalities GOAL #1: The resident is able to appropriately prescribe exercise programs and modalities for the MSK patient with a rheumatic disease or a joint replacement. OBJECTIVES: The resident is able to: Prescribe a pre/postoperative arthroplasty program of muscle strengthening/range of motion/gait training for an individual with a joint replacement of the LE, along with appropriate precautions. Demonstrate the ability to prescribe a total rehabilitation program for the patient with nonsurgical arthritis to include as appropriate the following components: Rest (local/systemic) Range of motion (passive/active assisted/active) Muscle strengthening (isometric/isotonic/isokinetic/eccentric/concentric as indicated) Endurance activities/aerobic activities Aquatic therapy /recreational exercise

Prescribe appropriate modalities of heat/cold for the MSK patient (knowing indications/contraindications)

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OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES Demonstrate the ability to appropriately prescribe TENS. GOAL # 2: The resident is able to appropriately prescribe exercise programs and modalities for the SCI/CVA patient.

OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for SCI patient which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity

GOAL # 3: The resident is able to appropriately prescribe activity programs for the post-polio patient. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate activity program for the post polio patient which includes at least the following components: Energy conservation techniques (including ambulatory aids) Exercise

GOAL # 4: The resident is able to demonstrate understanding of the neurologic consequences of spasticity. OBJECTIVES: The resident is able to: Use appropriate scales to quantify spasticity and/or function in those who demonstrate this abnormality (including the Ashworth scale, Fugal-Meyer scale, and the Pendulum Test) Understand the usage, indications, contraindications of oral medications used to treat spasticity including: Baclofen Diazepam Dantrolene Clonidine Tizanidine Gabapentin Understand the usage, indications, contraindications of intrathecal administration of Baclofen, nerve blocks and botulinum toxin in the treatment of spasticity. Understand the common neurosurgical interventions (including rhizotomies and myelotomies) to

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OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES treat spasticity (including those used to treat the upper extremity, leg scissoring, crouched gait, stiff knee gait, equinovarus foot, and valgus foot, as well as static contractures). GOAL # 5: The resident is able to demonstrate understanding of the principles of wound care. OBJECTIVES: The resident is able to: Recognize and diminish the factors that arrest wound healing and perpetuate wound status including: Pressure forces Shear forces Inadequate nutrition Chronic inflammation/infection Demonstrate understanding of the general principles of wound treatment including those indications/contraindications for: Surgical debridement Enzymatic debridement Mechanical non-selective debridement Autolytic debridement Use of appropriate dressings (including transparent dressings, hydrocolloid dressings, gel dressings, and calcium alginate dressings) Demonstrate the ability to assess a pressure ulcer by the National Pressure Ulcer Advisory Panel Classification System Therapeutic & Diagnostic Injections/Procedures GOAL #1: The resident is able to understand the need for interventional procedures for SCI patients as well as perform appropriate ones as needed. OBJECTIVES: The resident is able to:

Demonstrates ability to interpret the meaning of PVR scans and prescribe urodynamic evaluation as appropriate. Demonstrate appropriate interpretation of urodynamic studies and their clinical meaning. Demonstrate ability to read routine spinal/ brain films/MRI/CT scans and to diagnose by these studies vertebral fractures, spinal and brain infarcts/contusion/hemorrhages, and the development of a spinal syrinx. GOAL #2: The resident is able to understand the need for interventional procedures for MSK patients who are experiencing a rheumatologic disease or a joint replacement as well as perform appropriate ones as designated.

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OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Identify the signs of joint loosening via plain x-ray in those patients who have undergone arthroplasty. Demonstrate appropriate techniques in the performance of joint aspirations/injections. Demonstrate the ability to analyze the findings of laboratory tests pertinent to the diagnosis/evaluation of the arthritis patient including: Sedimentation rates Rh factor ANA HLA-B27 Demonstrate the ability to interpret common radiologic signs of arthritis in plain film. Electrodiagnostic Skills GOAL #1: The resident will acquire sufficient knowledge of pertinent anatomy, electrophysiology and NCS/EMG techniques so that he/she will be able to perform in an independent manner, simple examinations of cervical and lumbar radiculopathies as well as upper and lower limb peripheral nerve entrapments. OBJECTIVES: The resident is able to:

Demonstrate knowledge of the anatomic basis for localization of injuries to the cervical and brachial plexus and its peripheral nerves (including dorsal scapular nerve, suprascapular nerve, musculocutaneous nerve, and axillary nerve and their anomalies), lumbar plexus and its peripheral nerves (including iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral, saphenous, and obturator nerve), and the sacral plexus and its principal nerves (superior and inferior gluteal, sciatic, tibial, common peroneal and sural nerves). Demonstrate knowledge of the electrical properties of nerve and muscle. Demonstrates appropriate electromyographic (machine) set-up and lead placement for common nerve conduction studies, such as those for the median, ulnar, tibial, radial, peroneal, and sural nerves, as well as F&H wave studies. Demonstrate knowledge of electromyography and needle placement for common muscles. Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of medical equipment in the outpatient who has experienced an injury or impairments. OBJECTIVES: The resident is able to: Prescribe appropriate upper extremity orthotics to provide relative protection/rest in those parts

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OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES of the anatomy that require same. Prescribe appropriate lower extremity orthotics to provide relative protection/rest in those parts of the anatomy that requires same. Prescribe appropriate spinal orthotics to provide relative protection/rest in those parts of the anatomy that require same. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient. OBJECTIVES: The resident is able to:

Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome. PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to provide a comprehensive treatment program to the post polio patient. Demonstrate the ability to provide a comprehensive treatment program to the patient with a rheumatologic condition. Demonstrate the ability to provide a comprehensive treatment program to the patient with lymphedema secondary to breast cancer. Demonstrate the ability to provide a comprehensive, long term management program for the individual with a neurogenic bowel and/or bowel. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to predict the expected functional outcome of a PM&R ambulatory patient including his/her potential degree of independence in ADL’s ambulation and driving, based on the severity (and level as appropriate) of injury. OBJECTIVES: The resident is able to:

218 Integrated Competency Based Curriculum 2012-2013

OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES Demonstrate knowledge of the affects of aging on those with neuromusculoskeletal injuries and in particular on the GI, GU, MSK, skin, and cardiovascular systems. Demonstrate medical knowledge of the epidemiology of specific cancers. Demonstrate knowledge of the most common primary and metastatic diseases of the central nervous system and breast.

Demonstrate knowledge of epidemiology/financial impact of industrial injuries in this country. Demonstrate knowledge of spinal anatomy sufficient to differentiate stenosis, myelopathy, and radiculopathy as well as recognize the differences in the clinical presentations of these disorders. Demonstrate knowledge of brain anatomy sufficient to correlate physical diagnostic findings with the location of the cerebral vascular accident. Demonstrate understanding of the mechanisms, indications, and contraindications to the use of pharmacologic agents in the treatment of pain including: NSAID’s Muscle relaxants Tricyclic antidepressants Anticonvulsants narcotics Demonstrate knowledge of the incidence/age/gender distribution of individuals requiring TKA/THA. Demonstrate knowledge of the sign, symptoms, epidemiology, pathology, and course of the following diseases: Rheumatoid arthritis Osteoarthritis Spondyloarthropathies (AS, Reiter’s, PSA) Septic Arthritis Gout/Pseudo Gout SLE Progressive systemic sclerosis Polymyositis/Dermatomyositis

219 Integrated Competency Based Curriculum 2012-2013

OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES Demonstrate knowledge of the indications / contraindications / therapeutic applications of the various pharmacologic agents available to treat rheumatic diseases including: NSAID’s Antimalarial medications DMARDs including MTX, Enbrel, Arava, Gold, D-Penicillamine, Cytotoxic drugs Steroids Anti-hyperuricemia agents

Demonstrate awareness of non-pharmacologic and alternative medical care modalities for the patient with arthritis including: Acupuncture Relaxation therapy Massage therapy Diet Herbal remedies PHYSIATRIC KNOWLEDGE

GOAL # 1: The resident is able to demonstrate knowledge of the effects of aging upon those with a disability. OBJECTIVES: The resident is able to: Demonstrate knowledge of the effects of aging upon both the organ systems and psychosocial characteristics of the life of an individual with a disability. Demonstrate knowledge of a general health maintenance program for individuals with a disability and understand the barriers to same. GOAL # 2: The resident is able to demonstrate knowledge of post polio syndrome. OBJECTIVES: The resident is able to: Define PPS and demonstrate knowledge of its epidemiology/diagnostic criteria as well as its course. Develop a differential diagnosis of the patient with post polio syndrome. Demonstrate understanding of the psychology of the polio survivor. Describe the neuroanatomy/pathophysiology of spasticity. Demonstrate knowledge of the indications/contraindications/risks of medications used for the fatigue of post polio syndrome

220 Integrated Competency Based Curriculum 2012-2013

OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES GOAL # 3: The resident is able to demonstrate understanding of the neurologic consequences of injury to the bowel and bladder. OBJECTIVES: The resident is able to: Describe the pertinent innervation of the bowel and bladder. Demonstrate knowledge of those medications which influence the function of the bowel and bladder. Demonstrate knowledge of long term complications of an indwelling Foley vs. intermittent catheterization vs. super pubic catheter program. Demonstrate understanding of the long term GI complications for individuals with neurogenic bowel. PRACTICE-BASED LEARNING & IMPROVEMENT

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

221 Integrated Competency Based Curriculum 2012-2013

OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

222 Integrated Competency Based Curriculum 2012-2013

OPC SPECIALTY CLINICS ROTATION GOALS AND OBJECTIVES Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

223 Integrated Competency Based Curriculum 2012-2013

Pain Consultations

Pain Consultations at Washington Hospital Center Domain: General Physical Medicine & Rehabilitation Therapeutics Level: PGY-2 or 3 Length: 1 month Type: Outpatient and Inpatient Consults Rotation Director: Dr. Kodgi Faculty: Dr. Kodgi and Dr. LeeAnn Rhodes

General Educational Objective This rotation may be taken in the PGY-2 year or PGY-3 year. The resident will have a choice between this rotation and an elective rotation in the PGY-2 year. If they choose this rotation in the PGY-2 year then they will have an elective in the PGY-3 year, if not then they will have this rotation in the PGY-3 year with the elective in the PGY-2 year.

Scope of Learning and Exposures 1. Learn the physiology and basic science behind pain syndromes. a. Anatomy as it relates to regional anesthesia and main nerve blocks b. Autonomic: stellate, celiac, lumbar sympathetic c. Head and neck: cervical plexus d. Extremities: brachial plexus, ulnar, radial, median, sciatic, femoral, lateral femoral cutaneous, obturator, ilioinguinal, lumbar plexus e. Trunk – intercostals, paravertebral somatic f. Spine – epidural, caudal, intrathecal

2. Common types of adult Pain pathophysiology a. Neuropathic pain b. Nociceptive pain c. Psychosomatic pain d. Addiction, pseud-addiction, and tolerance e. Types of pain – cutaneous, deep somatic, visceral, central f. Specific pain syndromes – sympathetic dystrophy, phantom limb, low back pain, intractable cancer pain, causalgia, post-herpetic neuralgia, trigger points, fibromyalgia

3. Procedure Skills, methods, and techniques for regional anesthesia and main nerve blocks a. Peripheral and autonomic nerve blocks i. Indications 224 Integrated Competency Based Curriculum 2012-2013

ii. Contraindications iii. Techniques iv. clinical assessment v. complications b. IV regional i. Mechanism ii. Agents iii. Indications iv. Contraindications v. Techniques vi. complications

Methods of Teaching 1. Clinical Sites a. Washington Hospital Center b. Center for Ambulatory Surgery, Inc. – Medstar 2. Clinical teaching a. Ambulatory Clinic b. Inpatient Ward Rounding Consultations 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence.

4. Didactic Conferences a. Specific Rotation Didactics b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

225 Integrated Competency Based Curriculum 2012-2013

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 2nd or 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY2 resident reports directly to the Dr. Rhodes and Dr. Kodgi with direct supervision during procedures.

Specific Competency – Based Goals & Objectives PAIN MANAGEMENT GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the MSK outpatient who is experiencing pain.

OBJECTIVES: The resident is able to: Obtain a patient history that differentiates the patient’s pain into either an acute or chronic category. Demonstrate the ability to recognize the historical “red flags” to the chronic pain patient. Demonstrate proficiency in determining the mechanism of injury. Demonstrate proficiency in identifying the characteristics of local pain versus radiating pain versus referred pain. Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding psychosocial and financial/legal information.

PHYSIATRIC SKILLS

Functional Evaluations

226 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES GOAL: The resident is able to perform a meaningful examination of the MSK outpatient.

OBJECTIVES: The resident is able to:

Perform specific examinations that are focused towards the evaluation of the patient with neck/shoulder and/or low back/buttock/leg pain, with a goal of providing a prioritized differential diagnosis. Demonstrate the appropriate use of various measures of perceived pain, disability and dysfunction including the: Visual analog scale McGill pain questionnaire Algometer use MMPI Sickness impact profile Beck depression inventory Waddell’s signs and symptoms

Demonstrate the ability to detect Complex Regional Pain Syndrome (Type I and Type II) Demonstrate the ability to distinguish the difference between muscle tenderness and trigger points. Exercise Prescription and Modalities

GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the MSK outpatient in pain.

OBJECTIVES: The resident is able to:

Demonstrate the ability to prescribe and monitor an appropriate exercise program for MSK outpatients in pain which includes at least the following components: Use of temperature modalities including heat, cold packs, ice massage, contrast baths, vapocoolant spray, hot packs, paraffin, hydrotherapy, fluidotherapy, ultrasound, and phonophoresis. Electrical stimulation (iontophoresis, TENS). Physical therapeutic exercise (stretching, range of motion, isometric/isotonic/isokinetic exercise) Manual techniques (massage, manipulation) Other exercise techniques including PNF

Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the need for interventional procedures for MSK outpatients in pain as well as perform appropriate ones as needed.

OBJECTIVES: The resident is able to:

Demonstrate knowledge of the theory, indications and contraindications of trigger point injections, neuro blockade procedures, neurolytic procedures, and topical therapies. Demonstrate appropriate usage of electrodiagnostic testing and radiologic studies (e.g. CT/MRI/bone scan/plain films) in the evaluation of the MSK outpatient with pain. Demonstrate the ability to perform trigger point injections.

227 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES Demonstrate understanding of the use of adjunctive treatment techniques for the control of pain including but not limited to biofeedback/relaxation training, acupuncture, and hypnosis.

Demonstrate understanding of the use of a differential neuro blockade in the diagnosis of pain mechanisms. Electrodiagnostic Skills

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the MSK outpatient.

OBJECTIVES: The resident is able to:

Prescribe appropriate upper extremity orthotics to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate lower extremity orthotics to provide relative protection/rest in those parts of the anatomy that requires same. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient.

OBJECTIVES: The resident is able to:

Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome.

PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate.

OBJECTIVES: The resident is able to:

Demonstrate the ability to provide a comprehensive treatment program to the individual with a myofascial pain syndrome in the outpatient setting. Demonstrate the ability to consult/refer to surgical subspecialties and pain management specialty centers as needed. Demonstrate the ability to treat cumulative pain trauma disorders in the outpatient setting. Demonstrate the ability to treat lumbar spinal pain of differing etiologies in the outpatient setting. Demonstrate the ability to treat cervical spine pain of differing etiologies in the outpatient setting. Demonstrate the ability to treat pelvic pain syndromes in the outpatient setting. Demonstrate the ability to treat CRPS in the outpatient setting.

Demonstrate the ability to treat cervical vertigo in the outpatient setting.

228 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES Demonstrate the ability to apply psychological and behavioral components to the total pain management treatment program. Demonstrate the ability to treat/refer appropriately for those psychological/behavioral conditions that may interfere with the individual obtaining his/her highest functional level. Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate pain in those with musculoskeletal complaints in the outpatient setting. Detect pain which is intentionally produced or feigned as in a factitious disorder or malingering.

MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with MSK pain.

OBJECTIVES: The resident is able to:

Demonstrate knowledge of the epidemiology/financial impact of acute and chronic pain in this country. Demonstrate knowledge of spinal, muscular, and neuro anatomy sufficient to explain patterns of acute, radiating, and referred pain. Define the terms acute and chronic pain. Demonstrate understanding of the mechanisms, indications, and contraindications to the use of pharmacologic agents in the treatment of pain including: NSAID’s Muscle relaxants Tricyclic antidepressants Anticonvulsants Alpha adrenergic agonists Lidocaine analogs Calcium channel blockers Benzodiazepine/Non-Benzodiazepine hypnotics Narcotics

PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with a painful outpatient MSK condition. OBJECTIVES: The resident is able to:

Demonstrate understanding of the peripheral and central anatomic structures that are involved in the pain pathway.

Demonstrate understanding of the biochemistry/neurotransmitters of pain.

229 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES Demonstrate knowledge of referred pain patterns of myofascial trigger points.

Demonstrate understanding of the difference between an individual’s pain and pain behavior.

Demonstrate understanding of the chronic pain syndrome.

Demonstrate understanding of the differences between the types of pain rehabilitation found in: Comprehensive pain centers Interdisciplinary pain rehabilitation teams Inpatient chronic pain rehabilitation programs

Understand the psychological components of pain including those accounted for by mood and anxiety.

PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices.

OBJECTIVES: The resident is able:

To analyze practice experience and perform practice-based improvement activities using a systematic methodology.

To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status.

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

230 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to:

Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

231 Integrated Competency Based Curriculum 2012-2013

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Wall P, Melzack R. Textbook of Pain. 5th ed. New York: Churchill Livingstone, 2005

. Loeser, JD, editor. Bonica's Management of Pain. 3rd ed. Lippincott Williams & Wilkins, 2001

. Waldman, SD. Interventional Pain Management. 2nd ed. Saunders, 2000.

. Boswell, MV, Cole, BE eds. Weiner's Pain Management: A Practical Guide for Clinicians. 7th ed. Informa Healthcare, 2005

• Articles

. None Recommended

• Self directed learning modules

. None Recommended

• Videos

. None Recommended

• CD-ROMs

. None Recommended

232 Integrated Competency Based Curriculum 2012-2013

Pain Consultations at George Washington University Medical Center Domain: General Physical Medicine & Rehabilitation Therapeutics Level: PGY-2 or 3 Length: 1 month Type: Outpatient and Inpatient Consults Rotation Director: Dr. Mehul Desai Faculty: Dr. Mehul Desai, Dr. Thomas Heckman, Dr. Neil Chatterjee and Dr. May Chin.

3. Procedure Skills, methods, and techniques for regional anesthesia and main nerve blocks c. Peripheral and autonomic nerve blocks vi. Indications

233 Integrated Competency Based Curriculum 2012-2013

vii. Contraindications viii. Techniques ix. clinical assessment x. complications d. IV regional vii. Mechanism viii. Agents ix. Indications x. Contraindications xi. Techniques xii. complications

Methods of Teaching 1. Clinical Sites a. George Washington University Medical Center b. GW Pain Center 2131 K St, NW Washington, DC 20037 Office: (202) 715-4599, Fax: (202) 715-4598 2. Clinical teaching a. Ambulatory Clinic b. Inpatient Ward Rounding Consultations 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Decided at the beginning of the rotation, based on resident’s interest. b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination:

234 Integrated Competency Based Curriculum 2012-2013

a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 2nd or 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY2 resident reports directly to the faculty attending that they are assigned to that week/day with direct supervision during procedures.

Specific Competency – Based Goals & Objectives PAIN MANAGEMENT GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the MSK outpatient who is experiencing pain.

235 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES PHYSIATRIC SKILLS

Functional Evaluations

GOAL: The resident is able to perform a meaningful examination of the MSK outpatient.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the MSK outpatient in pain.

OBJECTIVES: The resident is able to:

Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the need for interventional procedures for MSK outpatients in pain as well as perform appropriate ones as needed.

OBJECTIVES: The resident is able to:

Demonstrate knowledge of the theory, indications and contraindications of trigger point injections, neuro blockade 236 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES procedures, neurolytic procedures, and topical therapies. Demonstrate appropriate usage of electrodiagnostic testing and radiologic studies (e.g. CT/MRI/bone scan/plain films) in the evaluation of the MSK outpatient with pain. Demonstrate the ability to perform trigger point injections. Demonstrate understanding of the use of adjunctive treatment techniques for the control of pain including but not limited to biofeedback/relaxation training, acupuncture, and hypnosis.

Demonstrate understanding of the use of a differential neuro blockade in the diagnosis of pain mechanisms. Electrodiagnostic Skills

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the MSK outpatient.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient.

OBJECTIVES: The resident is able to:

Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome.

PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate.

OBJECTIVES: The resident is able to:

237 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES Demonstrate the ability to treat pelvic pain syndromes in the outpatient setting. Demonstrate the ability to treat CRPS in the outpatient setting.

Demonstrate the ability to treat cervical vertigo in the outpatient setting.

Demonstrate the ability to apply psychological and behavioral components to the total pain management treatment program. Demonstrate the ability to treat/refer appropriately for those psychological/behavioral conditions that may interfere with the individual obtaining his/her highest functional level. Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate pain in those with musculoskeletal complaints in the outpatient setting. Detect pain which is intentionally produced or feigned as in a factitious disorder or malingering.

MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with MSK pain.

OBJECTIVES: The resident is able to:

PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with a painful outpatient MSK condition.

238 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES OBJECTIVES: The resident is able to:

Demonstrate understanding of the peripheral and central anatomic structures that are involved in the pain pathway.

Demonstrate understanding of the biochemistry/neurotransmitters of pain.

Demonstrate knowledge of referred pain patterns of myofascial trigger points.

Demonstrate understanding of the difference between an individual’s pain and pain behavior.

Demonstrate understanding of the chronic pain syndrome.

Understand the psychological components of pain including those accounted for by mood and anxiety.

PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices.

OBJECTIVES: The resident is able:

To analyze practice experience and perform practice-based improvement activities using a systematic methodology.

To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status.

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and significant others.

239 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

OBJECTIVES: The resident is able to:

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to:

Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW).

240 Integrated Competency Based Curriculum 2012-2013

PAIN MANAGEMENT GOALS AND OBJECTIVES Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Wall P, Melzack R. Textbook of Pain. 5th ed. New York: Churchill Livingstone, 2005

. Loeser, JD, editor. Bonica's Management of Pain. 3rd ed. Lippincott Williams & Wilkins, 2001

. Waldman, SD. Interventional Pain Management. 2nd ed. Saunders, 2000.

. Boswell, MV, Cole, BE eds. Weiner's Pain Management: A Practical Guide for Clinicians. 7th ed. Informa Healthcare, 2005

• Articles

. None Recommended

• Self directed learning modules

. None Recommended

• Videos

. None Recommended

• CD-ROMs

. None Recommended

241 Integrated Competency Based Curriculum 2012-2013

Outpatient Center - Bethesda NRH Regional Rehab GMEC Updated on: Domain: MSK, Sports & Occupational Medicine Level: PGY-4 Length: 3 months Rotation Director: Dr. Kathleen Fink Faculty: Dr. Kathleen Fink, Dr. John Toerge, Dr. Victor Ibrahim, Dr. Curtis Whitehair and Dr. Fatima Milani

General Educational Objective The PGY-4 resident will be able to manage patients with common musculoskeletal problems in an outpatient clinic as measured by their ability to develop a differential diagnosis for common problems including pain in the wrists, elbows, shoulders, hips, knees, ankle, foot, and spine based on the results of the physiatric history and physical as well as interpretation of radiographic, pertinent laboratory and electrodiagnostic studies. The resident will be exposed to interventional pain management.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of Musculoskeletal System 2. Common types of adult MSK, Sports and Occupational pathophysiology a. cervical spine injuries including transient quadriplegia b. mid and low back pain c. shoulder injuries, shoulder multidirectional instability d. golfer’s elbow, wrist injuries e. tennis elbow, shoulder pain, lower extremity sprains and strains f. pars defects and spinal hyperextension injuries g. overuse injuries including shin splints, stress fractures, tendonitis h. stingers, how to manage concussions and return to play guidelines, knee injuries i. common knee, ankle, hand injuries j. medial collateral ligament sprains of the elbow, rotator cuff injuries, labral injuries 3. Procedure Skills a. Trigger Point Injections b. Joint Injections i. Shoulders ii. Knees c. Carpal Tunnel Injections d. EMG/NCS 242 Integrated Competency Based Curriculum 2012-2013

Methods of Teaching 1. Clinical Sites a. Bethesda NRH Regional Rehab Center; Monday, Tuesday and Thursday 8:00am – 5:00pm b. Massachusetts Avenue Surgical Center or Suburban Outpatient Surgical Center; Wednesdays 8:00am – 5:00pm c. Outpatient Physician Center at NRH; Fridays 8:00am – 5:00PM 2. Clinical teaching a. Ambulatory care b. RO&CA evaluations 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

243 Integrated Competency Based Curriculum 2012-2013

7. The Program Director will assess the progress of the4th year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY4 resident reports directly to the a. Bethesda NRH Regional Rehab Center; Monday, Tuesday and Thursday 8:00am – 5:00pm; Dr. Kathleen Fink, Dr. John Toerge and Dr. Victor Ibrahim b. Massachusetts Avenue Surgical Center or Suburban Outpatient Surgical Center; Wednesdays 8:00am – 5:00pm; Dr. Kathleen Fink c. Outpatient Physician Center at NRH; Fridays 8:00am – 5:00PM; Dr. Curtis Whitehair or Dr. Fatimah Milani

Specific Competency – Based Goals & Objectives OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES PATIENT CARE GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate physiatric history from and perform a physiatric physical exam upon the MSK outpatient who is experiencing pain. OBJECTIVES: The resident is able to: Obtain a patient history pertinent to an industrial accident/sports injury, particularly as it relates to spine pain and/or cumulative trauma disorder. Obtain a patient history pertinent to the common musculoskeletal injuries of dancers/musicians. Obtain a patient history that differentiates the patient’s pain into either an acute or chronic category. Demonstrate the ability to recognize the historical “red flags” indicating the need for urgent/emergent care of the injured worker/patient (and in particular those of Cauda Equina Syndrome). Demonstrate proficiency in determining the mechanism of injury. Demonstrate proficiency in identifying the characteristics of local pain versus radiating pain versus referred pain versus non-organic pain.

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Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding psychosocial and financial/legal information. Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding the achievement of maximal medical improvement. PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a meaningful examination of the MSK outpatient. OBJECTIVES: The resident is able to: Perform specific examinations that are focused towards the evaluation of the patient with neck/shoulder and/or low back/buttock/leg pain, with a goal of providing a prioritized differential diagnosis. Demonstrate the appropriate use of various measures of perceived pain, disability and dysfunction including the: Visual analog scale Waddell’s signs and symptoms Demonstrate both appropriate usage and interpretation of the components of : Work conditioning programs FCE’s Work hardening programs Ergonomic analysis of the job site Aerobic conditioning programs Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities OBJECTIVES:f h MSK The resident i i is able i to: Demonstrate the ability to prescribe(knowing the indications/contraindications for) and monitor an appropriate exercise program for MSK outpatients in pain which includes at least the following components: Use of modalities including heat, cold packs, ice massage, contrast baths, vapocoolant spray, hot packs, paraffin, traction, hydrotherapy, fluidotherapy, ultrasound, phonophoresis, as well as: Electrical stimulation (iontophoresis, TENS). Physical therapeutic exercise (flexibility/range of motion, spinal stabilization, and

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other special procedures as noted on the procedural log) Splinting (static and dynamic) Acupuncture Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional and diagnostic procedures for MSK outpatients in pain as well as perform appropriate ones as needed. OBJECTIVES: The resident is able to: Demonstrate knowledge of the theory, indications and contraindications of trigger point injections, neuro blockade procedures, neurolytic procedures, and topical therapies. Demonstrate appropriate usage and interpretation of electrodiagnostic testing. Demonstrate appropriate usage and interpretation of radiologic studies (e.g. CT/MRI/bone scan/plain films) and be able to correlate anatomic structures with the images seen. Demonstrate the ability to perform trigger point injections. Demonstrate understanding of the use of adjunctive treatment techniques for the control of pain including but not limited to biofeedback/relaxation training, acupuncture, and hypnosis. Demonstrate understanding of the use of a differential neuro blockade in the diagnosis of pain mechanisms. Electrodiagnostic Skills

GOAL: The resident is able to perform electrodiagnostic procedures for MSK outpatients as needed. OBJECTIVES: The resident is able to:

Perform complete Electrodiagnostic history, physical and exam, progressing from mild to no immediate supervision. Interpret and complete Electrodiagnostic Diagnostics and Reporting with mild to no immediate supervision. Prosthetics/Orthotics/Medical Equipment GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the MSK outpatient. OBJECTIVES: The resident is able to: Prescribe appropriate upper extremity orthotics to provide relative protection/rest in those parts of the anatomy that require same.

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OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES

Prescribe appropriate lower extremity orthotics to provide relative protection/rest in those parts of the anatomy that requires same. Prescribe appropriate spinal orthotics to provide relative protection/rest in those parts of the anatomy that require same. CLINICAL JUDGEMENT GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient. OBJECTIVES: The resident is able to: Regularly integrate medical knowledge with clinical data and generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an Use diagnostici t and therapeutic t l procedures judiciously to achieve a quality outcome. PATIENT CARE GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to provide a comprehensive treatment program to the individual with a myofascial pain syndrome in the outpatient setting. Demonstrate the ability to consult/refer to surgical subspecialties and pain management specialty centers as needed. Demonstrate the ability to recognize and treat cumulative pain trauma disorders in the outpatient setting. Demonstrate the ability to recognize and treat lumbar spinal pain of differing etiologies in the outpatient setting. Demonstrate the ability to recognize and treat cervical spine pain of differing etiologies in the outpatient setting. Demonstrate the ability to recognize and treat common MSK disorders of dancers, musicians, and sports participants. Demonstrate the ability to perform an IME (and determine MMI & PPI). Demonstrate the ability to prepare an appropriate report regarding the patient with an industrial injury to include at least a history and physical exam as well as subsequent calculations of impairment ratings. Demonstrate the ability to apply psychological and behavioral components to the total

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OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES pain management treatment program. Demonstrate the ability to treat/refer appropriately for those psychological/behavioral conditions that may interfere with the individual obtaining his/her highest functional level Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate pain in those with musculoskeletal complaints in the outpatient setting. Detect pain which is intentionally produced or feigned as in a factitious disorder or li i MEDICAL KNOWLEDGE GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with MSK OBJECTIVES:i The resident is able to: Demonstrate knowledge of the epidemiology/financial impact of industrial injures in this country. Demonstrate knowledge of spinal, muscular, and neuro anatomy sufficient to explain patterns of acute, radiating, referred, and non-organic pain. Define the terms acute and chronic pain. Demonstrate understanding of the mechanisms, indications, and contraindications to the use of pharmacologic agents in the treatment of pain including: NSAID’s Muscle relaxants Tricyclic antidepressants Anticonvulsants Alpha adrenergic agonists Lidocaine analogs Calcium channel blockers Benzodiazepine/Non-Benzodiazepine hypnotics Narcotics

PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge of the patient with a painful outpatient MSK condition.

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OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES

OBJECTIVES: The resident is able to: Demonstrate knowledge of the risk factors/professions leading to spinal pain and cumulative trauma disorders in the industrial setting. Demonstrate knowledge of the risk factors/professions leading to common musculoskeletal disorders in the industrial setting including nerve entrapments (ulnar/median), DeQuervain’s Disease, epicondylitis, Vibration Syndrome, and rotator cuff disorders. Demonstrate knowledge of the determinants that help to provide a successful environment for return to work after an industrial injury. Demonstrate knowledge of barriers for return to work after an industrial injury, including economic disincentives and litigious interventions. Demonstrate knowledge of the workers compensation system and the social security system in this country. Demonstrate knowledge of the epidemiology of industrially related disorders. Demonstrate knowledge of the characteristics of common injuries experienced by amateur athletes as well as musicians. Demonstrate understanding of the peripheral and central anatomic structures that are involved in the pain pathway. Demonstrate understanding of the biochemistry/neurotransmitters of pain. Demonstrate knowledge of referred pain patterns of myofascial trigger points. Demonstrate understanding of the difference between an individual’s pain and pain behavior. Demonstrate understanding of the chronic pain syndrome. Demonstrate understanding of the differences between the types of pain rehabilitation found in: Comprehensive pain centers Interdisciplinary pain rehabilitation teams Inpatient chronic pain rehabilitation programs Back Schools Understand the psychological components of pain including those accounted for by mood Demonstrate understanding of the physician’s role as a potential witness in litigation regarding an industrial injury.

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OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES PRACTICE-BASED LEARNING & IMPROVEMENT

PROFESSIONAL ATTITUDE

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OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development. OBJECTIVES: The resident is able to: Assume responsibility and act responsibly. Demonstrate commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, informed consent, and business practices. Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES GOAL: The resident is able to see the patient beyond the disease. OBJECTIVES: The resident is able to: Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal, professional, organizational and social level). Understand how the healthcare system affects their practice (at the personal, professional, organizational, and social level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access,

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OPC - BETHESDA NRH REGIONAL REHAB GOALS AND OBJECTIVES

coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Physical Medicine and Rehabilitation: The Complete Approach, Martin Grabois, M.D., et al, Editor: Chapter 57 through 63.

. Practical Management of Pain by Prithvi Raj, 3rd Edition, 2000

. Snider, RK. Essentials of Musculoskeletal Care, AAOS, 2nd Edition

. Guides to the Evaluation of Permanent Impairment, Fifth Edition, Cocchiarella, L and Gummar, B. AMA Press

. Musculoskeletal Disorders in the Workplace, Principles and Practice Nordin, M., Andersson, G., and Pope, M. Mosby. 1997

• Articles

. Articles supplied on CD with hyper linked Excel spread sheet.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. MSK Reading List – GUH/NRH PM&R Residency – Outpatient MSK

252 Integrated Competency Based Curriculum 2012-2013

Electrodiagnostic Medicine GMEC Updated on: Domain: Electrodiagnostic Level: PGY3 (during 2009- 2010 transitional year, also includes PGY4) Length: 3 months Locations: Walter Reed Army Medical Center Type: Outpatient and Inpatient Consults Rotation Director: Dr. Kevin Fitzpatrick Faculty: WRAMC - Dr. Kevin Fitzpatrick, Dr. Jason De Luigi, Dr. David DuRussell, and Dr. Heather Powell NRH - Dr. Fatemeh Milani and Dr. John Aseff

General Educational Objective The PGY-3 resident will be able to perform Electromyography and Nerve Conduction Studies on patients with minimal supervision.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of Neuromuscular system 2. Common types of adult Neuromuscular pathophysiology a. Median Neuropathy b. Ulnar Neuropathy c. Radial Neuropathy d. Femoral Neuropathy e. Tarsal Tunnel Syndrome f. Facial and Trigeminal Neuropathy g. Polyneuropathy h. Motor Neuron Disease i. Radiculopathy j. Brachial Plexopathy k. Lumbosacral Plexopathy l. Neuromuscular Junction Disorders m. Myopathy n. Myotonic Muscle Disorders 3. Procedure Skills a. Electromyography i. Analysis of Spontaneous Activity ii. Analysis of Motor Unit Action Potential

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b. Nerve Conduction Studies i. Basic Sensory Nerve Conduction Studies ii. Basic Motor Nerve Conduction Studies iii. Late Responses 1. F-Wave 2. H-reflex iv. Blink Reflex v. Repetitive Nerve Stimulation

Methods of Teaching 1. Clinical Sites a. Walter Reed Army Medical Center b. National Rehabilitation Hospital 2. Clinical teaching a. Walter Reed Army Medical Center – Department of PM&R – performing EMG/NCS on Mondays, Tuesdays, Wednesdays on 4 patients per day from 8:00am – 5:00pm and half days on Fridays (2 patients) from 1:00pm – 5:00pm i. During EMG/NCS exams, the resident will be asked questions about the exam: 1. Anatomic location for electrode placement 2. Peripheral nerve 3. Nerve root level 4. Muscles supplied by the nerve being tested 5. Needle placement b. National Rehabilitation – performing EMG/NCS on Fridays from 8:00am – 12:00pm. 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Mondays from 7:30am – 9:00am: One chapter from Preston & Shapiro ii. Tuesday s from 8:30-9:30am: AANEM question review iii. Wednesdays, 1:00pm – 2:00pm: either Journal Article, Video Questions or AANEM questions review b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series

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ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. During the EMG/NCS exams, the resident will be asked questions about the exam: i. Anatomic location for electrode placement ii. Peripheral nerve iii. Nerve root level iv. Muscles supplied by the nerve being tested b. Needle placement c. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 3. Informal immediate feedback by supervision faculty attending during daily rounds. 4. Feedback forward to Program Director Biannual Core Competency evaluation 5. Written and oral 360 degree evaluation (healthcare team, patient, family) 6. The Program Director will assess the progress of the 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY-3 resident reports directly to the faculty staff attending which is assigned to the EDX clinic for that day. There is direct supervision which starts with constant monitoring in the beginning of the rotation and progress to reviewing of the report only base on the residents ability to perform at each appropriate level of the exam.

Specific Competency – Based Goals & Objectives

ELECTRODIAGNOSTIC MEDICINE ROTATION PATIENT CARELS GENERAL SKILLS (N/A) PHYSIATRIC SKILLS (N/A)

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ELECTRODIAGNOSTIC MEDICINE ROTATION Functional Evaluations (N/A) Exercise Prescription and Modalities (N/A) Therapeutic & Diagnostic Injections/ Procedures (N/A) Electrodiagnostic Skills GOAL 1: The resident will acquire knowledge of pertinent anatomy, electrophysiology, and electrodiagnostic technique that supports the standard studies for nerve conduction and electromyography. OBJECTIVES: The resident is able to: Demonstrate knowledge of the anatomy of the cervical roots, brachial plexus, and peripheral nerves of the upper extremity. Demonstrate knowledge of the electrical properties of nerves and muscles Demonstrate the ability of electromyographic setup and lead placement for common nerve conduction studies such as the median, ulnar, tibial, radial, and peroneal motor and sensory conduction studies as well as F and H wave studies Demonstrate familiarity with needle placement for common muscles Demonstrate the ability to identify normal and abnormal wave forms noted during electromyography Demonstrate the ability to perform simple examinations of cervical and lumbar radiculopathies as well as upper and lower limb peripheral nerve entrapment Prosthetics/Orthotics/Medical Equipment (N/A) CLINICAL JUDGEMENT (N/A) PATIENT CARE (N/A) MEDICAL KNOWLEDGE GENERAL KNOWLEDGE (N/A)

PHYSIATRIC KNOWLEDGE (N/A) GOAL 1: The resident will acquire knowledge of pertinent anatomy, electrophysiology, and electrodiagnostic technique that supports the standard studies for nerve conduction OBJECTIVES: The resident is able to: Demonstrate knowledge of the anatomy of the lumbar nerve roots, lumbosacral plexus, and peripheral nerve roots of the lower extremity

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ELECTRODIAGNOSTIC MEDICINE ROTATION Draw the Brachial Plexus, including the terminal nerves Describe the nerve root and peripheral nerve innervation of the skin in both the upper and lower extremity PRACTICE-BASED LEARNING & IMPROVEMENT GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able: To analyze practice experience and perform practice-based improvement activities using a systematic methodology. To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to: Communicate effectively with the patient about the purpose and results (as appropriate) of the electrodiagnostic exam and his/her expected comfort levels during this test. Demonstrate caring and respectful behaviors when interacting with patients and significant others. Provide a written report to the referring physician explaining his/her rationale for the differential diagnosis. Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group

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ELECTRODIAGNOSTIC MEDICINE ROTATION

PROFESSIONALISM

PROFESSIONAL ATTITUDE

Understand how the healthcare system affects their practice (at the personal/professional/organizational/societal level). Understand how different systems of medical care affect healthcare costs and the allocation of resources.

Educational Resources • Text Books

. Electromyography and Neuromuscular Disorders, Preston & Shapiro, 2005 258 Integrated Competency Based Curriculum 2012-2013

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Electrodiagnostic Medicine by D Dumitru. Hanley & Belfus/Mosby, 1995.

• Articles

. Articles selected throughout the rotation Dr. Fitzpatrick on topics in EDX literature.

• Self directed learning modules

. Recommended AANEM review questions.

• Videos

. Recommended AANEM review Videos on wave forms and sound.

• CD-ROMs

. CD containing EMG sounds.

259 Integrated Competency Based Curriculum 2012-2013

PM&R in Private Practice GMEC Approved on: November 4, 2009 Domain: MSK, Sports and Occupational Medicine Level: PGY4 Length: 1 month Type: Inpatient/Outpatient/Consults Rotation Director: Dr. Curtis Whitehair Faculty: Based on location - Dr. Andrew Panagos or Dr. Stanton Weiner

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Methods of Teaching 1. Clinical Sites The resident will choose from one of the locations below. a. Dr. Andrew Panagos i. Private Office - Dr. Andrew Panagos – Bethesda, Maryland ii. Suburban Hospital b. Dr. Stanton Wiener i. Quince Orchard Medical Center – Rockville, Maryland 2. Clinical teaching a. Outpatient Clinic Visits – Panagos & Weiener b. Hospital Consultations - Panagos 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

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Lines of Supervision The PGY4 resident reports directly to the Faculty / Attending based on the location chosen.

Specific Competency – Based Goals & Objectives

PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate history from and perform a physical exam upon the outpatient who has experienced an industrial or orthopedic OBJECTIVES: The resident is able to: Obtain a patient history pertinent to an industrial accident or other orthopedic injury. Obtain a patient history that differentiates the patient’s pain into either an acute or chronic category. Demonstrate the ability to recognize the historical “red flags” indicating the need for urgent/emergent care of the injured worker/patient (particularly those with back pain). Demonstrate proficiency in determining the mechanism of injury. Demonstrate proficiency in identifying the characteristics of local pain versus radiating pain versus referred pain versus non-organic pain. Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding psychosocial and financial/legal information. Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding the achievement of maximal medical improvement.

PHYSIATRIC SKILLS

Functional Evaluations

GOAL: The resident is able to perform a meaningful examination of the injured individual who has experienced a work/orthopedic type injury. OBJECTIVES: The resident is able to: Perform specific examinations focused towards body parts injured with a goal of providing a

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PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES prioritized differential diagnosis. Demonstrate the appropriate use of measures of perceived pain, disability, and dysfunction including Waddell’s signs and symptoms. Exercise Prescription and Modalities

GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the outpatient who has experienced an industrial/orthopedic injury. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe(knowing the indications/contraindications for) and monitor an appropriate exercise program for patients who have experienced an industrial injury or other orthopedic type injury which includes at least the following components: Use of modalities including heat, cold packs, ice massage, contrast baths, vapocoolant spray, hot packs, paraffin, traction, hydrotherapy, fluidotherapy, ultrasound, phonophoresis Electrical stimulation (iontophoresis, TENS) Physical therapeutic exercise (flexibility/range of motion, spinal stabilization, opened and closed kinetic exercises) Splinting (static and dynamic) Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the need for interventional and diagnostic procedures for those patients who have experienced industrial injuries or other orthopedic OBJECTIVES: The resident is able to: Demonstrate appropriate prescription of electrodiagnostic testing. Demonstrate appropriate usage and interpretation of radiologic studies (e.g. CT/MRI/bone scan/plain films) and be able to correlate anatomic structures with the images seen. Demonstrate the ability to perform joint injections/aspirations Electrodiagnostic Skills (N/A)

GOAL: The resident is able to demonstrate knowledge of the pertinent anatomy, physiology, electrophysiology of electro diagnostic studies as well as electro diagnostic techniques so that he/she will be able to perform examination of cervical and lumbar radiculopathies as well as OBJECTIVES: The resident is able to: Perform an appropriate set up of the electromyographic machine as well as correct placement for nerve conduction studies such as those of the median, ulnar, radial, tibial, peroneal, and

263

Integrated Competency Based Curriculum 2012-2013

PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES Demonstrate knowledge of the basic principles of electromyography and needle placement for his/her studies. Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of medical equipment in the outpatient who has experienced an industrial injury or other orthopedic type OBJECTIVES:ij The resident is able to: Prescribe appropriate upper extremity orthotics to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate lower extremity orthotics and or mobility aids to provide relative protection/rest in those parts of the anatomy that requires same. Prescribe appropriate spinal orthotics to provide relative protection/rest in those parts of the anatomy that require same. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient who has experienced an industrial or other orthopedic type injury. OBJECTIVES: The resident is able to: Regularly integrate medical knowledge with clinical data in order to generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an appropriate management plan Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome.

PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to provide a comprehensive treatment program to the individual with a myofascial pain syndrome in the outpatient setting. Demonstrate the ability to recognize and treat common office based orthopedic (MSK) injuries in the outpatient setting including: cumulative trauma disorders, spine disorders (including spondylolysis, spondylolisthesis, and compression fractures), nerve entrapment syndromes, DeQuervain’s Disease, epicondylitis, rotator cuff/impingement disorders, knee disorders (meniscal tears, patella femoral pain, cruciate/collateral ligament tears, osteochondritis

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PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES desiccans), stress fractures of the leg, compartment syndrome of the leg, poplites injury, iliotibial band injury, Baker’s cyst, heel pain, turf toe, interdigital neuroma, hallux valgus, sesamoid dysfunction, vibration syndrome, and tendon injuries of the hand. Demonstrate the ability to consult/refer to surgical subspecialties and pain management specialty centers as needed. Demonstrate the ability to recognize and treat cumulative pain trauma disorders in the outpatient setting. Demonstrate the ability to recognize and treat lumbar spinal pain of differing etiologies in the outpatient setting. Demonstrate the ability to recognize and treat cervical spine pain of differing etiologies in the outpatient setting. Demonstrate the ability to prepare an appropriate report regarding the patient with an industrial injury to include at least a history and physical exam as well as subsequent calculations of impairment ratings. Demonstrate the ability to apply psychological and behavioral components to the total pain management treatment program. Demonstrate the ability to refer appropriately for those psychological/behavioral conditions that may interfere with the individual obtaining his/her highest functional level. Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate pain in those with industrial injuries or other orthopedic type injuries. Detect pain which is intentionally produced or feigned as in a factitious disorder or malingering.

MEDICAL KNOWLEDGE GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with an industrial injury or other orthopedic type injury. OBJECTIVES: The resident is able to: Demonstrate knowledge of the epidemiology/financial impact of industrial injures in this country. Demonstrate knowledge of spinal, muscular, and neuro anatomy sufficient to explain patterns of acute, radiating, referred, and non-organic pain.

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PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES Demonstrate understanding of the mechanisms, indications, and contraindications to the use of pharmacologic agents in the treatment of pain including: NSAID’s Muscle relaxants Tricyclic antidepressants Anticonvulsants/membrane stabilizers Alpha adrenergic agonists/beta blockers Lidocaine analogs Calcium channel blockers Benzodiazepine/Non-Benzodiazepine hypnotics Narcotics Corticosteroids (injectable) Chondroprotective agents (glucosamine, chondroitin sulfate, hyaluronic acid) PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate knowledge of the patient with an industrial injury or other orthopedic type injury. OBJECTIVES: The resident is able to: Demonstrate knowledge of the risk factors/professions leading to spinal pain and cumulative trauma disorders in the industrial setting. Demonstrate knowledge of the determinants that help to provide a successful environment for return to work after an industrial injury. Demonstrate knowledge of barriers for return to work after an industrial injury, including economic disincentives and litigious interventions. Demonstrate knowledge of the workers compensation system and the social security system in this country. Demonstrate understanding of the physician’s role as a potential witness in litigation regarding an industrial injury. Understand the psychological components of pain including those accounted for by mood and Demonstrate knowledge of the epidemiology of industrially related disorders.

Demonstrate knowledge of the signs/symptoms/pathophysiologic mechanisms of office based orthopedic (MSK) injuries in the outpatient setting including: cumulative trauma disorders, spine disorders (including spondylolysis, spondylolisthesis, and compression fractures), nerve

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PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES entrapment syndromes, DeQuervain’s Disease, epicondylitis, rotator cuff/impingement disorders, knee disorders (meniscal tears, patella femoral pain, cruciate/collateral ligament tears, osteochondritis desiccans), stress fractures of the leg, compartment syndrome of the leg, popliteus injury, iliotibial band injury, Baker’s cyst, heel pain, turf toe, interdigital neuroma, hallux valgus, sesamoid dysfunction, vibration syndrome, and tendon injuries of the hand. Demonstrate knowledge of the adaptability of tendon tissues and its relationship to tendon injury healing. Demonstrate knowledge of the definition of isometric, isokinetic, plyometric, eccentric, and concentric contractions of muscles and their relationship to muscle force and muscle injury. Demonstrate knowledge of the structure of striated muscle and its relationship to force development (i.e. the length tension curve). Demonstrate knowledge of the electrical properties of nerve and muscle. Demonstrate knowledge of the anatomy of the brachial and lumbar plexus from the nerve root distally to their end principal nerves. PRACTICE-BASED LEARNING & IMPROVEMENT

Applyi knowledge ’ h l h of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals.

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PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES with patients and significant others. Create and sustain a therapeutic relationship with patients and significant others. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

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PM&R IN PRIVATE PRACTICE MEDICINE ROTATION GOALS AND OBJECTIVES Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another, and in particular that of private practice from those systems within or operated by medical institutions. Understand the financial responsibilities/ramifications of a private practitioner. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

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270 Integrated Competency Based Curriculum 2012-2013

Sports Medicine or Orthopedic Surgery GMEC Approved on: November 4, 2009 Domain: MSK, Sports and Occupational Medicine Level: PGY4 Length: 1 month Type: Outpatient Clinic Rotation Director: Dr. Wiemi Douoguih Faculty: Dr. Weimi Douoguih

General Educational Objective The PGY-4 resident will be able to manage patients with common sports related musculoskeletal problems in an outpatient clinic as measured by their ability to develop a differential diagnosis for common sports related problems including pain in the wrists, elbows, shoulders, hips, knees, ankle, foot, and spine based on the results of the physiatric history and physical as well as interpretation of radiographic, pertinent laboratory and electrodiagnostic studies. The resident will be exposed to Orthopedic and Surgical Treatment options.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of Musculoskeletal System 2. Common types of adult MSK, Sports and Occupational pathophysiology a. Swimmers: shoulder injuries, shoulder multidirectional instability, mid back pain b. Golf: golfer’s elbow, wrist injuries, low back pain c. Tennis: tennis elbow, shoulder pain, lower extremity sprains and strains d. Gymnasts: pars defects and spinal hyperextension injuries e. Runners: overuse injuries including shin splints, stress fractures, tendonitis f. Football: stingers, cervical spine injuries including transient quadriplegia, how to manage concussions and return to play guidelines, knee injuries, turf toe g. Basketball: common knee, ankle, hand injuries h. Baseball: medial collateral ligament sprains of the elbow, rotator cuff injuries, labral injuries 3. Procedure Skills a. Trigger Point Injections b. Joint Injections i. Shoulders ii. Knees iii. Elbows iv. Hands/Fingers v. Ankles vi. Hips 271 Integrated Competency Based Curriculum 2012-2013

Methods of Teaching 1. Clinical Sites a. Washington Hospital Center b. Physician Office Building @ WHC 2. Clinical teaching a. Clinic evaluations b. Operating Theater Observation 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 4th year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

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Lines of Supervision The PGY4 resident reports directly to the Dr. Weimi Douoguih

Specific Competency – Based Goals & Objectives

ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate history from and perform a physical exam upon the outpatient who has experienced an office based, orthopedic (MSK) injury. OBJECTIVES: The resident is able to: Obtain a patient history pertinent to an office based orthopedic (MSK) injury Obtain a patient history that differentiates the patient’s pain into either an acute or chronic category. Demonstrate the ability to recognize the historical “red flags” indicating the need for urgent/emergent care of the injured MSK patient Demonstrate proficiency in determining the mechanism of injury. Demonstrate proficiency in identifying the characteristics of local pain versus radiating pain versus referred pain versus non-organic pain. Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding psychosocial and financial/legal information. Demonstrate the ability to include in his/her interview of the patient with MSK pain, appropriate questions regarding the achievement of maximal medical improvement. PHYSIATRIC SKILLS

Functional Evaluations

GOAL: The resident is able to perform a meaningful examination of the office outpatient with an office based orthopedic (MSK) injury OBJECTIVES: The resident is able to: Perform specific examinations focused towards body parts injured with a goal of providing a prioritized differential diagnosis. Demonstrate the appropriate use of measures of perceived pain, disability, and dysfunction

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ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES including Waddell’s signs and symptoms. Exercise Prescription and Modalities

GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the outpatient who has experienced an office based orthopedic (MSK) injury. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe(knowing the indications/contraindications for) and monitor an appropriate exercise program for patients who have experienced an office based orthopedic (MSK) type injury which includes at least the following components: Use of modalities including heat, cold packs, ice massage, contrast baths, vapocoolant spray, hot packs, paraffin, traction, hydrotherapy, fluidotherapy, ultrasound, phonophoresis Electrical stimulation (iontophoresis, TENS) Physical therapeutic exercise (flexibility/ROM, strengthening, agility, proprioception) Splinting (static and dynamic) Demonstrate knowledge of the indications/contraindications for closed/open chain kinetic exercises Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the need for interventional and diagnostic procedures for those patients who have experienced an office based orthopedic (MSK) injury as well as perform appropriate ones as needed. OBJECTIVES: The resident is able to: Demonstrate appropriate prescription of Electrodiagnostic testing. Demonstrate appropriate usage and interpretation of radiologic studies (e.g. CT/MRI/bone scan/plain films) and be able to correlate anatomic structures with the images seen; in particular demonstrate appreciation of the radiologic signs/symptoms that indicate post-arthroplasty infection, fracture, dislocation, component loosening, and heterotopic ossification. Demonstrate the ability to perform joint injections/aspirations Electrodiagnostic Skills (N/A)

Prosthetics/Orthotics/Medical Equipment

GOAL: The resident is able to understand the appropriate use and prescription of medical equipment in the outpatient who has experienced an office based orthopedic (MSK) injury. OBJECTIVES: The resident is able to:

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ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES Prescribe appropriate upper extremity orthotics to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate lower extremity orthotics to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate spinal orthotics to provide relative protection/rest in those parts of the anatomy that require same. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient who has experienced an office based orthopedic (MSK) injury. OBJECTIVES: The resident is able to:

Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome.

PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate.

OBJECTIVES: The resident is able to: Demonstrate the ability to consult/refer to surgical subspecialties and pain management specialty centers as needed. Demonstrate the ability to recognize and treat common office based orthopedic (MSK) injuries in the outpatient setting including: cumulative trauma disorders, spine disorders (including spondylolysis, spondylolisthesis, and compression fractures), nerve entrapment syndromes, DeQuervain’s Disease, epicondylitis, rotator cuff/impingement disorders, knee disorders (meniscal tears, patella femoral pain, cruciate/collateral ligament tears, osteochondritis dissecans), stress fractures of the leg, compartment syndrome of the leg, popliteus injury, iliotibial band injury, Baker’s cyst, heel pain, turf toe, interdigital neuroma, hallux valgus, and sesamoid dysfunction. Demonstrate the ability to appreciate the complications of arthroplastic surgery including post- operative infection, fracture, dislocation, component loosening, and heterotopic ossification. Demonstrate the ability to apply psychological and behavioral components to the total pain management treatment program. Demonstrate the ability to refer appropriately for those psychological/behavioral conditions that

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ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES may interfere with the individual obtaining his/her highest functional level. Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate pain in those with office based orthopedic (MSK) injuries. Detect pain which is intentionally produced or feigned as in a factitious disorder or malingering.

MEDICAL KNOWLEDGE GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the patient with an office based orthopedic (MSK) injury. OBJECTIVES: The resident is able to: Demonstrate knowledge of spinal, muscular, and neuro anatomy sufficient to explain patterns of acute, radiating, referred, and non-organic pain. Demonstrate understanding of the mechanisms, indications, and contraindications to the use of pharmacologic agents in the treatment of pain including: NSAID’s Muscle relaxants Tricyclic antidepressants Anticonvulsants/Membrane Stabilizers Beta Blockers/Alpha adrenergic agonists Lidocaine analogs Corticosteroids (injectable) Calcium channel blockers Narcotics Chondroprotective agents (glucosamine, chondroitin sulfate, hyaluronic acid) PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate knowledge of the patient with an office based orthopedic (MSK) injury. OBJECTIVES: The resident is able to:

Demonstrate knowledge of the functional anatomy and biomechanics of the spine, shoulder, elbow, wrist/hand, hip, knee, and ankle/foot as they relate to the development of office based orthopedic (MSK) injuries. Demonstrate knowledge of the risk factors/professions leading to spinal pain and cumulative

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ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES trauma disorders in the office based orthopedic (MSK) injuries. Demonstrate knowledge of the signs/symptoms/pathophysiologic mechanisms of office based orthopedic (MSK) injuries in the outpatient setting including: cumulative trauma disorders, spine disorders (including spondylolysis, spondylolisthesis, and compression fractures), nerve entrapment syndromes, DeQuervain’s Disease, epicondylitis, rotator cuff/impingement disorders, knee disorders (meniscal tears, patella femoral pain, cruciate/collateral ligament tears, osteochondritis dissecans), stress fractures of the leg, compartment syndrome of the leg, popliteus injury, iliotibial band injury, Baker’s cyst, heel pain, turf toe, interdigital neuroma, hallux valgus, and sesamoid dysfunction. Demonstrate knowledge of the post-operative complications of joint arthroplasty, both surgical and non-surgical. Demonstrate knowledge of the structure of striated muscle and its relationship to force development (i.e. the length tension curve). Demonstrate knowledge of the definition of isometric, isokinetic, plyometric, eccentric, and concentric contractions of muscles and their relationship to muscle force and muscle injury. Demonstrate knowledge of the compartments of the lower extremity and their relationship to signs/symptoms of compartment disease. Demonstrate knowledge of the adaptability of tendon tissues and its relationship to tendon injury healing.

PRACTICE-BASED LEARNING & IMPROVEMENT

To analyze practice experience and perform practice-based improvement activities using a s stematic methodolog To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health stat s Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

Use information technology to manage information, access on-line medical information, and support their didactic education.

Facilitate the learning of students and other healthcare professionals.

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ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development OBJECTIVES: The resident is able to: Assume responsibility and act responsibly. Demonstrate commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, informed consent, and business practices. Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

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ORTHOPEDICS/SPORTS MEDICINE ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal, professional, organizational, social level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. Article 1 or None Recommended.

• Self directed learning modules

. Module 1 or None Recommended.

• Videos

. Video 1 or None Recommended.

• CD-ROMs

. CD 1 or None Recommended.

279 Integrated Competency Based Curriculum 2012-2013

National Institutes of Health GMEC Approved on: November 4, 2009 Domain: General Physical Medicine & Rehabilitation and Therapeutics, Medical Rehabilitation Level: PGY3 Length: 1 month Type: Outpatient and Inpatient Consults Rotation Director: Dr. Jay Shah Faculty: Dr. Jay Shah, Dr. Scott Paul, Dr. Monique Perry, Dr. Galen Joe and Dr. Leighton Chan.

General Educational Objective The PGY3 resident will perform physiatric H&P and consultations for patients with complex and uncommon diseases as measured by their ability to independently develop a plan of care.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology. 2. Uncommon and rare types of pathophysiology a. Congenital deformities and disease b. Acquired deformities and disease c. Connective Tissue Diseases d. Caner related impairments e. Neurologic disorders 3. Procedure Skills a. Assistive Device Prescription Writing

Methods of Teaching 1. Clinical Sites a. National Institutes of Health – Rehabilitation Medicine 2. Clinical teaching a. Residents will observe the specialist within their respected clinics. b. Residents may exam and document H&P on certain patients that expand the resident’s patient care management experience. c. Participate in Trial Clinics and collect data. 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions.

280 Integrated Competency Based Curriculum 2012-2013

c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Weekly Journal Club 1. Resident will be assigned one JC presentation ii. Weekly Case Presentations 1. Resident will be assigned one Case presentation b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY3 resident reports directly to the attending faculty which is assigned on a weekly basis.

Specific Competency – Based Goals & Objectives

NIH Rotation GOALS AND OBJECTIVES

281 Integrated Competency Based Curriculum 2012-2013

NIH Rotation GOALS AND OBJECTIVES PATIENT CARE GENERAL SKILLS

GOAL: The resident is able to obtain a history and physical exam related to the cancer OBJECTIVES:i The resident is able to: Perform a history which obtains adequate information in order to contribute to the rehabilitation plan regarding the following subjects: • Baseline assessment of the patient (including information regarding functional status, treatment received and projected, chemotherapy, immunotherapy, radiation therapy, and surgery) • Pain • Symptoms of neuropathy, myopathy, lymphedema, radiation fibrosis, cognitive/perceptual deficits • Mobility status • Self-care status • Psychosocial status (including educational/vocational/avocational functioning, psychosocial adjustment/coping status, vocational/career status) PHYSIATRIC SKILLS

Functional Evaluations GOAL: The resident is able to coordinate the functional evaluation of the patient with his/her history taking abilities. OBJECTIVES: The resident is able to: Use his/he finding of the patient’s functional history and medical physical exam in order to prioritize a rehabilitation plan for the cancer patient. Specifically, the resident will be able to identify the following impairments that impact upon the cancer patient’s functional status: Generalized deconditioning Skin impairment Contractures Myopathy, Neuropathy, Plexopathy

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NIH Rotation GOALS AND OBJECTIVES Bone replacement by tumor Myelopathy Lymphedema Bowel/bladder disorders Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the cancer patient. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for cancer patients which includes at least the following components: Contracture prevention Promotion of ROM Promotion of functional mobility Treatment/prevention of lymphedema Demonstrate knowledge of the indications and contraindications of the use of heat/cold modalities. Demonstrate knowledge of the hematologic contraindications to exercise. Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the indications, contraindications, and limitations of diagnostic procedures for those patients experiencing cancer. OBJECTIVES: The resident is able to: Prescribe electrodiagnostic testing to differentiate between neoplastic invasion either of the brachial or lumbosacral plexus versus radiation changes to same. Demonstrate knowledge of the indications, contraindications, and limitations of the use of MRI scans to differentiate between tumor recurrence/metastases versus radiation induced changes to the brain. Electrodiagnostic Skills GOAL: The resident is able to use an electrodiagnostic study to diagnose the OBJECTIVES: The resident is able to: Identify those EMG/nerve conduction characteristics that differentiate impairments of the brachial/lumbosacral plexus due to radiation changes versus invasive tumor. Prosthetics/Orthotics/Medical Equipment

283 Integrated Competency Based Curriculum 2012-2013

NIH Rotation GOALS AND OBJECTIVES GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the cancer patient. OBJECTIVES: The resident is able to: Demonstrate knowledge of the indications for the use of halo-vest orthotics and test for proper fit. Demonstrate knowledge of the indications for the use of TLS orthotics and test for proper fit (including SOMI braces, Yale vests, Jewitt braces, Taylor-Knight braces, and body jackets). Demonstrate knowledge of the indications for the use of hand orthotics including resting and functional splints. Demonstrate knowledge of adaptive ADL equipment. Demonstrate knowledge of appropriate wheelchair and seating prescriptions for cancer patients. CLINICAL JUDGEMENT

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to:

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NIH Rotation GOALS AND OBJECTIVES Demonstrate recognition of and provide a treatment/rehabilitation program for the patient with cancer who exhibits the following: Generalized deconditioning, decubitus ulcers, contractures, myopathy/neuropathy/plexopathy, pathological fractures Spinal Cord Injury Graft vs. Host disease Lymphedema Osseous Pain Bowel/bladder dysfunction Communication impairment (including impaired speech production for laryngectomized patients) Chondrosarcoma Pain Early and delayed complications of brain tumor radiation therapy Fatigue Nutritional impairment Coping/adjustment difficulties secondary to his/her diagnosis and/or circumstances

MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge of the epidemiology of OBJECTIVES:i The resident is able to:

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NIH Rotation GOALS AND OBJECTIVES Demonstrate knowledge of the most common primary and metastatic diseases of the following systems: Central nervous system Head and neck Breast Lung Hematopoietic tumors (leukemias and lymphomas) Sarcomas of the extremities Metastatic skeletal cancers Demonstrate knowledge of the population at risk for “second” cancers and the types of disease they experience. PHYSIATRIC KNOWLEDGE

GOAL #1: The resident is able to demonstrate physiatric knowledge of the side effects of commonly used chemotherapeutic agents. OBJECTIVES: The resident is able to: Demonstrate knowledge of the pulmonary, cardiac, myopathic, neurologic, urologic, and vestibular side effects of the following agents and types of therapy: Platinum agents Methotrexate Vinca alkaloids (vincristine) 5 - Fluorouracil Taxanes Bleomycin Alkylating agents (ifosfamide, mitomycin C) Cyclophosphamide Ara-C Suramin Cytoxan Doxorubicin Nitrosoureas (BCNU) Isolated limb profusion

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NIH Rotation GOALS AND OBJECTIVES GOAL #2: The resident is able to demonstrate medical knowledge of the patient with OBJECTIVES:i The resident is able to: Demonstrate knowledge of the neurophysiology/biochemistry of pain (including knowledge of the neurotransmitters of pain) Demonstrate knowledge of the neuroanatomy of pain sufficient to explain patters of acute, radiating, referred, and neuropathic pain. Demonstrate knowledge of the mechanism, indications, and contraindications to the use of pharmacologic agents in the treatment of pain including: NSAID’s Topical analgesics Muscle relaxants Tricyclic antidepressants Anticonvulsants Alpha adrenergic agonists Lidocaine analogs Calcium channel blockers Benzodiazepine/Non-Benzodiazepine hypnotics Bisphosphonates Steroids Narcotics

Demonstrate knowledge of the indications to refer patients for neuroablative procedures for the relief of pain PRACTICE-BASED LEARNING & IMPROVEMENT

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NIH Rotation GOALS AND OBJECTIVES Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals. INTERPERSONAL & COMMUNICATION SKILLS

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to: Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and significant others. Create and sustain a therapeutic relationship with patients and significant others. Educate the patient and his/her significant(s) other in the characteristics of hospice care. Engage in active listening, provide information using appropriate language, ask clear questions, and provide an opportunity for input and questions from/with staff and patients/significant others. Work effectively as a member or leader of a health care team or other professional group Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE

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NIH Rotation GOALS AND OBJECTIVES Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

GOAL: The resident is able to see the patient beyond the disease. OBJECTIVES: The resident is able to: Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their practice (at the personal, professional, organizational, and social level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Understand how the benefits and limitations of hospice care. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity. Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, hospice professionals).

Educational Resources • Text Books 289 Integrated Competency Based Curriculum 2012-2013

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

Rheumatology

For the 2009 – 2010 transition year, PGY4’s and PGY3’s will have this rotation. From 2010-2011 on this will be a PGY3 rotation. There are 2 location that resident may choose from for the Rheumatology rotation, Washington Hospital Center or Georgetown University Hospital.

Rheumatology – WHC (Washington Hospital Center) GMEC Approved on: November 4, 2009 Domain: Joint & Connective Tissue Rehabilitation Level: PGY3 Length: 1 month Type: Outpatient and Inpatient Consults Rotation Director: Dr. Florina Constantinescu Faculty: Dr. Arthur Weinstein, Dr. Brian Wallit, and Dr. Florina Constantinescu

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The resident will become proficient with the management of rheumatologic and connective tissue diseases. At the end of the rotation the resident should require minimal supervision in joint injections.

Scope of Learning and Exposures 1. Basic Anatomy and Physiology of 2. Common types of adult Rheumatologic pathophysiology a. Osteoarthritis b. Rheumatoid arthritis c. Vasculitis d. Crystalline Arthropathies e. Scleroderma f. Systemic Lupus Erythematosus g. Sjögren’s Syndrome h. Spondyloarthropathy i. Septic Arthritis j. Lyme Disease k. Fibromyalgia l. Osteoporosis m. Inflammatory Myopathy 3. Procedure Skills a. Joint Injections and aspiration i. Shoulders ii. Knees iii. Elbows iv. Wrist

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a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Core Lectures – July - August 1. Joint Exam 2. Soft tissue Rheumatology 3. Injection techniques 4. Glucocorticoids 5. Immunosuppressive Medications 6. Vasculitis 7. SLE 8. Septic Arthritis / Lyme Disease 9. Rheumatoid Arthritis 10. Osteoarthritis 11. Gout 12. Scleroderma 13. Pulmonary HTN / ILD 14. Osteoporosis 15. Fibromyalgia 16. Pediatric Rheumatology ii. Fellow Attending Lectures – throughout the year and selected by area of interest of the supervision Fellow or resident’s choice. 1. Joint Exam 2. Soft tissue Rheumatology 3. Injection techniques 4. Glucocorticoids 5. Immunosuppressive Medications 6. Vasculitis 7. SLE 8. Septic Arthritis / Lyme Disease 9. Rheumatoid Arthritis 10. Osteoarthritis 11. Gout 12. Scleroderma

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13. Pulmonary HTN / ILD 14. Osteoporosis 15. Fibromyalgia 16. Pediatric Rheumatology iii. X-ray rounds 1. 2 times per month b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY3 (and 4) resident reports directly to the Director of Resident Education – Dr. Florina Constantinescu, as well as to the 2nd year Fellow on service and covering attending physicians.

Specific Competency – Based Goals & Objectives

RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate history from and perform a physical exam upon the office outpatient who has experienced a rheumatologic disorder. OBJECTIVES: The resident is able to: Obtain a patient history pertinent to an office based patient with a rheumatologic disorder Obtain a patient history that differentiates the patient’s symptoms into either an acute or chronic category. Demonstrate the ability to include in his/her interview of the patient with rheumatologic pain, appropriate questions regarding psychosocial and financial/legal information. PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a meaningful examination of the office outpatient who is experiencing a rheumatologic disorder. OBJECTIVES: The resident is able to: Perform specific examinations focused towards the body’s joints with a goal of providing a prioritized differential diagnosis of the rheumatologic condition. Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the outpatient who has experienced a rheumatologic disorder. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe (knowing the indications/contraindications/side effects of) and monitor an appropriate exercise program for office patients who have experienced a rheumatologic disorder, which includes at least the following components: Moist heat packs, moist heating pads, hot showers, paraffin baths and ice, topical counterirritant ointments, and hydrotherapy Electrical Stimulation (TENS) Therapeutic Exercise (ROM, strengthening, endurance) Splinting (static and dynamic) Therapeutic & Diagnostic Injections/Procedures

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES GOAL: The resident is able to understand the need for interventional and diagnostic procedures for those office patients who have experienced a rheumatologic disorder OBJECTIVES: The resident is able to: Demonstrate appropriate prescription of electrodiagnostic testing. Demonstrate appropriate usage and interpretation of radiologic studies (e.g. CT/MRI/bone scan/plain films/DEXA scans) and be able to correlate anatomic structures with the images seen. Demonstrate the ability to perform joint injections/aspirations Demonstrate the ability to interpret the meaning of synovial fluid results Demonstrate the ability to effectively and efficiently use laboratory tests to diagnose the presence/absence of rheumatic disease Electrodiagnostic Skills (N/A)

Prosthetics/Orthotics/Medical Equipment GOAL: The resident is able to understand the appropriate use and prescription of medical equipment in the outpatient who has experienced a rheumatologic disorder. OBJECTIVES: The resident is able to: Prescribe appropriate upper extremity orthotics to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate lower extremity orthotics (including shoes) to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate spinal orthotics to provide relative protection/rest in those parts of the anatomy that require same. Prescribe appropriate canes, crutches, wheelchairs, and other assistive devices to increase functional capacity CLINICAL JUDGEMENT GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her office patient who has experienced a rheumatologic disorder. OBJECTIVES: The resident is able to:

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to recognize office based rheumatologic diseases including: rheumatoid arthritis, seronegative spondyloarthropathy, septic arthritis, Lyme disorder, osteoarthritis, crystal arthritis, SLE, inflammatory diseases of muscle, polyarteritis nodosa, fibromyalgia, and osteoporosis. Appropriately refer office patients with rheumatologic disorders for arthroplastic procedures Demonstrate the ability to apply psychological and behavioral components to the total pain management treatment program. Demonstrate the ability to refer appropriately for those psychological/behavioral conditions that may interfere with the individual obtaining his/her highest functional level. Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate rheumatic disease, disability, and pain. MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE GOAL: The resident is able to demonstrate medical knowledge of the outpatient with a rheumatologic disorder. OBJECTIVES: The resident is able to: Demonstrate knowledge of joint anatomy Demonstrate understanding of the mechanisms, indications, contraindications, and side effects to the pharmacologic agents used in the treatment of rheumatologic disorders including: NSAID’s DMARD’s Corticosteroids (oral, IM, IV) Herbal Supplements/Vitamins Chondroprotective agents (glucosamine, chondroitin sulfate, hyaluronic acid) Bisphosphonates, calcium supplements, calcitonin, estrogen, and SERM’s PHYSIATRIC KNOWLEDGE GOAL: The resident is able to demonstrate knowledge of the outpatient with a rheumatologic disorder. OBJECTIVES: The resident is able to:

Demonstrate knowledge of the social and economic consequences of rheumatic disease.

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES Demonstrate knowledge of the composition of cartilage Demonstrate knowledge of the indications/contraindications to arthroplastic surgery (joint specific) as well as the prescription of necessary post op precautions to prevent complications such as joint dislocation, neurovascular compromise, DVT, HO, and future revision Demonstrate knowledge of the indications/contraindications for therapeutic injection of musculoskeletal structures as well as knowledge of the effects/side effects of the medications used. Demonstrate knowledge of the signs/symptoms both skeletal and extraskeletal seen in common rheumatologic disorders including: rheumatoid arthritis, seronegative spondyloarthropathy, septic arthritis, Lyme disorder, osteoarthritis, crystal arthritis, SLE, inflammatory diseases of muscle, polyarteritis nodosa, fibromyalgia, and osteoporosis. PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES Work effectively as a member or leader of a health care team or other professional group

Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals. PROFESSIONALISM

PROFESSIONAL ATTITUDE GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development. OBJECTIVES: The resident is able to: Assume responsibility and act responsibly. Demonstrate commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, informed consent, and business practices. Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to: Demonstrate respect, integrity and responsiveness to the needs of patients and the disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Primer on the Rheumatic Diseases, 11th edition 1997, John Klippel, MD

• Articles

. Current articles from Rheumatology journals are selected and discussed with 2nd year fellow.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. MKSAP (Medical Knowledge Self assessment Program – American College of Physicians) section on Rheumatology

. Includes objectives and questions.

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Rheumatology – GUH (Georgetown University Hospital) GMEC Approved on: November 4, 2009 Domain: Joint & Connective Tissue Rehabilitation Level: PGY3 Length: 1 month Type: Outpatient and Inpatient Consults Rotation Director: Dr. Dr. Virginia Steen Faculty: Dr. Virginia Steen, Dr. Sean Whelton, and Dr. Thomas Cupps

General Educational Objective The PGY3 resident (and PGY4 during the transitional year) will provide outpatient care with attending supervision and round on a consult service as measured by attending faculty evaluation. The resident will understand the epidemiology and cause of rheumatoid diseases. The resident will become proficient with the management of rheumatologic and connective tissue diseases. At the end of the rotation the resident should require minimal supervision in joint injections.

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iii. Elbows iv. Wrist

Methods of Teaching 1. Clinical Sites a. Washington Hospital Center – Rheumatology Clinic b. Washington Hospital Center – Inpatient Consultations c. Department of VA Medical Center – Washington DC – core lectures d. Georgetown University Hospital – core lectures 2. Clinical teaching a. Ambulatory Clinic b. Ward Rounding 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics i. Core Lectures 1. Joint Exam 2. Soft tissue Rheumatology 3. Injection techniques 4. Glucocorticoids 5. Immunosuppressive Medications 6. Vasculitis 7. SLE 8. Septic Arthritis / Lyme Disease 9. Rheumatoid Arthritis 10. Osteoarthritis 11. Gout 12. Scleroderma 13. Pulmonary HTN / ILD 14. Osteoporosis 15. Fibromyalgia 16. Pediatric Rheumatology ii. X-ray rounds

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1. 2 times per month b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 3rd year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY3 (and 4) resident reports directly to the Faculty Attending, as well as to the 2nd year Fellow on service and covering attending physicians.

Specific Competency – Based Goals & Objectives

RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

GOAL: The resident is able to demonstrate the ability to take an appropriate history from and perform a physical exam upon the office outpatient who has experienced a rheumatologic disorder.

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Obtain a patient history pertinent to an office based patient with a rheumatologic disorder Obtain a patient history that differentiates the patient’s symptoms into either an acute or chronic category. Demonstrate the ability to include in his/her interview of the patient with rheumatologic pain, appropriate questions regarding psychosocial and financial/legal information. PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a meaningful examination of the office outpatient who is experiencing a rheumatologic disorder. OBJECTIVES: The resident is able to: Perform specific examinations focused towards the body’s joints with a goal of providing a prioritized differential diagnosis of the rheumatologic condition. Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the outpatient who has experienced a rheumatologic disorder. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe (knowing the indications/contraindications/side effects of) and monitor an appropriate exercise program for office patients who have experienced a rheumatologic disorder, which includes at least the following components: Moist heat packs, moist heating pads, hot showers, paraffin baths and ice, topical counterirritant ointments, and hydrotherapy Electrical Stimulation (TENS) Therapeutic Exercise (ROM, strengthening, endurance) Splinting (static and dynamic) Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the need for interventional and diagnostic procedures for those office patients who have experienced a rheumatologic disorder OBJECTIVES: The resident is able to: Demonstrate appropriate prescription of electrodiagnostic testing. Demonstrate appropriate usage and interpretation of radiologic studies (e.g. CT/MRI/bone scan/plain films/DEXA scans) and be able to correlate anatomic structures with the images seen. Demonstrate the ability to perform joint injections/aspirations

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES Demonstrate the ability to interpret the meaning of synovial fluid results Demonstrate the ability to effectively and efficiently use laboratory tests to diagnose the presence/absence of rheumatic disease Electrodiagnostic Skills (N/A)

Regularly integrate medical knowledge with clinical data in order to generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an appropriate Use diagnostict andl therapeutic procedures judiciously to achieve a quality outcome. PATIENT CARE GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to recognize office based rheumatologic diseases including: rheumatoid arthritis, seronegative spondyloarthropathy, septic arthritis, Lyme disorder, osteoarthritis, crystal arthritis, SLE, inflammatory diseases of muscle, polyarteritis nodosa, fibromyalgia, and osteoporosis. Appropriately refer office patients with rheumatologic disorders for arthroplastic procedures Demonstrate the ability to apply psychological and behavioral components to the total pain 304 Integrated Competency Based Curriculum 2012-2013

RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES management treatment program. Demonstrate the ability to refer appropriately for those psychological/behavioral conditions that may interfere with the individual obtaining his/her highest functional level. Demonstrate the ability to develop both a pharmacologic and non-pharmacologic treatment program of care designed to alleviate rheumatic disease, disability, and pain. MEDICAL KNOWLEDGE

Demonstrate knowledge of the social and economic consequences of rheumatic disease. Demonstrate knowledge of the composition of cartilage Demonstrate knowledge of the indications/contraindications to arthroplastic surgery (joint specific) as well as the prescription of necessary post op precautions to prevent complications such as joint dislocation, neurovascular compromise, DVT, HO, and future revision Demonstrate knowledge of the indications/contraindications for therapeutic injection of musculoskeletal structures as well as knowledge of the effects/side effects of the medications used.

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES Demonstrate knowledge of the signs/symptoms both skeletal and extraskeletal seen in common rheumatologic disorders including: rheumatoid arthritis, seronegative spondyloarthropathy, septic arthritis, Lyme disorder, osteoarthritis, crystal arthritis, SLE, inflammatory diseases of muscle, polyarteritis nodosa, fibromyalgia, and osteoporosis. PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team. OBJECTIVES: The resident is able to:

Demonstrate proficiency in the ability to write, for allied health professionals, adequately detailed prescriptions based on the patient’s functional goals.

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RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES PROFESSIONALISM

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to: Demonstrate respect, integrity and responsiveness to the needs of patients and the disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal, professional, organizational, social level). Understand how the healthcare system affects their own practice (at the personal, professional, organizational social level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, 307 Integrated Competency Based Curriculum 2012-2013

RHEUMATOLOGY ROTATION GOALS AND OBJECTIVES and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

. Primer on the Rheumatic Diseases, 11th edition 1997, John Klippel, MD

• Articles

. Current articles from Rheumatology journals are selected and discussed with 2nd year fellow.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. MKSAP (Medical Knowledge Self assessment Program – American College of Physicians) section on Rheumatology

. Includes objectives and questions.

308 Integrated Competency Based Curriculum 2012-2013

Washington Hospital Center Consultations GMEC Approved on: November 4, 2009 Domain: General Physical Medicine & Rehabilitation and Therapeutics Level: PGY4 Length: 1 month Type: Inpatient Consults Rotation Director: Dr. Fatemeh Milani Faculty: Dr. Fatemeh Milani

General Educational Objective The PGY4 resident will be able to independently conduct complete Physiatric consultation on patients in the acute care hospital as measured by consultation recommendation of rehabilitation care need during acute and post acute admission.

Scope of Learning and Exposures Basic Anatomy and Physiology of Adult Brain and Spinal Cord 1. Common types of adult Brain pathophysiology a. Ischemic Stroke i. Thrombotic ii. Embolic b. Hemorrhagic Stroke i. Subarachnoid ii. Intracerebral (intraparenchymal) c. Traumatic Brain Injury d. Spinal Cord Injury

2. Procedure Skills a. Neurologic Exam b. Mini Mental Status Exam

Methods of Teaching 1. Clinical Sites a. Washington Hospital Center 2. Clinical teaching a. Staffing consultations that have completed prior by the PGY4 resident. 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions.

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Methods of Assessment 1. Standardized Core Competencies Based Global Assessment Evaluations by faculty at the end of the rotation. 2. Resident Observation & Competency Assessment tool (RO&CA – designed by Association of Academic Physiatrist) at minimum once a month and ad hoc as desired by faculty. 3. Informal Core Competencies Based Global Assessment Evaluations midway through rotation. 4. Informal immediate feedback by supervision faculty attending during daily rounds. 5. Feedback forward to Program Director Biannual Core Competency evaluation 6. Written and oral 360 degree evaluation (healthcare team, patient, family) 7. The Program Director will assess the progress of the 4th year resident through frequent communication with those in supervisory positions on an as needed basis and through monthly (informal) and quarterly (formal) Competency Committee assessment meetings.

Lines of Supervision The PGY4resident reports directly to the Dr. Fatemeh Malini

Specific Competency – Based Goals & Objectives

WHC CONSULT ROTATION GOALS AND OBJECTIVES PATIENT CARE

GENERAL SKILLS

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WHC CONSULT ROTATION GOALS AND OBJECTIVES GOAL: The resident is able to demonstrate the ability to take an appropriate focal physiatric history from and perform a focal physiatric physical exam upon the inpatient in an acute care hospital that requires a PM&R consult. OBJECTIVES: The resident is able to: Relate the anatomy of the central nervous system to the signs/symptoms of common stroke syndromes. Assess the patient in his/her: Higher mental functions Communication skills Level of motor/sensory impairment Cranial nerve impairment Abnormalities of balance/coordination/posture/gait/tone/movement disorders Demonstrate the ability to detect DVT in the CVA patient. Demonstrate appropriate usage of the ASIA system of neurologic classification. Demonstrate proficiency in determining the mechanism of injury (as appropriate) of the TBI/CVA/SCI Demonstrate proficiency in establishing the length of coma/ post traumatic amnesia as appropriate. Demonstrate an appropriate assessment and differential diagnosis of a: comatose patient patient in a persistent vegetative state patient with akinetic mutism minimally responsive patient mild traumatic brain injured patient agitated patient Demonstrate the ability to assess the endocrinologic condition of the patient for: DI SIADH gynecomastia galactorrhea Demonstrate the ability to detect signs/symptoms of hydrocephalus.

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WHC CONSULT ROTATION GOALS AND OBJECTIVES Demonstrate the ability to detect decorticate and decerebrate posturing in the head injured patient. PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to perform a functional examination of the acute care patient who requires a PM&R consult. OBJECTIVES: The resident is able to: Demonstrate adequate performance of a bedside test to determine ADL skills. Demonstrate adequate performance of a bedside test to determine potential for the expected functional outcome of a patient, including his/her potential degree of independence in ADL’s, ambulation and driving, based on level of injury. Demonstrate understanding as to how the ASIA rating affects patient prognosis. Demonstrate adequate performance of a bedside test for dysphagia. Demonstrate adequate performance of a bedside test of communication disorders and differentiate between: Dysarthria versus apraxia of speech Aphasia versus dysarthria Dementia versus aphasia Demonstrate the ability to detect homonymous hemianopsia versus hemineglect. Demonstrate adequate ability to assess spasticity as well as use the Ashworth Scale (if applicable). Demonstrate appropriate usage and interpretation of the following scales: GOAT scale Rancho Los Amigos scale FIM scale Disability rating scale Understand use/limitation of the GLASGOW Outcome score. Understand use/limitation of the Rancho Los Amigos cognitive scale. Understand the various indications for the various discharge options available to the patient including nursing home discharge (short term rehabilitative care) vs. chronic long term care, residential behavioral management programs, and supervised group homes.

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WHC CONSULT ROTATION GOALS AND OBJECTIVES Exercise Prescription and Modalities GOAL: The resident is able to appropriately prescribe exercise programs and modalities for the acute care patient who requires a PM&R consult. OBJECTIVES: The resident is able to: Demonstrate the ability to prescribe and monitor an appropriate exercise program for the patient which includes at least the following components (as is appropriate): Contracture prevention Promotion of ROM Promotion of functional mobility Control of spasticity Therapeutic & Diagnostic Injections/Procedures GOAL: The resident is able to understand the need for interventional procedures for acute care patients who requires a PM&R consult. OBJECTIVES: The resident is able to: Demonstrate the ability to read neuro imaging studies (CT/MRI) and successfully denote the presence of ischemia, SAH, cerebral hematoma, cerebral edema, mass effects, etc. Demonstrate the ability to interpret PVR’s for clinical use. Demonstrate hands on ability to provide halo maintenance (including pin assessment for looseness and the need for replacement/tightening). Demonstrate ability to read routine spinal films/MRI’s/CT scans and to diagnose by these studies vertebral fractures, and spinal infarcts/contusion/hemorrhages. Demonstrate knowledge of the indications for emergency decompressive spinal surgery. Demonstrate knowledge of post-operative complications of bone graft harvesting/application, and metal fixation devices used in spine stabilization surgery. Demonstrate understanding of the results of the MBS study. Electrodiagnostic Skills (N/A) Prosthetics/Orthotics/Medical Equipment GOAL: The resident is able to understand the appropriate use and prescription of prosthetics, orthotics, and medical equipment in the acute care patient who requires a PM&R consult. OBJECTIVES: The resident is able to:

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WHC CONSULT ROTATION GOALS AND OBJECTIVES Demonstrate knowledge of adaptive ADL equipment appropriate to the acute care patient (in particular, for feeding) Demonstrate knowledge of the indications for the use of halo-vest orthotics and test for proper fit. Demonstrate knowledge of the indications for the use of CTLS orthotics and test for proper fit. Demonstrate knowledge of indications/contraindications for the use of canes/walkers. CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patient. OBJECTIVES: The resident is able to: Regularly integrate medical knowledge with clinical data and generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an appropriate management plan. Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome. Regularly integrate medical knowledge with clinical data and generate a differential diagnosis Prioritize rehabilitation goals along with medical needs in order to formulate an appropriate management plan Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome. PATIENT CARE GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to: Demonstrate the ability to treat spasticity with appropriate pharmacologic and therapeutic interventions. Demonstrate the ability to care for bowel/bladder/retention/incontinence both pharmacologically & non pharmacologically. Demonstrate the ability to prescribe appropriate diet intervention and feeding alternatives for patients with dysphagia (including compensatory maneuvers and dietary modifications).

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WHC CONSULT ROTATION GOALS AND OBJECTIVES Demonstrate the ability to provide a preventative as well as an acute treatment programs for DVT. Demonstrate the ability to pharmacologically treat disorders of arousal/attention/reduced initiation. Understand the psychological adjustment required by the newly disabled patient and his/her significant other and treat/refer appropriately for depression and other conditions that may interfere with the individual obtaining his/her highest possible function. Demonstrate the ability to prescribe a program of pulmonary rehabilitation for the SCI patient as needed (including antibiotics/vaccinations/respiratory therapy/ventilation weaning). Demonstrate the ability to anticipate and treat autonomic dysreflexia. Demonstrate the ability to prevent and treat pressure ulcers. Demonstrate the ability to prescribe an appropriate program of environmental/psychological/pharmaceutical intervention for the: Agitated patient Mild TBI patient Patient with post traumatic amnesia Demonstrate the ability to prevent ocular injury in the TBI patient. Demonstrate the ability to treat hypo/hypertension in the TBI patient with appropriate drugs and physical agents. Demonstrate the ability to treat spasticity with appropriate pharmacologic and therapeutic intervention. Demonstrate the ability to both treat seizures and prescribe seizure prophylaxis in the TBI patient. Demonstrate the ability to treat movement disorders in the TBI patient with appropriate pharmacologic and therapeutic intervention. Demonstrate the ability to recognize and appropriately treat the endocrinologic disorders of DI and SIADH. Demonstrate the ability to recognize and treat language/communication disorders of those who are brain injured. Demonstrate the ability to treat neuro behavioral disorders of the TBI patient using pharmacologic/behavioral/environmental therapy.

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WHC CONSULT ROTATION GOALS AND OBJECTIVES MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate medical knowledge appropriate to the acute care patient who requires a PM&R consult. OBJECTIVES: The resident is able to: Demonstrate adequate knowledge of the epidemiology of CVA/SCI/TBI including incidence/prevalence/age distribution/survival rate/race distribution. Demonstrate understanding of the definitions of TIA and RIND and discuss their relationship to CVA. Demonstrate understanding of the anatomy & pathophysiology of common stroke and SCI d Provide a differential diagnosis of stroke in the young adult and child as compared with Demonstrate knowledge of the anatomy/neuroanatomy and physiology of bowel/bladderh voiding and elimination (both normal and common abnormal patterns).

Demonstrate understanding of the acute medical management of spinal cord injury, including pharmacotherapy. Demonstrate knowledge of anatomy/neuroanatomy and physiology of sexual functioning in the male and female Define the clinical features of locked in syndrome. Define the clinical features of akinetic mutism Define and contrast the difference between increased intracranial pressure and cerebral perfusion pressure and demonstrate knowledge of the consequences of both as well as their treatment. Define the pathophysiology of TBI including the mechanisms of: Diffuse axonal injury Cerebral contusion Coup/contra coup injury PHYSIATRIC KNOWLEDGE

GOAL: The resident is able to demonstrate physiatric knowledge appropriate to the acute care patient who requires a PM&R consult.

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WHC CONSULT ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Demonstrate understanding of risk factors in CVA/SCI/TBI. Understand the process whereby an individual with a CVA/SCI/TBI is evaluated for acute rehabilitation. Understanding the usual period for potential recovery for: Hemiparetic arm Aphasia Visual impairment Dysphagia Traumatic vs. non-traumatic patient in a persistent vegetative state. Define the following terms: Aphasia Alexia Agraphia Prosody Perceptual deficit (versus hemisensory loss versus homonymous hemianopsia) Apraxia (including dressing apraxia/constructional apraxia/ideomotor apraxia) Dysarthria Neglect Dysphagia Agnosia Provide definitions of the following terminology used to describe Aphasia: Agrammatism Anomia Circumlocution Echolalia Empty speech Paraphasias Telegraphic speech Jargon versus neologism

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WHC CONSULT ROTATION GOALS AND OBJECTIVES Define the anatomy as well as the language characteristics of the following types of communication disorders: Broca’s aphasia Global aphasia Anomia Wernicke’s aphasia Transcortical motor aphasia Transcortical sensory aphasia Conduction aphasia Demonstrate understanding of the communication disorders resulting from an injury of the right hemisphere. Understand the physiology of the swallowing mechanism as well as the incidence and recovery of dysphagia in the CVA/TBI patient. Demonstrate knowledge of both flexion and extension synergy pattern. Demonstrate understanding of the physiology of spasticity. Demonstrate knowledge of the acute care management of the CVA patient. Understanding the ASIA System of neurological classification of SCI Demonstrate understanding of the physiology of autonomic dysreflexia. Demonstrate understanding the medical and surgical intervention of pressure ulcers. Demonstrate knowledge of the anatomic/physiologic basis of the common medical conditions which are associated with brain injury including: Post traumatic seizures Undetected fractures Post traumatic hydrocephalus Autonomic dysfunction (hyper/hypotension, temperature instability) Cranial nerve damage Ocular injury (including corneal damage) Spasticity DVT

PRACTICE-BASED LEARNING & IMPROVEMENT GOAL: The resident is able to investigate and evaluate their patient care practices,

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WHC CONSULT ROTATION GOALS AND OBJECTIVES analyze and simulate scientific evidence and improve their patient care practices. OBJECTIVES: The resident is able to: Analyze practice experience and perform practice-based improvement activities using a systematic methodology. Analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness. Accept feedback willingly and eagerly Use information technology to manage information, access on-line medical information, and support their didactic education. Facilitate the learning of students and other healthcare professionals.

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

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WHC CONSULT ROTATION GOALS AND OBJECTIVES OBJECTIVES: The resident is able to: Assume responsibility and act responsibly. Demonstrate commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, informed consent, and business practices. Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, OT, SLP, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, case 320 Integrated Competency Based Curriculum 2012-2013

WHC CONSULT ROTATION GOALS AND OBJECTIVES managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. None Recommended.

• Self directed learning modules

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

Electives There are a total of 4 electives available throughout the residents PGY2-PGY4 years.

PGY2 The resident is given the opportunity to have an elective in their PGY2 year. If they choose this option, they will do so in leu of their Pain Consultation rotation and which must then be done in the PGY3 year.

PGY3 There are a total of two electives in the PGY3 year if the resident did their Pain Consultation in the PGY2 year; otherwise, there is one elective and Pain Consult rotation in their PGY3 year.

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PGY4 There are 2 electives rotations available in the PGY4 year. One is considered a pure PGY4 elective and the other is an elective or an Adult Neurology at WHC rotation.

PGY4 or Adult Neurology at WHC

Adult Neurology at WHC GMEC Approved on: November 4, 2009 Domain: Neurorehabilitation Level: PGY4 Length: 1 month Type: Outpatient/Inpatient Consults Rotation Director: Dr. Robert Laureno Faculty: Dr. Robert Laureno and Dr. Mark Lin.

General Educational Objective The PGY4 resident will be able to independently conduct complete neurologic consultation on patients in the acute care hospital as measured by consultation recommendation of acute neurologic care need during acute and post acute admission.

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Methods of Teaching 1. Clinical Sites a. Washington Hospital Center – Department of Neurology b. Washington Hospital Center – ICU c. Washington Hospital Center – Emergency Department d. Washington Hospital Center – Medical Wards 2. Clinical teaching a. Outpatient – Ambulatory Center visits b. Emergency Department – Consultations c. ICU – Consultations d. Medical Wards - Consultations 3. Procedure Skills a. Education: First the resident is taught the indications, contraindications, complications and step-by-step instructions. b. Demonstration: The faculty demonstrates and comments on step-by-step instructions. c. Performance: Then Direct observation by faculty attending, with progression towards independence. 4. Didactic Conferences a. Specific Rotation Didactics b. General Didactic while on this rotation include i. MEDSTAR GUH - MEDSTAR NRH PM&R Didactic Series ii. Resident Peer MSK/Rehabilitation Protocol Lecture Series iii. Monthly M&M Conference iv. MedStar GUH - MedStar NRH Journal Club 5. Examination: a. All residents will be tested on material learned specifically in this rotation on the next Quarterly Exam

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Lines of Supervision

The PG4 resident reports directly to the Dr. Laureno and Dr. Lin. The resident will independently exam and present the patient for staffing by the attending physician.

Specific Competency – Based Goals & Objectives

ADULT NEUROLOGY WHC GOALS AND OBJECTIVES PATIENT CARE GENERAL SKILLS

GOAL: The resident is able to obtain a problem focused history and physical exam in order to provide a prioritized differential diagnosis of the patient with neurologic disease.

OBJECTIVES: The resident is able to:

Obtain the patient’s history, focusing on the duration type and distribution of symptoms in order to determine a differential diagnosis of the patient with neurologic complaints. Demonstrate the ability to detect neurologic abnormalities including those involving: Muscle tone (spasticity, cogwheel rigidity, clasp-knife rigidity), Muscle mass and strength (atrophy, hypertrophy, pseudohypertrophy, paresis, paralysis) Movement (tremor, ticks, choreiform/athetoid movements, dystonia, ballismus, myoclonus, tetany, myotonia) Reflexes (corneal, jaw, direct/consensual pupillary reflexes, cremasteric, Babinski, clonus, Hoffman’s, snout limb) Coordination/motor planning (apraxia, ataxia, Romberg’s sign, dysdiadochokinesia, dyssynergia) Posturing/gait patterns of (UMN deficit, myopathic, ataxic, parkinsonian, LMN deficit) Sensation (anesthesia, hypesthesia, hyperesthesia, proprioception, stereognosis, 2 point discrimination, graphesthesia, hyperalgesia, allodynia) Communication disorders (aphasia, dysarthria) Cranial nerves

PHYSIATRIC SKILLS Functional Evaluations GOAL: The resident is able to coordinate the functional examination of the patient with his/her neurologic physical exam.

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES OBJECTIVES: The resident is able to:

Use his/her finding of the patient’s functional history and physical exam to determine a differential diagnosis in order to plan a differential diagnosis of the neurological disease process. Exercise Prescription and Modalities

Therapeutic & Diagnostic Injections/Procedures

GOAL: The resident is able to understand the indications, contraindications and limitations of diagnostic procedures (both radiologic and clinical) for those patients experiencing neurologic disease.

OBJECTIVES: The resident is able to:

Demonstrate knowledge of the indications, contraindications, and limitations of: Computed tomography (with and without enhancement) Magnetic resonance imaging (with and without enhancement)

Demonstrate understanding of the characteristics of T1 & T2 weighted MRI and their usefulness. Demonstrate the ability to detect on MRI/CT/myelogram (as appropriate): Hemorrhagic/ischemic abnormalities of the SCI and brain Syringomyelia of the spinal cord Vertebral fractures (acute and chronic) associated with and without spinal cord compression Discal disease (including bulging and herniated disc) Meningoceles Spinal stenosis Spinal/brain tumors Epidural/subdural hematoma Brain aneurysms Brain edema Skull fracture

Demonstrate the ability to interpret the findings of a lumbar puncture examination. Demonstrate knowledge of the indications/contraindications/limitations of an EEG. Electrodiagnostic Skills GOAL: The resident is able to use the patient’s history and physical exam in order to interpret the electrodiagnostic study performed in the diagnosis of neurologic disease.

OBJECTIVES: The resident is able to:

Demonstrate that electrodiagnostic testing is not a substitution for the clinical examination, but is an extension of same. Demonstrate the understanding that the significance of electrical abnormalities should be seriously questioned if they do not correlate with the patient’s clinical findings.

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES CLINICAL JUDGEMENT

GOAL: The resident is able to demonstrate the ability to provide high standards of care to his/her patients. OBJECTIVES: The resident is able to:

Regularly integrate medical knowledge with clinical data and generate a differential diagnosis. Prioritize rehabilitation goals along with medical needs in order to formulate an appropriate management plan. Use diagnostic and therapeutic procedures judiciously to achieve a quality outcome. PATIENT CARE

GOAL: The resident is able to provide patient care that is effective and appropriate. OBJECTIVES: The resident is able to:

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES Demonstrate the recognition of the following disease states: Motor neuron diseases (primary lateral sclerosis, classic amyotrophic lateral sclerosis and its variants , familial spastic paraplegia, spinal muscular atrophy Type I through IV, scapuloperoneal muscular atrophy, acute polio myelitis, post-polio syndrome). Peripheral neuropathies including diabetic neuropathies, alcoholic neuropathy acute inflammatory demyelinating polyradiculopathy, chronic inflammatory demyelinating polyneuropathy, Charcot-Marie Tooth disease (HMSN), mononeuritis multiplex, idiopathic brachial neuritis (Parsonage-Turner Syndrome), and ischemic monomelic neuropathy, Myopathies including Duchenne muscular dystrophy, Becker’s muscular dystrophy, limb girdle dystrophy, (including congenital forms), Emery-Dreifuss dystrophy, congenital myopathies (including central core myopathy, nemaline myopathy, myotubular myopathy, and congenital fiber disproportion myopathy), metabolic myopathies (including McArdle disease), endocrine myopathies (including hyper/hypo thyroid myopathy, corticosteroid myopathy), inflammatory myopathies (including polymyositis, dermatomyositis, and inclusion body myositis), infectious myopathies (including HIV myopathy), and toxic myopathy (including alcohol and chemotherapeutic related disease). Plexopathy injuries (including those secondary to trauma and chemotherapeutic agents, root avulsions, radiculopathy, and peripheral nerve entrapment syndrome) as well as those of the median, ulnar, radial, peroneal, femoral, and tibial nerve. Facial neuropathy (including Bell’s palsy) Neuromuscular Junction Disorders (including myasthenia gravis, Lambert-Eaton myasthenic syndrome, and botulism) Myotonic muscle disorders (including myotonic dystrophy, myotonia congenita) Periodic Paralysis Syndromes (including hypokalemic periodic paralysis) Movement disorders (including Parkinson’s disease, progressive supranuclear palsy, stiff man syndrome, restless leg syndrome) Brain injury (secondary to trauma, CVA, tumor) Dementias Spinal cord injuries Hereditary/degenerative disorders (including glycogen storage disease, Friedreich’s disease, Huntington’s chorea) Metabolic/toxic syndromes (including diabetes mellitus, hypo/hyperthyroidism, hyper/hypocalcemia, botulism, lead, alcohol) Infectious disorders (including HIV related neuropathy/myopathy) Pain syndromes (including thalamic pain and complex regional pain syndrome)

Demonstrate the ability to consult/refer to neuropsychiatric specialists as needed.

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES MEDICAL KNOWLEDGE

GENERAL KNOWLEDGE

GOAL: The resident is able to demonstrate the knowledge of neuroanatomy and neurophysiology that will allow him/her to understand the neurologic disease process.

OBJECTIVES: The resident is able to:

Correlate the neurovascular anatomy of the central nervous system to injury of that same structure. Demonstrate knowledge of the formation of the brachial plexus, and lumbosacral plexus (including the spinal nerves from which they are derived) as well as the relationship of these plexus to the peripheral nerves of the extremity. Demonstrate knowledge of the sensory distribution and motor innervation of the brachial plexus, lumbosacral plexus, and peripheral nerves of the extremities, trunk and face and correlate this knowledge to the spinal nerve root supply of these structures. PHYSIATRIC KNOWLEDGE

GOAL: The resident will be aware of the epidemiology, genetics, clinical features, and pathology of those common neurologic disorders which are frequently seen in a physiatric practice.

OBJECTIVES: The resident is able to:

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES Demonstrate familiarity with the signs and symptoms of the following disease states: Motor neuron diseases (primary lateral sclerosis, classic amyotrophic lateral sclerosis and its variants , familial spastic paraplegia, spinal muscular atrophy Type I through IV, scapuloperoneal muscular atrophy, acute polio myelitis, post-polio syndrome). Peripheral neuropathies including diabetic neuropathies, alcoholic neuropathy acute inflammatory demyelinating polyradiculopathy, chronic inflammatory demyelinating polyneuropathy, Charcot-Marie Tooth disease (HMSN), mononeuritis multiplex, idiopathic brachial neuritis (Parsonage-Turner Syndrome), and ischemic monomelic neuropathy, Myopathies including Duchenne muscular dystrophy, Becker’s muscular dystrophy, limb girdle dystrophy, (including congenital forms), Emery-Dreifuss dystrophy, congenital myopathies (including central core myopathy, nemaline myopathy, myotubular myopathy, and congenital fiber disproportion myopathy), metabolic myopathies (including McArdle disease), endocrine myopathies (including hyper/hypo thyroid myopathy, corticosteroid myopathy), inflammatory myopathies (including polymyositis, dermatomyositis, and inclusion body myositis), infectious myopathies (including HIV myopathy), and toxic myopathy (including alcohol and chemotherapeutic related disease). Plexopathy injuries (including those secondary to trauma and chemotherapeutic agents, root avulsions, radiculopathy, and peripheral nerve entrapment syndrome) as well as those of the median, ulnar, radial, peroneal, femoral, and tibial nerve. Facial neuropathy (including Bell’s palsy) Neuromuscular Junction Disorders (including myasthenia gravis, Lambert-Eaton myasthenic syndrome, and botulism) Myotonic muscle disorders (including myotonic dystrophy, myotonia congenita) Periodic Paralysis Syndromes (including hypokalemic periodic paralysis) Movement disorders (including Parkinson’s disease, progressive supranuclear palsy, stiff man syndrome, restless leg syndrome) Brain injury (secondary to trauma, CVA, tumor) Dementias Spinal cord injuries Hereditary/degenerative disorders (including glycogen storage disease, Friedreich’s disease, Huntington’s chorea) Metabolic/toxic syndromes (including diabetes mellitus, hypo/hyperthyroidism, hyper/hypocalcemia, botulism, lead, alcohol) Infectious disorders (including HIV related neuropathy/myopathy) Pain syndromes (including thalamic pain and complex regional pain syndrome)

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES PRACTICE-BASED LEARNING & IMPROVEMENT

GOAL: The resident is able to investigate and evaluate their patient care practices, analyze and simulate scientific evidence and improve their patient care practices.

OBJECTIVES: The resident is able:

To analyze practice experience and perform practice-based improvement activities using a systematic methodology.

To analyze and assimilate evidence of “best practices” from scientific studies related to their patient’s health status.

Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information considering diagnostic/therapeutic effectiveness.

Accept feedback willingly and eagerly

GOAL: The resident is able to communicate appropriately with the patient, significant other, and the rehabilitation team.

OBJECTIVES: The resident is able to:

PROFESSIONAL ATTITUDE

GOAL: The resident is able to demonstrate a commitment to excellence and ongoing professional development.

OBJECTIVES: The resident is able to:

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ADULT NEUROLOGY WHC GOALS AND OBJECTIVES Demonstrate sensitivity and responsiveness to cultural differences including awareness of their own and their patient’s cultural perspectives. HUMANISTIC QUALITIES

GOAL: The resident is able to see the patient beyond the disease.

OBJECTIVES: The resident is able to:

Demonstrate respect, integrity and responsiveness to the needs of patients and disabled community that supersedes self interest. SYSTEMS-BASED PRACTICE GOAL: Residents must demonstrate an awareness of and responsiveness to the larger context of healthcare as well as demonstrate the ability to effectively call on system resources to provide care that is of optimal value. OBJECTIVES: The resident is able to: Understand how their professional practices affect the healthcare system in general (at the personal/ professional/organizational/societal level). Understand how the healthcare system affects their own practice (at the personal/professional/organizational/societal level). Understand how various systems of delivery in medical care differ from one another. Understand how different systems of medical care affect healthcare costs and the allocation of resources. Practice cost effective healthcare/resource allocation without compromising quality of care. Advocate for quality patient care and assist patients through the system complexity Demonstrate understanding of each allied health professional’s role in the attainment of patient function (including PT, TO, SLP, TR, Voc Rehab, RN, Case Management, SW). Understand how to partner with healthcare managers and other providers to access, coordinate, and improve healthcare in the healthcare system (and in particular, vocational rehabilitation specialists and case managers).

Educational Resources • Text Books

. Physical Medicine & Rehabilitation, 3rd edition 2007 (as of July 1, 2009) 2nd edition 2000 prior, Randall L Braddom MD MS.

• Articles

. None Recommended.

• Self directed learning modules

331 Integrated Competency Based Curriculum 2012-2013

. None Recommended.

• Videos

. None Recommended.

• CD-ROMs

. None Recommended.

OCOR (Outpatient Center for Orthopedic Rehabilitation) Physical Therapy This rotation is currently being developed during the 2009-2010 academic year.

Advanced Radiology This rotation is currently being developed during the 2009-2010 academic year.

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GUH- NRH PM&R RESIDENCY

Chapter 4 Didactics

he PM&R didactic series runs every Thursday from 8:00am to 12:00pm. The competency- based didactic curriculum includes topics from the 12 Domains and will comprehensively T cover all of the general and subspecialty subjects in the field of PM&R. The series will be presented in an 18-month cycle and each resident will be exposed to the material twice before they complete the training program. This ½ day protected academic time include sessions which consist of lectures, physiatry bedside rounds, inter-disciplinary conferences (Rheumatology-Orthopedic- PM&R Rounds), hands-on workshops, and team-based learning activities with interactive games (Jeopardy). Journal Clubs are held monthly (3rd Thursday) and coordinated by resident teams and rotating faculty. Learning objectives are provided by presenters and given to the residents before each session. All didactic sessions are staffed and facilitated by faculty physiatrists.

The resident peer lecture series is from 11:00-12:00 pm (weekly, Thursdays). This educational series complements the MSK Continuity Clinic experience. Lecture topics include MSK system anatomy, physical and functional examination, diagnosis and rehabilitation management with focus on rehabilitation protocols referenced from a PM&R textbook (Clinical Orthopedic Rehabilitation, Brotzman and Wilk). All residents are provided a copy of this textbook and are expected to have read the assigned topic for the week. A schedule is provided at the beginning of the academic year and is available at New Innovations. Each resident is assigned to present each week and assignments emphasize progression of learning (PGY 2=Anatomy; PGY 3= Physical and Functional Examination; PGY 4 =Diagnosis and Rehabilitation Management). This interactive activity promotes leadership, communication skills and team-based learning.

Other educational sessions which complement the didactic experience include Grand Rounds (Fridays 12:00-1:00 pm, weekly) and Board Review Sessions. Morbidity and Mortality Conferences are held monthly (4th Thursday). Resident teams present cases utilizing the Quinn Matrix. This is staffed by a multi-disciplinary team (Physiatrists, Quality Improvement Staff, Emergency Response Team and Nursing).

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Aside from these core didactic sessions, residents have the opportunity to participate in didactic programs in their other rotations and departments. Residents are also encouraged to attend weekly Grand Rounds (Wednesdays, 12-1 pm) at the Washington Hospital Center.

Engaging Our Learners through Interactive Pedagogies The following innovations have been introduced in our didactic sessions to promote active learning:

Audience Response System (ARS) Each student/resident is given a remote control. Participants are asked to respond to multiple- choice questions which are displayed on the video screen. The tally of answers is shown. This process encourages learner interaction and engagement with the content, the instructor and with one another.

Immediate Feedback – Assessment Tool (IF-AT) The student/resident is given a written multiple choice quiz (or test). An answer sheet that looks similar to a lottery scratch off is provided with corresponding answer choices. The learner scratches off their answer choice. The correct answer will have an asterisk “*” behind the silver scratch off material. The learner will continue to scratch off until the asterisk is revealed. This process allows participants to re-think why or how they got the incorrect answer while still thinking about the subject.

Hands-on Workshops Interactive hands-on practice of joint injection techniques are performed using mannequins. With this technique, a needle is inserted on the life-like limb and if the learner is in the correct location a green light will shine, if incorrect a red light shines. This provides immediate feedback and promotes active learning.

Objective Structured Clinical Examinations (OSCE) OSCE sessions are done in a simulation center with standardized patients. The resident is given a scenario and the opportunity to examine or manage the patient presented. This is staffed by faculty evaluators and residents are given formative feedback on their performance. Videos can also be viewed individually and emphasizes practice-based learning and improvement. (Refer to Assessment Tools–Chapter 6.)

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Didactic Lecture Topics

General Physical Medicine & Rehabilitation Therapeutics Complementary and alternative medicine: acupuncture, massage, nutraceuticals DVT prophylaxis in inpatient rehab Heterotopic ossification Driving evaluation Ostomy care Therapeutic recreation and adaptive sports Subacute rehabilitation Principles of osteopathy/OMM Environmental control units Rehabilitation issues in pregnancy Chronic pain management Complex regional pain syndrome Sleep disorders Vestibular rehabilitation Physiatric consultation PM&R Therapy Prescription Writing Rehabilitation placement Infection control Rehabilitation nursing Rehabilitation psychology Pharmacology (pain medications, NSAIDs, antiepileptics, cannabinoids, neuro-pharm) Electrodiagnostic Medicine Anatomy of Nerves and Muscles Neural Reaction to Injury Instrumentation Nerve Conduction Studies Normal Needle EMG Abnormal Needle EMG Radiculopathy Plexopathy Focal Peripheral Neuropathy General Peripheral Neuropathy Motor Neuron Disease

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NMJ Disease Myopathy SSEP Basic Nerve Conduction Studies OSCE – Needle EMG Musculoskeletal, Sports and Occupational Medicine Physiologic Basis of Therapeutic Exercise Gross Anatomy Lab – Upper Extremities @ GUSOM Gross Anatomy Lab – Lower Extremities @ GUSOM Fitness Essentials of Gait Evaluation and Orthopedic Management of Common Hand Injuries Evaluation and Orthopedic Management of Common Knee Injuries Team Doctor Weight Lifting – How, Why, and What not to do. Return to Work Guides to the Evaluation of Permanente Impairments Basic of Joint Injections Joint Injection Workshop Basics of Rehabilitation & Physical Therapy Prescription Writing Treatment of Epicondylitis Common problems of Dancers and Musicians Injuries to the Throwing Athlete New Frontiers in the Pathophysiology of Myofascial Pain: Enter the Matrix Common injuries to Runners Evaluation, Management and Rehabilitation of Osteoporosis MSK Radiographic Imaging Pearls Ultrasound in Rehabilitation Medicine

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Amputee Rehabilitation and Prosthetics & Orthotics Evaluation of an AKA Patient Prosthetic Gait Deviations Upper Limb Prosthetics Lower Limb Prosthetics Spinal Orthotics Upper Limb Orthotics Lower Limb Orthotics Phantom Pain Dermatological/Skin Issues in the Amputee Peripheral Artery Disease Essentials of Gait Abnormal Gait Evaluation of a BKA Patient Orthotics and Prosthetics: Writing Prescriptions Spinal Cord Injury Rehabilitation Spinal Cord Anatomy and Syndromes The Search for the Cure: From Translational Research to Clinical Trials in SCI: What does the future hold? Neurogenic Bowel Sexuality and Fertility in SCI Pressure Ulcer Prevention and Wound Management Cardiovascular Disease in SCI Neurologic Exam in SCI & ASIA Classification TBI and SCI Dual Diagnosis Spasticity Evaluation and Management MRI of the Spine Anatomy of the Spine Acute Management of SCI Neurogenic Bladder Musculoskeletal Issues in SCI Functional Outcomes in SCI Pulmonary Management in SCI Non-traumatic SCI Wheelchair Prescription Neurorehabilitation Post-Traumatic Seizures Use of Psychotropic Medications in Rehabilitation after Stroke Central Post-Stroke Pain

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Acute Stroke Management Traumatic Brain Injury Update Neuroradiology rounds Rehabilitation Emergencies: Agitation, Seizures The Neurologic Examination, Cranial Nerve Testing Post-Polio Syndrome Movement Disorders Headaches Epidemiology of TBI (inc. Mild TBI) Stroke Syndromes Neuropsychology and Cognitive Rehabilitation Depression, Fatigue and Sleep Disorders Post-Stroke & TBI Speech, Language & Communications Disorders Post-Stroke & TBI Multiple Sclerosis Neuroanatomy and Pathophysiology Humanities in Rehabilitation Medicine Literature Review: Strategies in Dealing with Stress and Fatigue in Residency Training Overview of Ethics and Professionalism Essential Elements of Communication and the Art of Effective Listening Bioethics Communicating with Family Members in the Rehabilitation Setting Appreciative Inquiry and Listening Skills-Paired Interviews Stress and Fatigue Recognition and Management Spirituality in Medicine Connecting Art and Literature to Medical Education Resident as Teacher Series Delivering Bad News Focusing on Caregivers in the Rehabilitation Setting Physician Impairment Healthcare Disparities Self-Reflection and PBLI Cultural Competency Communicating with Difficult Patients Doctors as Healers

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Medical Rehabilitation Pulmonary Rehabilitation Burn Rehabilitation 1 Burn Rehabilitation 2 Cardiac Rehabilitation Balance and Gait Dysfunction in Cancer Rehabilitation End of Life and Palliative Care Evaluation and Management of Lymphedema Fall Prevention and Rehabilitation Geriatric Rehabilitation Exercise and Fatigue Management in the Cancer Patient Rehabilitation Research How to Study a Study and Test a Test: Reliability, Validity, Sensitivity, Utility The Research to Practice Cycle; Pragmatic Considerations Tele-rehabilitation: Using Technology to Provide Rehabilitation Services at a Distance Understanding Statistics, Research Design and Data Analysis Through the Prism of Rehabilitation Randomized Controlled Trials in Rehabilitation The Relevance of Clinical Research Research Ethics and the Role of IRB Using Research to Detect Clinically Significant Change: Statistical Foundations for Diagnosis, Treatment and Medical Decision Making Anatomy of the Research Proposal Advantages and Disadvantages of Non-randomized Cohort Studies Evidenced-based Practice Reviewing the Evidence; Appraising Traditional and Systematic Reviews Rehabilitation Administration and Practice Management Involving Residents in Quality Improvement Dollars and Sense of Rehabilitation The Future of Post-Rehabilitation Care (Part 1) Systems-Based Practice Essentials The Alphabet Soup of Health Care Understanding Reimbursement Systems and Documentation in Rehabilitation How to Build and Run a Private Practice in PMR

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New Innovations The Therapeutic Recreation and Adaptive Sports Program Billing and Coding 101 Patient Safety Seminar The Future of Post-Rehabilitation Care (Part 2) Understanding Types of Rehabilitation Delivery Workers Compensation and Reimbursement in PM&R Fellowship/Job Search Techniques and Contracts Historical and Current Legislations and Policies Facing PM&R Understanding Medicare, Medicaid and Private Insurances Medico-legal Documentation National Organizations in PM&R Joint & Connective Tissue Rehabilitation Rheumatoid Arthritis Osteoarthritis Psoriatic Arthritis Ankylosing Spondylitis Scleroderma and Progressive System Sclerosis Systemic Lupus Erythematosus Pediatric Rehabilitation Neural Tube Defects Cerebral Palsy Bracing and the Pediatric Patient: Orthotics Rehabilitation of Brain Tumor and Ataxia Carotid Artery Dissection Scoliosis Pediatric Trauma (SCI, TBI) Developmental Pediatrics (Milestones) Neuromuscular Disorders Pediatric Movement Disorders Spasticity Evaluation and Management Table 5 - List of Didactic Lectures

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Chapter 5 5 Other Learning Opportunities Here are multiple way beyond lectures and rotations used in the tradition residency program in which the resident are exposed to the material needed to study to become a T competent physiatrist.

Continuity clinic Clinic Design There are 4 teams; Yellow, Green, Blue, Red

Each resident is assigned a team for their entire residency PGY2 – 4 years.

Each team consists of a resident from each class. PGY2, PGY3 and PGY4.

All residents will participate in the clinic every Thursday after didactic lectures, except when post in- house call to maintain compliance with ACGME duty hour rules.

Patient scheduling: Each patient will be scheduled for 1 hour regardless if a new visit or follow up. Therefore each team 2 patients at 1:00pm, 2:00pm, 3:00pm and 4:00pm every Thursday.

The PGY2 + PGY4 will see one patient together. This allows the Senior Resident to act in a supervisory and teaching manner. In the beginning of the year the PGY4 will provide the examination and treatment plan formation education. As the year progresses, it is expected for the PGY2 to take on more the initial evaluation and treatment with guidance from the PGY4. The PGY3 will see a patient by him/herself for that year.

The patients will be rescheduled to the same doctors. The PGY4’s will pass their existing patients to the PGY2 residents.

Clinic logistics • 8 Rooms used from 1:00pm to 5:00pm. • Scheduling with the Front Desk. • Each Resident will be assigned a Doctor Number that they will have throughout their residency. The PGY4 and PGY2 will share a doctor number. (see below)

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• Administrative Support will be done by Dr. Whitehair’s staff. • Each patient visit will be staffed by Dr. Curtis Whitehair, the program director and additional faculty that will be assigned on a rotational basis.

Doctor Number assignment Initially (and Odd years) Yellow Green Blue Red PGY2 501 502 503 504 PGY3 505 506 507 508 PGY4 501 502 503 504

Second year (and even years) Yellow Green Blue Red PGY2 505 506 507 508 PGY3 501 502 503 504 PGY4 505 506 507 508 Table 6 - Doctor Number assignment

Resident’s responsibility • Post Call Duty hours: The resident that will not be able to continue past 2pm due to ACGME duty hours or any vacation or holidays will be required to have the schedule set at least 6 weeks in advance for him/her to not be at the clinic. The program’s call schedule is set for an entire year in June prior to the academic year starting. It will be the resident responsibility to facilitate any scheduling changes at the last minute with the patient and the front desk schedulers. It will not be accepted to simply inform the front desk and have them rearrange last minute changes except in emergencies only.

• Vacation will need to be scheduled for at least 6 weeks in advance except for emergencies.

• The PGY3 and PGY4 residents will be responsible for patient management (i.e. prescription refill authorization, forms, paper work, insurance authorizations) Monday through Friday 8:00am – 5:00pm. If a PGY3 or PGY4 is away at an outside rotation, the PGY3 or PGY4 remaining will cover the entire teams patients. Once they return the patient will return to their original doctor.

• The resident will be responsible for providing lectures, see below. This has replaced the old Physiatry Rounds lectures series. Learning/Education • We use the text book Clinic Orthopaedic Rehabilitation. . Each resident is supplied with the text by the residency program. 342 Integrated Competency Based Curriculum 2012-2013

• A Lecture Series will review the entire text book in 18 months. . This will allow review of the book 2 times during the PGY2- 4 residency program.

• The residents will provide the lectures in the form of a PowerPoint presentation:  PGY2 – Gross anatomy of selected body part which includes imaging studies.  PGY3 – Examination, Normal Biomechanics, Physiology and Kinematics of selected body part.  PGY4 - Pathology and Rehabilitation Protocol

Continuity Clinic Peer Lecture Schedule Clinical Orthopaedic Rehabilitation Second Edition Lecture Topic Chapter Pages 1 Anatomy of the Wrist, Hand and Fingers 1 2 How to examine the Wrist, Hand and Fingers 1 3 Flexor Tendon Injuries 1 1-13 Trigger Finger (Stenosing Flexor Tenosynovitis) Flexor Digitorum Profundus Avulsion (Jersey Finger) 4 Extensor Tendon Injuries 1 15-23 5 Fractures and Dislocations of the Hand 1 22-32 Fifth Metacarpal Neck Fracture (Boxer’s fracture) 6 Injuries to the Ulnar collateral Ligament of the Thumb 1 32-34 Metacarpophalangeal Joint 7 Carpal Tunnel Syndrome 1 34-40 8 Nerve Compression Syndromes 1 40-42 Pronator Syndrome Ulnar Tunnel Syndrome Radial Tunnel Syndrome Posterior Interosseous Nerve Syndrome 9 Nerve Injuries 1 42-44 Splinting of Nerve Palsies 10 Replantation 1 45-50 Dupuytren’s Contracture Arthroplasty 11 Scaphoid Fractures 1 50-54 12 Fracture of the Distal Radius 1 55-67 13 Triangular Fibrocartilage Complex Injury 1 67-72 14 De Quervain’s Tenosynovitis 1 72-79 Intersections Syndrome of the Wrist Dorsal and Volar Carpal Ganglion Cyst 15 Anatomy of the Elbow 2

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16 How to examine the Elbow / Evaluation 2 85-88 17 Rehabilitation Rationale for Throwers 2 89-95 General Rehabilitation Principles Medial Collateral Ligament (Ulnar Collateral Ligament) injuries 18 Ulnar Nerve Injury at the Elbow (Cubital Tunnel) 2 95-97 19 Treating Flexion Contractures (Loss of Extension) in the 2 97- Throwing Athletes 101 A Basic Elbow Exercise Program (Performed Three times a Day)

20 Treatment and Rehabilitation of Elbow Dislocations 2 101- 103

21 Lateral and Medial Epicondylitis 2 104- Olecranon Bursitis 115 118 22 Isolated Fracture of the Radial Head 2 101- Elbow arthroplasty 103 Post-Traumatic Elbow Stiffness 115- 122 23 Anatomy of the Shoulder 3 24 How to Examine the Shoulder / Intake Evaluation 3 124- 142 25 General Principles of Shoulder Rehabilitation 3 128- General Shoulder Rehabilitation Goals 129 142- 148 26 Impingement Syndrome 3 142- 158 27 Rotator cuff Tendinitis in the Overhead Athlete 3 159- 168 28 Rotator Cuff Tears 3 168- 196 29 Shoulder Instability 3 196- 227 30 Frozen Shoulder (Adhesive Capsulitis) 3 227- 234 31 Rehabilitation after Shoulder Arthroplasty 3 231- Acromioclavicular Joint Injury 234 Scapular Dyskinesis 240- 244 244-

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248 32 Biceps Tendon Disorders 3 234- 240 33 Anatomy of the Knee 4 34 How to Examine the Knee 4 The Painful Knee: Evaluation, Examination and Imaging 251- Evaluation of the Patellofemoral Joint 265 321- 327 35 Anterior Cruciate Ligament Injuries 4 266- 293 36 Posterior Cruciate Ligament Injuries 4 293- 303 37 Medial Collateral Ligament Injury 4 308- 315 38 Meniscal Injuries 4 315- 319 39 Patellofemoral Disorders – Important Points in the 4 327- Rehabilitation 344 40 Patellar Tendon Ruptures 4 345- Patella Fractures 350 357- 362 41 Articular Cartilage Procedures of the Knee 4 350 Baker’s Cyst (Popliteal cyst) 4 355 42 The Arthritic Knee 6 458- 473 43 Anatomy of the Ankle, Foot and Toes 5 44 How to examine the Ankle, Foot and Toes 5 45 Ankle Sprains 5 371- Chronic Lateral Ankle Instability: Rehabilitation after 392 Lateral Ankle Ligament Reconstruction 46 Inferior Heel Pain (Plantar Fascitis) 5 393- 404 47 Achilles Tendon Dysfunction 5 405- Posterior Tibial Tendon Insufficiency 416

48 Metatarsalgia 5 416- Hallus Rigidus 438 First Metatarsophalangeal Joint Sprain (Turf Toe) Morton’s Neuroma (Interdigital Neuroma) 49 Anatomy of the Hip 50 How to examine the Hip

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51 The Arthritic Hip 6 441- 458 52 Anatomy of the Thigh 7 53 How to examine the Thigh 7 54 Hamstring Injuries 7 475- 490 55 Quadriceps Strains and Contusions 7 490- 493 56 Groin Pain 7 493- (SI Dysfunction – not in book but common referral source) 503 57 Anatomy of the Spine 9 Definitions and Common Terms 555- 557 58 How to examine the Lumbar Spine / Evaluation of 9 560- Patients with Low Back Pain 574 59 How to examine the Cervical and Thoracic Spine 60 Incidence of Low Back Pain 9 558- False-positive Radiographic Studies in Low Back Pain 558 Evaluation 558- Risk Factors Previously Associated with the Development 558 of Low Back Pain 558- Predictors of Return-to-Work status of patients with Back 560 pain 560- 560 61 Overview of Management Guidelines for Acute Low Back 9 575- Pain 584 Clinical Pearls for Low Back Pain 584- 588 62 Physical Therapy Approaches in Low Back Pain – Overview 9 588- of Extension-Flexion Bias 599 63 Special MSK Topics - Complex Regional Pain Syndrome 8 543- (RSD) 554 64 Special MSK Topics - Aquatic Therapy for the Injured 7 522- Athlete 527 65 Special MSK Topics - Running Injuries 7 511- 521 66 Special MSK Topics - Shin Splints in Runners 7 522- 526 67 Special MSK Topics - Return to Play after a Concussion 7 527- 530 68 Special MSK Topics - Osteoporosis: Evaluation, 7 530- Management and Exercise 539

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Table 7 - Continuity Clinic Lectures

Research Residents are expected to participate in one research project during their education. Residents are mentored as well as didactics overseen by the Research Domain. Each senior will present their research at a special Grand Rounds for “Senior Resident’s Research”. All residents are supported in any research manner and will receive funding to present at any scientific conference. Many residents in the past presented posters at the American Academy of Physical Medicine and Rehabilitation.

Educational Conferences and Workshops Residents also participate in other conference and workshop to achieve a well rounded education. List below is a table of conferences and workshop that are not part of the Didactic series and which of the core competencies they provide.

SESSIONS & MEDICAL PATIENT INTER- PROFESSION PRACTICE- SYSTEMS- KNOWLEDGE CARE PERSONAL -ALISM BASED BASED Competencies AND LEARNING PRACTICE COMMUNIC AND ATION IMPROVE SKILLS MENT GRAND ROUNDS Weekly + + + + + + PEER TEACHING SERIES Weekly + + + + + JOURNAL CLUB Monthly + + + + MORBIDITY AND Monthly MORTALITY CONFERENCE + + + + + + (QUINN MATRIX) JOINT INJECTION Annually WORKSHOP + + ANATOMY DISSECTION Annually WORKSHOP + + ANNUAL ACLS/BLS Annually TRAINING SESSIONS + + SYSTEMS-BASED Annually PRACTICE SEMINAR (April) + + + + + + PATIENT SAFETY Annually( SEMINAR June) + + + + + + Table 8 - Other Educational Conferences and Workshops & Competencies

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Chapter 6 6 Assessment Tools

he ability to demonstrate educational outcomes as the achievement of competency-based learning objectives provides evidence of preparing competent physicians who can meet the T health care needs of the public. Educational assessment is, therefore, a key component to our PM&R Residency program and is intended to:

1. Assess residents' attainment of competency-based objectives 2. Facilitate continuous improvement of the educational experience 3. Facilitate continuous improvement of resident performance 4. Facilitate continuous improvement of residency program performance

Assessment System

1. Assessment is consistent with curriculum/program objectives.

Consistency between objectives and assessment occurs because there are clear parallels between what is taught and what is assessed in the MEDSTAR GUH - MEDSTAR NRH PM&R residency training program. Consistency between objectives and assessment also increases the likelihood that residents will attend to a broader scope of course objectives and not just content that will be assessed.

2. The educational objectives are representative of our 12 educational domains of interest.

It is not feasible to assess attainment of all educational objectives in all contexts; therefore, it is necessary to select a sample of what will be assessed. Representative behaviors for each competency in defined contexts have been identified.

3. Multiple assessment approaches/instruments are employed.

Because competence is multi-dimensional and individual assessment approaches have limitations, it is unlikely that a single approach to assessment will be adequate. This problem is addressed by using a different assessment approaches.

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4. Multiple observations are conducted.

Multiple observations improve the reliability or precision of assessment and allow identification of patterns of behavior over time.

5. Multiple observers/raters provide assessments.

Using multiple observers improves the reliability or precision of assessment and enhances the scope of assessment.

6. Performance is assessed according to pre-specified standards.

Pre-specified standards indicate objective criteria for "good enough" or "borderline" performance and help to reduce subjective assessment.

7. Assessment is fair.

Fairness pertains to giving all residents the same or equal opportunity to perform. While fairness may be enhanced by valid and reliable assessment, an assessment may still be unfair if the results are influenced by something other than ability. For example, it would be unfair to compare the assessment results of a resident who was on call the night before an assessment with the results of peers who were not on call. With the exception of baseline or needs assessments, fairness pertains also to providing residents opportunities to learn the material on which they will be assessed. Residents are informed about what will and will not be assessed. In addition, there is clarity about the assessment format and how performance will be rated before the assessment.

Resident Assessment

OSCE The Objective Structured Clinical Examination (OSCE) at the MEDSTAR GUH - MEDSTAR NRH PM&R Residency Training Program is a standardized patient encounter developed to assess competency in clinical skills. By using simulated patients in standardized scenarios, our resident’s abilities are evaluated in an environment that is realistic, safe and educational. The observers, which include the standardized patient (SP) and designated PM&R faculty, use pre-defined checklists that evaluate clinical competence with components that reflect the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies. All residents participate in bi-annual OSCE’s during the three-year residency training program. OSCE’s are conducted at the Clinical Simulation Center located at Washington Hospital Center.

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STANDARDIZED PATIENTS (SP)

1. SP are individuals who have been taught to present history and physical examination findings of a particular illness or injury in an accurate and reproducible manner;

2. The SP may have real findings or they may be simulating signs and symptoms;

3. They are trained professional actors who have been given structured scripts;

4. SP in different stations vary in authenticity;

5. The SP will be used to assess your skills in history-taking, physical and functional examination, listening and information processing, teaching, communication and patient advocacy;

6. The SP will not give you immediate or verbal feedback on your performance.

GUIDELINES FOR THE RESIDENT

1. You are to approach, interview and examine the SP exactly as you would an actual patient. We are evaluating your performance on the assumption that you would behave identically with an actual patient. All of the cases are based on real patient encounters.

2. The following tasks are expected during each encounter:

(a) Obtain a focused history (b) Perform a relevant physical and functional examination (c) Discuss your initial diagnostic impression and your work-up plan with the patient

3. In the interest of time and convenience, the following are not expected:

(a) General physical examination (b) Rectal examination (c) Pelvic/genital examination (d) Female breast examination (e) Demonstration of procedural skills

4. There will be 2 encounters assigned to each resident. You will be given 15 minutes for each encounter. It is your responsibility to pace your time with the patient. An announcement will be made to tell you when to begin the encounter, when there are 2 minutes remaining and when the time allotted has elapsed. There will be a 5 minute break between the 2 encounters which will allow the SP to complete their checklist.

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5. The examination room will consist of an area modified to simulate a series of examination suites, equipped with tables and gloves. You are expected to bring your own diagnostic instruments that you commonly use during a typical patient encounter in the inpatient/outpatient setting (a stethoscope, penlight and reflex hammer). A goniometer will be provided.

6. Be considerate of the SP and always keep them comfortable and properly draped during the examination.

7. If you complete the encounter in less than the allotted time, you may leave the examination room early but are not permitted to re-enter. Be certain that you have gathered all the pertinent information before leaving the examination room.

FEEDBACK AND EVALUATION

1. Residents will be evaluated by the SP and designated faculty using checklists designed to evaluate clinical competence based on the 6 ACGME Core Competencies which include Medical Knowledge, Patient Care, Interpersonal and Communication Skills, Professionalism, Practice- based Learning and Improvement and Systems-based Practice as applicable.

2. There will be Faculty Attendings that will use the standard Resident Observation & Competency Assessment tool, recommend by the American Board of Physical Medicine and the Association of Academic Physiatrist.

3. The encounters will be videotaped and can only be reviewed by the PD, APD, faculty evaluators and designated simulation staff.

4. Residents will be allowed to view their own videotaped encounters which will give them an opportunity to reflect on their individual performance and encourage Practice-based Learning and Improvement.

5. Individual feedback regarding resident performance will not be given immediately after these encounters. The PD/APD will meet with the residents at a subsequent time to review aggregate results of the OSCE.

6. A gap analysis will be done based on observed resident clinical practice vs. best practice. This will be the basis of modification/implementation of a curriculum focused on any identified aggregate deficiency.

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Competencies addressed • All 6 core competencies

Global Clinical Performance Rating With the uses of electronic house staff administration software, the faculty attending for the rotation will receive an end of rotation evaluation. The resident is evaluated on a standard assessment form, which includes evaluation based on each of the ACGME core competencies. The resident is rated on a scale of 0 to 9. These performance ratings mimic the summary and final evaluation that is used by the American Board of Physical Medicine & Rehabilitation at the end of each year and the end of a resident’s training, respectively.

Sample Global Assessment Evaluation:

Competencies addressed • All 6 core competencies

Focused Evaluation / Observation of Patient Encounter

RO&CA The PM&R Resident Observation and Competency Assessment tool is used at least once on each rotation, with a goal of one monthly.

The PM&R Resident Observation and Competency Assessment (RO&CA)

Description The PM&R Resident Observation and Competency Assessment (RO&CA) Tool was developed by the ABPMR Foundation Program Directors’ Advisory Committee in 2004. A multi-site trial to assess reliability and other psychometric parameters was undertaken by the residency programs at Carolinas Health Care Systems, East Carolina University, Loyola University, Mercy Hospital of Pittsburgh, Northwestern University (RIC), University of Rochester, and University of Washington. Preliminary results from this study were presented at the 2008 AAP meeting.1

A good resident evaluation program utilizes multiple evaluation methods by multiple raters. The evaluation methods should ideally be reliable, valid, feasible, and provide useful information to the program director. The RO&CA provides a way of assessing and giving feedback about resident skills in 5 competencies. Patient care skills include interviewing, physical examination, and procedures. Professionalism skills include obtaining informed consent and demonstrating sensitivity to patient characteristics or patient tolerance of a procedure. Interpersonal and communication skills include listening and counseling. The Systems-Based practice skill assesses the ability to use resources efficiently when developing a diagnostic or therapeutic plan. The practice based learning and improvement skill assesses a specific teaching activity by the resident. With the exception of the

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teaching activity, most observations are expected to be 10-15 minutes long, followed by up to 5 minutes of feedback. Reliability and validity data will be addressed in an upcoming manuscript. The RO&CA is feasible and does not require expensive resources to implement. Comments are typically more specific and goal oriented than the usual end-of-rotation evaluations.

Instructions for use Once per rotation, a resident should ask an attending physician to observe the resident in some aspect of patient care in the inpatient, consult, outpatient, electrodiagnosis, or procedure setting. (Or the resident may have a planned teaching activity which may be evaluated). The resident provides the attending with the RO&CA form. The attending rates the resident real time on a scale of 1 (unsatisfactory) to 4(superior) for any of the skills observed. All areas do not need to be rated, just the ones performed by the resident and observed by the attending. Immediately following the observation, the attending provides verbal and written feedback to the resident and both sign the form. The RO&CA should be returned to the program director and may be reviewed as part of the semi-annual performance evaluation process.

Although the RO&CA is simple to use, some faculty development is necessary to orient them to the process. During a RO&CA evaluation, the faculty should observe without intruding, if possible. When rating the resident, care should be taken to rate only the skills observed in that observation and not add in ratings related to other patient encounters. Some skills may be performed at a superior level while others may require improvement. When a resident performs a procedure, the faculty should also try to observe the resident obtaining informed consent. The form will be more useful to the program director for semi-annual review if written comments are provided. Any score of 1 (unsatisfactory) or 2 (marginal) really should be accompanied by comments.

The RO&CA can certainly be used more often than once per rotation or attending. However, if the program chooses to require a certain number per year, it makes sense to have them spread over the course of the year, so that the resident can be evaluated over time, and by multiple evaluators.

(*1 Massagli TL, Musick D, Sliwa J, Bockenek, Miknevich M, Steiner M, Poduri KR. Reliability of the PM&R resident observation and competency assessment (ROCA) tool. Am J Phys Med Rehabil 2008;87:S4. )

Sample RO&CA

PM&R RESIDENT OBSERVATION & COMPETENCY ASSESSMENT

(RO&CA) Instructions for Evaluator The RO&CA evaluation is a brief (10-20 minute) spot check of resident clinical skills followed by immediate feedback. Directly observe a focused exam, a complete exam, a procedure or other resident-patient encounter, or a formal teaching experience by the resident with students or other health care professionals. Complete the assessment 353 Integrated Competency Based Curriculum 2012-2013

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and give feedback to the resident immediately after the observation. Base your evaluation on only 1 observation, not on a composite of encounters. It is not necessary to observe and rate all these competencies during the evaluation. Use the ratings: NA=not assessed at this observation. 1=unsatisfactory. 2=marginal but satisfactory performance. 3=satisfactory. 4=superior.

Resident Name: PGY1 PGY2 PGY3 PGY4 Date: Patient diagnosis (for this observation): ______NA=not assessed 1=unsatisfactory 2=marginal 3=satisfactory 4=superior Inpatient____ Inpatient Outpatient EMG____ Procedure____ Consult____ Clinic____ PATIENT CARE Interviewing Skills: gathers essential and accurate information that NA 1 2 3 4 identifies impairments/diagnoses and functional impact on patient; efficient. Physical Exam Skills: proficient, thorough, elicits subtle findings; NA 1 2 3 4 sensitive to patient comfort and modesty Complete exam____ Focused exam: check all that apply Neuro exam____ MMT ____ Spine exam____ Upper limb mus/skel ____ Mental Status exam ____ ROM ____ Neck exam____ Lower limb mus/skel ____ ASIA exam (SCI) ____ Mobility/gait ____ Other (specify) ______Procedure Skills: proficient; safe; uses equipment correctly; minimizes patient risk or discomfort NA 1 2 3 4 Procedure observed (e.g. electrodiagnosis, injection): ______

PROFESSIONALISM Informed consent: obtains informed consent including explanation of risks, benefits, and alternate methods of NA 1 2 3 4 treatment prior to procedures Sensitivity: demonstrates sensitivity and responsiveness to patient’s culture, age, gender, disability, and NA 1 2 3 4 tolerance to exam/procedure INTERPERSONAL AND COMMUNICATION SKILLS Listening skills: uses effective listening skills, elicits information using effective questioning and nonverbal NA 1 2 3 4 skills Counseling Skills: counsels and educates patient/family/caregiver; presents rationale for tests or treatment NA 1 2 3 4 clearly and logically and appropriate to patient’s level of understanding; elicits patient confidence and cooperation SYSTEMS-BASED PRACTICE Efficient use of resources: develops cost effective diagnostic or treatment or discharge plan of care, using NA 1 2 3 4 services in the continuum of care; does not compromise quality of care PRACTICE BASED LEARNING AND IMPROVEMENT Teaching skills: facilitates the learning of students and other health care professionals NA 1 2 3 4 Title of resident presentation observed: ______

Strengths or Areas Needing Improvement: For scores of 1 or 2, comments must include areas for remediation. Attending Signature: ______Resident Signature: ______Figure 2 - Sample RO&CA

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Competencies addressed • All 6 core competencies

360-degree Evaluation

A 360-degree Evaluation provides multiple perspectives of resident’s performance and provides the opportunity for residents to improve self-assessment skills. The members of the resident’s team (including nursing, social work, case management, PT, OT, and SLP) may collaborate or individually provide the answers to the questionnaire provided. Specifically, the survey is inquiring as to the professional conduct and communications skills that the residents demonstrated when he/she worked on the rotation noted at the top of the survey. The resident is judged as satisfactory or unsatisfactory in characteristics noted. If the resident is judged unsatisfactory, comments should be provided in the designated space. Also, positive comments should be provided. Unless there is a matter of urgency to address, the resident will receive this feedback/information in an anonymous manner. This evaluation is done semi-annually.

Sample survey - 360o evaluation

GUH/NRH PM&R RESIDENCY TRAINING PROGRAM Team Appraisal of Resident Resident Name: ______PGY: ______Date: ______

Rotation: ______

1.The resident demonstrated effective interpersonal and communication skills with patients and their significant others by creating and sustaining a therapeutic relationship with these individuals. In order to accomplish this goal, the resident used effective listening skills to address the concerns and questions of the patient/significant others and then replied to same in an effective, clear and non judgmental way which the patient/significant other could understand. Also, the resident was noted to be sensitive to both the educational and cultural characteristics of the patient/significant other. [ ] Satisfactory [ ] Unsatisfactory [ ] Not Applicable

Comments______

2.The resident demonstrated effective interpersonal and communication skills with team members by using effective listening skills of their concerns and suggestions and then by replying in an effective, concise, and non judgmental way. Specifically, the resident was noted to actively engage the opinion of team members and respond appropriately to their concerns/interest/questions. [ ] Satisfactory [ ] Unsatisfactory [ ] Not Applicable

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Comments______

3.The resident demonstrated a commitment to ethical principles regarding the provision/withholding of clinical care, confidentiality of patient information, and business practices. [ ] Satisfactory [ ] Unsatisfactory [ ] Not Applicable

Comments ______

4.The resident demonstrated an awareness of and responsiveness to the larger context of healthcare by demonstrating the ability to effectively call upon system resources to provide that which was necessary for the patient. Specifically, the resident attempted to practice effective resource allocation understanding how different systems of medical care affect healthcare cost and the allocation of services to patients. [ ] Satisfactory [ ] Unsatisfactory [ ] Not Applicable

Comments ______

5.The resident demonstrated understanding of how to partner with healthcare managers and/or other providers to access, coordinate, and improve healthcare for the patients. [ ] Satisfactory [ ] Unsatisfactory [ ] Not Applicable Comments______Figure 3 - Sample survey - 360o Evaluation

Competencies addressed • Interpersonal and Communication Skills • Professionalism

Written Exams

Written exams occur under two circumstances. There are scheduled quarterly exams and there are unannounced quizzes.

UNANNOUNCED QUIZZES Unannounced quizzes occur without warning. They are the discretion of the program director, assistant program director, or at the request of the faculty. The quizzes consist of 10 questions and uses the uses the IF-AT tool. See Lecture Techniques in Chapter 4. The quiz typically revolves around a prior reading assignment but may come from a prior didactic lecture as well previously presented.

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Current lectures use other methods of interaction as outlined in Lecture Techniques in Chapter 4.

QUARTERLY EXAMS Quarterly Exams by GUH-NRH Residency Training Program are administered and are custom designed for the rotations that the resident completed during that quarter with standard topics as well. The exam consists of 50 questions and uses the IF-AT tool. See Lecture Techniques in Chapter 4.

Each month will receive 10 questions covering the topic of the rotation, these totals 30 questions for rotations. Ten questions will come from the EMG lecture topics covered during that quarter and an additional 10 question will be on general PM&R topics that are not specific to any particular rotation, but should be common knowledge used in any rotation. Self-Assessment Exam by American Board of Physical Medicine & Rehabilitation

Competencies addressed • Medical Knowledge • System Based Learning • Professionalism

Case Logs

Provides documentation of the breath of clinical and operative experience

May be necessary for future credentialing in some specialties

Competencies addressed • Patient Care

Portfolio

A collection of materials that represents the resident’s efforts, progress and achievements in multiple areas of the curriculum as they progress through their entire educational experience in PM&R training. This portfolio is reviewed with the Program Director in a biannual basis. It helps reflect their progress through the ACGME Core Competencies.

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PORTFOLIO MEDICAL PATIENT INTERPERSONAL PROFESSIONALISM PRACTICE- SYSTEMS- KNOWLEDGE CARE AND BASED BASED ITEMS & COMMUNICATION LEARNING AND PRACTICE Competencies SKILLS IMPROVEMENT ROTATION EVALUATIONS + + + + + + BIANNUAL EVALS + PROCEDURE LOGS + + PRESENTATION LOGS + 360 EVALS + + + + + PEER EVALS + + QUARTERLY EXAMS + ATTENDANCE IN HOSPITAL + COMMITTEES RESEARCH PROJECT + + + RO & CA (The PM&R Resident Observation and + + + + + + Competency Assessment) OSCE (Objective Structured Clinical + + + + + + Examination) QUALITY IMPROVEMENT + + PROJECT/SEMINAR* VOLUNTEER TR ACTIVITIES + + + Table 9 - Portfolio Items & Competencies

Competencies addressed • All 6 core competencies

Curriculum Assessment

The Curriculum Committee reviews, develops and organizes the overall didactic curriculum as recommend by the individual domains and oversees that it is consistent with the ACGME PM&R requirements, program needs and resources. The Committee meets monthly and is composed of the Assistant Program Director (Chair), designated faculty, chief resident/senior resident representative and the Program Director. The Curriculum Committee is advisory to the

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Graduate Medical Education Committee (GMEC) and reports to it on a monthly and as needed basis.

Rotational Assessment After each rotation, the resident is surveyed electronically about the rotation. The individual results are saved until the end of the year, and are then summated by the program director and reported anonymously to the faculty members. Residents are encouraged by an open door policy to discuss immediate issues with the program director without fear of retaliation.

Faculty Assessment After each rotation, the resident is surveyed electronically about the faculty on the rotation. The individual results are saved until the end of the year, and are then summated by the program director and reported anonymously to the faculty member. Residents are encouraged by an open door policy to discuss immediate issues with the program director without fear of retaliation.

Program Assessment The program is assessed through multiple survey tools each conducted separately by the ACGME, MedStar and NRH on an annual basis. The MEDSTAR GUH - MEDSTAR NRH PM&R Residency Training program also assess the program with an Internal Review as defined by the policies of the ACGME/RRC, MedStar and NRH’s House Staff Policies. The NRH also uses anonymous surveys that are exact online replicas of the ACGME Resident annual survey. The program director has an open door policy and encourages residents to discuss issues about the program, faculty and the hospital without fear of retaliation or judgement. Also on a quarterly basis he has an informal group discussion about the program during Program Director & Resident Meeting which takes place weekly before the didact lectures.

Clinical Competency Committee This committee meets for formal scheduled evaluation of residents on a quarterly basis. It includes sponsoring institution faculty of the GMEC, as well as faculty from affiliate association and outside rotations. The committee also meets informally after each GMEC meeting for an ad hoc discussion of residents on any issues that have come to the attention of faculty, program director and information provided to the training program. During the beginning of the New Year the PGY2 residents are informally discussed to elicit any issues that may need the program’s attention.

• Current Committee members are: • GMEC – NRH members • Dr. Kathleen Fink – NRH – Bethesda Rotation Director • Dr. Jay Sha – NIH Rotation Director

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• Dr. Kevin Fitzpatrick – WRAMC – EMG Rotation Director

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Chapter 7 7 Current Outcomes

Contact Information You may contact us by the following:

Phone: (202) 877-1627

US Mail: MEDSTAR GUH - MEDSTAR NRH PM&R Residency Training Program National Rehabilitation Hospital 102 Irving Street, NW Room 2146 Washington, DC 20010

E-mail: [email protected]

Or lastly through the contact page on our web site www.nrhrehab.org.

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ABPM&R – Written Boards

5 YEAR DATA

TOTAL GROUP 2008 2009 2010 2011 2012 SUMMARY % Passed Part I 4 4 3 5 4 20 95.2% Failed Part I 0 0 0 0 1 1 4.8% NRH Pass Rate Part I 100% 100% 100% 100% 80% Nat’l Pass Rate Part I 77% 78% 75% 76% 76% 5 year average = 76.4% FIRST TIME TAKERS Passed Part I 4 4 3 5 4 20 95.2% Failed Part I 0 0 0 0 1 1 4.8% NRH Pass Rate Part I 100% 100% 100% 100% 80% Nat’l Pass Rate Part I 90% 90% 87% 88% 90% 5 year average = 89% REPEAT TIME TAKERS Passed Part I 0 0 0 0 0 0 N/A Failed Part I 0 0 0 0 0 0 N/A NRH Pass Rate Part I N/A N/A N/A N/A N/A Nat’l Pass Rate Part I 32% 31% 28% 33% 27% 5 year average = 29% Table 10 - 5 year Board Scores Part I

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ABPM&R – Oral Boards

5 YEAR DATA

TOTAL GROUP 2009 2010 2010 2011 2012 SUMMARY % Passed Part II 4 4 5 5 3 21 91.7% Failed Part II 2 0 0 0 1 3 8.3% NRH Pass Rate Part II 670% 100% 100% 100% 75% Nat’l Pass Rate Part II 84% 83% 90% 80% 79% 5 year average = 83.2% FIRST TIME TAKERS Passed Part II 4 4 4 4 3 19 90.5% Failed Part II 1 0 0 0 1 2 9.5% NRH Pass Rate Part II 80% 80% 100% 100% 100% Nat’l Pass Rate Part II 89% 87% 95% 86% 84% 5 year average = 88.2% REPEAT TAKERS Passed Part II 0 1 1 0 0 2 66.7% Failed Part II 0 1 0 0 0 1 33.3% NRH Pass Rate Part II N/A 0% 100% N/A N/A Nat’l Pass Rate Part II 54% 57% 67% 33% 55% 5 year average = 53.2% Table 11 - 5 year Board Scores Part II

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Chapter 8 8 Appendix REFERENCES Triple D 2004 (Compiled by Joel A DeLisa, MD, MS) Recommended reading list.- Association of Academic Physiatrist Joel A. DeLisa, MD, MS REFERENCES 1. AAMC: The American with Disabilities Act (ADA) and the Disabled Student in Medical School: Guidelines for Medical Schools. Washington, DC, AAMC, 1993, pp 1-20.

2. AAP: Recommended guidelines for admission of candidates with disabilities to medical school (developed by the Association of Academic Physiatrists). Am J Phys Med Rehabil 1993;72:45-47.

3. Corbet B, Madorsky JG. Physicians with disabilities. Physicians with Disabilities. West Med J. 1991;154:514-521.

4. DeJong G. Primary Care for Persons with Disabilities: An Overview of the Problem. Am J Phys Med Rehabil. 1997;76 (Suppl):S2-S8.

5. DeLisa JA, Walsh N. Are We Overlooking the Needs of the Disabled? Acad. Med 1999;74:853-854.

6. Hartman DW, Hartman CW. Disabled Students and Medical School. Arch. Phys. Med Rehabil. 1981;62:90-91.

7. Helms LB, Helms CM. Medical Education and Disability Discrimination: The Law and Future Implications. Acad Med 1994;69:535-543.

8. Jha A, Patrick DL, Maclehose JN, et al. Dissatisfaction with Medical Services Among Medicare Beneficiaries with Disabilities. Arch Phys Med Rehabil. 2002;83:1335-1339.

9. Iezzoni L.I. The Canary in the Mine. Arch Phys Med Rehabil. 2002;83:1476-1478.

10. Iezzoni L.I. When Walking Fails: Mobility Problems of Adults with Chronic Conditions. Berkeley, University of California Press. 2003.

11. Lawn BB. Experiences of a paraplegic psychiatry resident on an inpatient psychiatric ward. Am J Psychiatry 1989; 146:771-774. 12. Losh DP, Church L. Provisions of the Americans with Disability Act and the Development of Essential Job Functions for Family Practice Residents. Fam Med 364 Integrated Competency Based Curriculum 2012-2013

1999;31:617-621.

13. Meier RH III. Issues Concerning Medical School Admission for Students with Disabilities. Am J Phys Med Rehabil. 1993;72:341-342.

14. National Organization on Disability, “2000 N.O.D./Harris Survey of Americans with Disabilities,” Washington, D.C., 2000.

15. Reichgott MJ. “Without Handicap”:Issues of Medical Schools and Physically Disabled Students. Acad Med. 1996;71:724-729.

16. San Agustin TB, Atchinson J, Gracer B. Healthcare and Deafness: Deaf Professionals Speak Out: A Chapter in Welner’s Guide to the Care of Women with Disabilities. Edited by Florence Haseltine, MD, PhD. Philadelphia, PA. Lippincott Williams and Wilkins Publishers, Pages 31-44, 2004.

17. Steinberg AG, Iezonni LI, Conill A., Stineman M. Reasonable Accommodations for Medical Faculty with Disabilities. JAMA. 2002;288:3147-3154.

18. Stineman MG, Steinberg AG, Iezzoni LI, Conill A. The Promotion of Medical Faculty with Disabilities. AAP Newsletter, Spring 2003; 7-10.

19. Strax TE, Wainapel SF, Welner S. Physicians with Physical Disabilities. AMA. The Handbook of Physician Health. Chapter 3 (pages 17-38).

20. Takakuwa KM, Ernst AA, Weiss SJ. Residents with Disabilities: A National Survey of Directors of Emergency Medical Residency Programs. South Med J 95(4):436-440, 2002.

21. VanMatre RM, Nampiaparampil DE, Curry RH, Kirschner KL. Technical Standards for the Education of Physicians with Physical Disabilities: Perspectives of Medical Students, Residents, and Attending Physicians. Am J Phys Med Rehabil. 2004;83:54-60.

22. Wainapel SF. Physical Disability Among Physicians: An Analysis of 259 Cases. Int. Disabil Studies. 1987;9:138-140.

23. Wainapel SF. The Physically Disabled Physician. JAMA. 1987;257:2935-2938.

24. Weiss L. Compliance by Physical Medicine and rehabilitation Residency Applicants with the American with Disability Act, The Civil Rights Act of 1964, and the Rehabilitation Act of 1973: A Commentary. Am J Phys Med Rehabil 1997;76:433-434.

25. Wu SSH, Tsang P, Wainapel SF. Physical Disability Among American Medical Students. Am J Phys Med Rehabil. 1996;75:183-187. Videotape: Physician with Disabilities: Profiles of Health Science Professionals with Disabilities: Profiles of Health Science Professionals with Disabilities. Oregon Health Science University. 2002. www.healthsciencefaculty.org

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Essential Articles in PM&R Training 1980 – 2003; Baylor College of Medicine - Association of Academic Physiatrist

ESSENTIAL ARTICLES IN PHYSICAL MEDICINE AND REHABILITATION TRAINING: 1980-2003 Compiled by: PM&R Alliance, Baylor College of Medicine/University of Texas-Houston (Gerard E. Francisco, M.D., Amy Bowles, M.D., Viviana Tastard, M.D.) With Contributions From: Eastern Virginia Medical School, Norfolk (Cindy Flick, M.D.) Marianjoy Rehabilitation Hospital and Clinics (Noel Rao, M.D.) Mercy Hospital, Pittsburgh (Mary Ann Miknevich, MD) Mt. Sinai Medical Center, NY (Adam Stein, MD) Nassau University Medical Center, NY (Lynn Weiss, MD) Rehabilitation Institute of Chicago (James Sliwa, D.O.) UMDNJ/New Jersey Medical School (Denise A. Campagnolo, M.D.) University of Washington-Seattle (Teresa Massagli, M.D.) Walter Reed Army Medical Center, D.C. (Paul A. Pasquina, M.D.) University of Michigan-Ann Arbor (Catherine Spires, M.D.) 2 INTRODUCTION When I was a resident in the early 1990’s, I remember being handed a list of the “Classic Journal Articles in PM&R” by one of my attendings. That list served as a great starting point for self-study, supplemented by countless new research articles and book chapters. While I valued---and still do--- those articles, I have always thought that just like many other things, the list needed updating in order to keep the residents abreast of the current literature in physiatry. Many years later, as an attending, I was frequently asked by my residents for advice on what articles to read. Considering that the breadth of clinical practice and literature in PM&R has increased significantly in the last several years, I felt it was a daunting task to provide residents with a comprehensive list of articles that they should be familiar with before completion of training, without overwhelming them. Over the years, I have prepared and constantly updated my own list of articles in my areas of interest: traumatic brain injury, stroke, and spasticity. Many residents were appreciative of the articles (although I doubt that they’ve read each and every one of them), but raised their concern that they were not getting a similar compilation from their other rotations. When I assumed the program directorship of the PM&R Alliance of the Baylor College of Medicine and the University of Texas-Houston, one of the first things that I

366 Integrated Competency Based Curriculum 2012-2013

organized was a “task force” to prepare a list of the “new classic articles in PM&R” in order to meet our residents’ educational needs. However, the job was still daunting, and I realized that it will not be feasible for myself and two of our hard-working residents (Amy Bowles and Viviana Tastard) to complete the task. Thus, our group decided to collaborate and share the final list with other residency programs. In the process, we opted to change the compilation’s name to “Essential Articles” (less controversial than “new classics”) but kept the same intent and criteria: 1. “Essential Articles” are defined as those articles that a PM&R resident should have read or at least be familiar with by completion of training; 2. Only articles from 1980 to the present will be included, in order to make the list manageable; 3. Original research and review articles will be considered; 4. Book chapters and the AAEM mini-monographs (we felt that each and every one of these is a “must read”) will not be included; The list is not officially endorsed by any PM&R organization. Rather, it is a compilation of article titles that a handful of PM&R residency program directors consider as “essential” to resident training. I am indebted to those program directors who shared their own lists and assisted in assembling the final compilation: Terry Massagli, Jim Sliwa, Paul Pasquina, Denise Campagnolo, Mary Ann Miknevich, Lynn Weiss, Adam Stein, Noel Rao, Catherine Spires, and Cindy Flick; our former residents, Amy Bowles and Viviana Tastard for helping start-up the project; my secretary, Danielle Hawkins, for preparing the draft; Kwai Chan, my associate program director; and my two chairmen, Marty Grabois and Bill Donovan for their generous support and encouragement. Gerard E. Francisco, M.D. Residency Program Director Education Office PM&R Alliance, Baylor College of Medicine and 1333 Moursund Avenue University of Texas Health Sciences Center Houston, TX 77030 3 TABLE OF CONTENTS Page Cardiac Rehabilitation 4 Pulmonary Rehabilitation 5 Musculoskeletal/Low Back Pain 6 Pain, other than low back pain 8 Bone, Joint, and Connective Tissue Disorders 10 Prosthetics, Orthotics, Assistive Devices, Gait 11 Traumatic Brain Injury 14 Spinal Cord Medicine 17 Stroke 20 Pediatric Rehabilitation 22 367 Integrated Competency Based Curriculum 2012-2013

Neuromuscular and Motor Neuron Disorders; Neuropathies 25 Electrodiagnosis 27 Occupational/Industrial Medicine 29 Cancer Rehabilitation 31 Other Rehabilitation Topics 32 4 CARDIAC REHABILITATION Cardiac precautions for non-acute inpatient settings. Fletcher BJ, Dunbar S, Coleman J, Jann B, Fletcher GF. Am J Phys Med Rehabil1993; 72:140-3 Hospital-based cardiac rehabilitation. Flores AM. Phys Med Rehabil Clin N Amer 1995;6(2):243-261 Exercise testing & prescription. Myers JN, Froelicher VF. Phys Med Rehabil Clin N Amer 1995;6(2):117-151 Cardiac rehabilitation in the lower-extremity amputee. Gitter A. Halar EM. Phys med Rehabilitation Clin North Am 1995;6(2):311-330. Cardiac rehabilitation of the patient with stroke. Gitter A. Halar EM. Phys med Rehabilitation Clin North Am 1995;6(2):297-310. Rehabilitation after cardiac transplantation: case series and literature review. Joshi A, Kevorkian CG. Am J Phys Med Rehabil 1997; 76:249-254. 5 PULMONARY REHABILITATION Update and perspectives on noninvasive respiratory muscle aids: Bach JR. part 1-- the inspiratory muscle aids. Chest 1994;105:1230-1240. Update and perspectives on noninvasive respiratory muscle aids: Bach JR. part 2-- the expiratory muscle aids. Chest 1994;105:1538-1544. Effects of Pulmonary Rehabilitation of COPD. Annals Int Med Bach JR. Phys Med Rehabil Clin North Am 1996; 7: 423-43. Pulmonary rehabilitation in the acute inpatient rehabilitation hospital. Glassman SJ. Respiratory Care Clin North Am 1998; 4: 47-57 Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Bach JR, Alba AS. Chest 1993:74-82 6 MUSCULOSKELETAL/ LOW BACK PAIN Non-organic physical signs in low back pain. Waddell G, McCulloch JA, Kummel E, Venner RM. Spine 1980; 5:117-125. Behavioral responses to examination: a reappraisal of the interpretation of “nonorganic signs”. Main CJ, Waddell G. Spine 1998; 23: 2367-2371 Disc pressure measurements. Nachemson AL. Spine. 1981;6(1):93-7. What can the history and physical examination tell us about low back pain? Deyo 368 Integrated Competency Based Curriculum 2012-2013

RA, et al.. JAMA 1992; 268: 760-5. How effective are exercise and physical therapy for chronic low back pain? Carter IR; Lord JL. J Fam Pract 2002:51(3):209 Lumbar fusion versus nonsurgical treatment for chronic low back pain. FritzellP; Hagg O: Spine 2001 Dec 1; 29(23): 2521-32 (VOLVO award winner) Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. Carlsson CP; Sjolund BH: Clin J Pain 2001; 17(4) 296-305 Evaluation and treatment of low back pain: an evidence-based approach to clinical care. Atlas SJ, Nardin RA.Muscle Nerve. 2003; 27(3): 265-84. The Natural History of Lumbar Intervertebral Disc Extrusions. Saal JA, Saal JS. .Spine. 1990; 15(7): 683-6. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Saul JS, Transon RC, Dobrow R, et. Al. Spine 1990; 15:674-678. Magnetic resonance imaging of the lumbar spine in people without back pain. Jensen MC. Brant-Zawadzki MN. Obuchowski N, et al. N Engl J Med. 1994; 31(2): 69- 73 The treatment of low back pain: bed rest, exercises, or ordinary activity? Malmivarra, A . N Engl J Med 1995; 322:351-5. What can the history and physical examination tell us about low back pain? Deyo RA. Rainville J. Kent DL. JAMA 1992; 268(6): 760-5 Drug therapy for back pain: which drugs help which patients? Deyo RA. Spine 1996; 21(24): 2840-9; discussion 2849-50 How many days of bed rest for acute low back pain? Deyo RA, et al. N Engl J Med 1996;315:1064-1070 7 Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Saal JA and Saal JS. Spine 1989; 14: 431-437 A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. Deyo RA, Walsh NE, et al. N Eng J Med 1990; 322: 1627-34. The sacroiliac joint in chronic low back pain. Schwarzer AC, April CN, et al. Spine 1995; 20: 31-7. Acute low back pain problems in adults. US Department of Health and Human Services. Agency for Health Care Policy and Research. Clinical practice guideline, No 14, AHCPR publication. No 95-0643, 1994. 8 PAIN (OTHER THAN LOW BACK PAIN) Neurosurgical procedures for chronic pain: general neurosurgical practice. North RB. Clin Neurosurg 1993; 40: 182-96. Radiofrequency lumbar facet denervation: analysis of prognostic factors. North RB, Han M, et al. Pain 1994; 57: 77-83. 369 Integrated Competency Based Curriculum 2012-2013

Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. Lord SM, Barnsley L, et al. N Engl J Med 1996; 335: 1721-6. Efficacy of first-time steroid injection for painful heel syndrome. Miller RA, Torres J, et al. Foot Ankle Int 1995; 16: 610-2. Mechanisms of causalgia and related clinical conditions. Schott GD. Brain 109: 717-738, 1986 Pathophysiologic and electrophysiologic mechanisms of myofasical trigger points. Arch Phys Med Rehabil. 1998 Jul; 79(7): 863-72. (complete) Lidocaine injection versus dry needling to myofascial trigger point: the importance of the local twitch response. Hong CZ. Am J Phys Med Rehabil 1994; 73(4): 256-63. Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison. Hong CZ, Kuan TS, Chen JT, Chan SM. Arch Phys Med Rehabil. 1997; 78(9): 957-60. Lack of analgesic effects of opioids on neuropathic and idiopathic forms of pain. Arner S et al. Pain 33 (1988): 11-23. Are opioids effective in relieving neuropathic pain? Dellemijn P. Pain 1999; 80:453- 62. Integrating medical and behavioral treatment in chronic pain management. Gallagher RM et al. Med Clin N Amer 1999; 83(5): 555-585. Long term intraspinal drug therapy: A review. Wallace MS et al. Reg Anesth and Pain Med 2000; 25:117-157. Prognostic factors of spinal cord stimulation for chronic back and leg pain. Burchiel K. Neurosurgery 1995; 36:1101-1111. Origin of nerves supplying the posterior portion of the lumbar intervertebral discs. Nakamura S et al. Spine 1996; 21:917-24. 9 The tissue origin of low back pain and sciatica. Kuslich SD et al. Orthop Clin North Am 1991; 22:181-87. Is acupuncture effective for the treatment of chronic pain? A systematic review. Ezzo J et al. Pain 86 (2000): 217-25. Evidence for and against the use of opioid analgesics for chronic nonmalignant low back pain: A Review. Bartleson JD. Pain Medicine 2002; 3(3): 260-71. The effect of antidepressant treatment on chronic back pain. Salerno SM et al. Arch Int Med 2002;162:19-24. Grading the severity of chronic pain. Von Korff M et al. Pain 1992; 50:133-49. Internal J Pain Med Pall Care. Nurmikko TJ. Trigeminal Neuralgia. 2003; 3(1): 2-11. Anticonvulsants in neuropathic pain: Rationale and clinical evidence Jensen TS. Europ J Pain. 2002; 6(SupplA): 61-68. Enhanced temporal summation of second pain and its central modulation in fibromyalgia patients. Price DD et al. Pain 2002; 99: 49-59 Complex regional pain syndromes: Sympathetic vasoconstrictor activity enhances 370 Integrated Competency Based Curriculum 2012-2013

pain and hyperalgesia. Baron BR, et al. Lancet 2002; 359: 1655-1660. National Institutes of Health Workshop: Reflex sympathetic dystrophy/ Complex regional pain syndromes: State of the science. Baron BR et al. Anesth Analg. 2002; 95: 1812-6. Complex regional pain syndrome is a disease of the central nervous system. Baron, et al. Clin Auton Res. 2002; 12: 150-64. Spinal cord stimulation for complex regional pain syndrome (RSD): a retrospective multicenter experience from 1995 to 1998 of 101 patients. Bennett DS, et al. Neuromodulation 1999; 2(3): 202 10 BONE/JOINT/CONNECTIVE TISSUE DISEASES Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. Hochberg MC, Altman RD, et al. Arthritis Rheum 1995; 38: 1541-6. Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. Hochberg MC, Altman RD, et al. Arthritis Rheum 1995; 38: 1535--40. A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty. McInnes J, Larson MG, Daltroy LH, et al.. JAMA. 1992; 268(11): 1423-8. Guidelines for the management of rheumatoid arthritis: 2002 update. American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002; 46(2): 328-346 Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. Lieberman U. N Engl J Med 1995; 333:1437-43. 11 PROSTHETICS, ORTHOTICS, ASSISTIVE DEVICES, GAIT Upper limb amputee rehab. Meier RH. Phys Med Rehabil: State of the art reviews. 1994; 8(1): 165-85. Upper limb powered components and controls: current concepts. Michael JW. Clin Prosthet Orthot 1986; 10(2): 66-77. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses Stein,R. Arch Phys Med Rehabil. 1983; 64(6): 243-8 Prosthetic usage in major upper extremity amputations. Wright.J Hand Surg [Am]. 1995; 20(4): 619-22. Upper limb powered components and controls: current concepts. Michael JW. Clin Prosth Orthotics 1986;10:66-77 The biomechanics of canes, crutches, and walkers. Deathe AB, Hayes KC, Winter DA: Crit Rev Phys Rehabil Med 1993; 5(1): 15-29 Canes, crutches and walkers. Joyce BM, Kirby RL. Am Fam Physician. 1991; 43:535- 42. Energy cost of ambulation with crutches. Fisher,S. Arch Phys Med Rehabil. 1981; 62(6): 250-6. Ambulation levels of bilateral lower extremity amputees. Volpecelli, L. J Bone Joint 371 Integrated Competency Based Curriculum 2012-2013

Surg Am. 1983; 65(5): 599-605. Gait problems in diabetic neuropathic patients. Courtemanche R, Teasdale N. et al. Arch Phys Med Rehabil 1996; 77:849-55. External spinal orthotics. Sypert GW. Neurosurg. 1987; 20(4): 642-9. Analysis of prosthetic gait. Esquanazi A. Phys Med Rehabil State Art Rev 1994; 8: 201-20. Silicone soft socket system: its effect on the rehabilitation of geriatric patients with above knee amputations. Trieb, K Arch Phys Med Rehabil 1999; 80(5): 522-5. Transfemoral amputation: biomechanics and surgery. Gottschalk F. Clin Orthop 1999; 361:15-22. Current transfemoral sockets. Schuch CM, Pritham CH Clin Orthop 1999;361: 48-54. Modern prosthetic knee mechanisms. Michael JW. Clin Orthop 1999;361:39-47. 12 Lower limb prosthetic sockets. Leonard JA Jr. Phys Med Rehabil: State of the art reviews 1994; 8(1): 129-45 Suspension systems for prostheses. Kapp S. Clin Orthop 1999;361:55-62. Prosthetic feet: a scientific and clinical review of current components. Czerniecki JM, Gitter A. Phys Med Rehabil 1994;8(1):109-128 Rehabilitation in limb deficiency. 2. The pediatric amputee. Jain S. Arch Phys Med Rehabil 1996; 77: S9-13. Prosthetic management of children with limb deficiencies. Krebs DE, et al. Phys Ther 1991; 71: 920-34. Geriatric amputee. Friedman LW. PM&R State of the Art Reviews 1994; 8(1): 187- 192 Rehabilitation of the elderly amputee. Clark GS, Blue B. J Am Geriatr Soc 1983; 67- 76. Geriatric amputee rehabilitation. Esquenazi A. Clin Geriatr Med 1993; 9 (4): 731-43. Rehabilitation after amputation. Esquenazi A, DiGiacomo R. J Am Podiatr Med Assoc. 2001;91(1):13-22. The pathogenesis of diabetic foot problems: an overview. Shaw JE, Boulton AJM. Diabetes 1997; 46 Suppl 2: S58-61. Assessment and management of foot disease in patients with diabetes. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. New Engl J Med 1994; 331:854-60. Consensus development conference on diabetic foot wound care: 7-8 April 1999, Boston, Massachusetts. American Diabetes Association. Diabetes Care 1999:22; 1354- 60. Total contact casting in diabetic patients with neuropathic foot ulcerations. Helm PA, Walker SC, Pullium G. Arch Phys Med Rehabil 1984; 65: 691-3. Pharmacologic management of peripheral vascular disease. McNamara DB, Champioon HC, Kadowitz PJ. Surg Clin North Am 1998;78:447-64. Phantom limb sensation and phantom pain. Kamen LB, Chapis GJ. Phys Med 372 Integrated Competency Based Curriculum 2012-2013

Rehabil: State of the Art Rev. 1994; 8(1): 73-88. 13 TRAUMATIC BRAIN INJURY Head trauma as a risk factor for Alzheimer’s disease: a collaborative re-analysis of case-control studies Mortimer JA, Van Duijn CM, et al. Int J Epidemiol 1991; 20 (suppl 2): S28-35. Apopipoprotein E e4 associated with chronic traumatic brain injury in boxing. Jordan B, Relkin NR, Ravdin LD, et al. JAMA 1997;278:136-140 Neuroimaging in patients with traumatic brain injury. Newberg AB, et al. J Head Trauma Rehabil 1996; 11(6): 65-79. The effectiveness of traumatic brain injury rehabilitation: a review. Cope DN. Brain Inj 1995; 9: 649-70. Mild traumatic brain Injury: pathophysiology, natural history, and clinical management. Alexander MP: Neurol 1995; 45:1253-1260. A randomized, double-blind study of phenytoin for the prevention of posttraumatic seizures. Temkin NR, et al. N Engl J Med. 1990 23;323(8):497-502. Posttraumatic Seizures. Yablon SA. Arch Phys Med Rehabil 1993;74(9):983-1001. Recommendations for use of uniform nomenclature pertinent to patients with severe alterations in consciousness. Position paper. Arch Phys Med Rehabil 1995; 76:205-9. Medical aspects of the persistent vegetative state (1). The Multi-Society Task Force on PVS. N Engl J Med. 1994;330(21):1499-508. Medical aspects of the persistent vegetative state (2). The Multi-Society Task Force on PVS. N Engl J Med. 1994;330(22):1572-9. Subacute methylphenidate treatment for moderate to moderately severe traumatic brain injury: a preliminary double-blind placebo-controlled study. Plenger PM, et al Arch Phys Med Rehabil 1996; 77(6):536-40. Pharmacological treatment of arousal and cognitive deficits.Wroblewski BA, et al. J Head Trauma Rehabil 1994; 91 (3): 19-42. The Brain Trauma Foundation: the American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Guidelines for the management of severe head injury. J Neurotrauma. 2000;17(6-7):471-595. Diffuse axonal injury-associated traumatic brain injury: current concepts. Meythaler JM, et al. Arch Phys Med Rehabil. 2001;82(10):1461-71 14 Axonal response to traumatic brain injury: reactive axonal change, deafferentation, and neuroplasticity. Povlishock JT, et al. J Neurotrauma 1992; ( Suppl 1): S 189-200. Posttraumatic Hydrocephalus. Beyerl B, Black PM: Neurosurgery, 1984; 15: 257- 261. 373 Integrated Competency Based Curriculum 2012-2013

Agitation following traumatic head injury: equivocal evidence for a discrete stage of cognitive recovery.Corrigan JD, and Mysiw WJ. Arch Phys Med Rehabil. 1988;69(7):487-92. The agitated brain injured patient. Part I: definitions, differential diagnosis, and assessment Saundel ME, et al. Arch Phys Med Rehabil 1996; 77: 617-23. The agitated brain injury patient. Part II. Pathophysiology and treatment. Mysiw WJ, et al. Arch Phys Med Rehabil 1997; 78: 213-20. Agitation and restlessness after closed head injury: a prospective study of 100 consecutive admissions. Brooke MM, Questad KA, Patterson DR, Bashak KJ. Arch Phys Med Rehabil. 1992;73(4):320-3. Behavioral sequelae of closed head injury: a quantitative study. Levin HS, Grossman RG. Arch Neurol 1978;35:720-727 Cognitive remediation in TBI: update and issues. Ben-Yishay Y, Diller L. Arch Phys Med Rehabil 1993; 74: 204-13. Employment following traumatic head injuries. Dikmen SS, et al. Arch Neurol 1994; 51: 177-86. Neurobehavioral sequelae of severe pediatric traumatic brain injury: a cohort study Massagli, T, Jaffe KM, Fay GC, et al. Arch of Phys Med Rehabil. 1996 Mar;77(3):223- 31. Medical and surgical complications of pediatric brain injury McLean DE, Keitz ES, Keenan CJ, et al. J Head Trauma Rehabil 1995;10(5):1-12 Recovery trends over three years following pediatric traumatic brain injury. Jaffe KM, Polissar NL, et al. Arch Phys Med Rehabil 1995; 76: 17-26. Predictor of family functioning and change 3 years after traumatic brain injury in children. Rivara JB, et al. Arch Phys Med Rehabil 1996; 77: 754-64. Concussion Grading Systems And Return-To-Play Guidelines: A Comparison. Cantu,RC The Physician and Sports Medicine 14:75-76, 79, 83, 1986 15 Intervention with environmental enrichment after experimental brain trauma enhances cognitive recovery in male but not female rats. Wagner AK, Kline AE, Sokoloski J, et al. Neurosci Lett (Ireland), 2002;334(3):165-168 Second Impact Syndrome. McCrory PR and Berkovic SF. Neurology 50:677-683, 1998. Traumatic brain injury. Predicting course of recovery and outcome for patients admitted to rehabilitation. Katz DI, Alexander MP. Arch Neurol. 1994;51(7):661-70. 16 SPINAL CORD MEDICINE A randomized controlled trial of methylprednisolone or naloxone in the 374 Integrated Competency Based Curriculum 2012-2013

treatment of acute spinal cord injury, Bracken M, et al. N Engl J Med. 1990 May 17;322(20):1405-11. Administration of methylprednisolone for 24 or 48 hours or tirilizad mesylate for 48 hours in the treatment of acute spinal cord injury, Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. Bracken, et al. JAMA. 1997 May 28;277(20):1597-604. ( Methylprednisolone or tirilazad mesylate administration after acute spinal cord injury: 1-year follow up. Results of the third National Acute Spinal Cord Injury randomized controlled trial. Bracken MB, J Neurosurg. 1998 Nov;89(5):699-706 Methylprednisolone or naloxone treatment after acute SCI: 1 year-follow up data Bracken MB, et al. J Neurosurgery 1992; 76: 23-31. Bacteriuria with fever after spinal cord injury. Cardenas DD, Mayo ME. Arch Phys Med Rehabil 1987;68: 291-3 Classification of chronic pain associated with spinal cord injuries. Cardenas DD, Turner JA, Warms CA, Marshall HM. Arch Phys Med Rehabil 2002;83:1708-1714. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Denis F. Spine. 1983 Nov-Dec;8(8):817-31. Functional hand surgery following tetraplegia. Waters R, et al. Arch Phys Med Rehabil. 1996 Jan;77(1):86-94. (complete) Aerobic training effects of electrically induced lower extremity exercises in spinal cord injured people. Pollack S, et al. Arch Phys Med Rehabil. 1989 Mar; 70(3): 214-219. (complete) Prevention of Thromboembolism after Spinal Cord Injury Using Low Molecular Weight Heparin, Green D, et al. Ann Int Med. Vol 113 No 8 1990. Physiologic parameters associated with sexual arousal in women with incomplete SCI. Sipski ML, Alexander CJ, Rosen RC. Arch Phys Med Rehabil 1997;78:305-13. Physiological parameters associated with psychogenic sexual arousal in women with complete SCI. Sipski ML, Alexander CJ, Rosen RC. Arch Phys Med Rehabil 1995;76:811-8 17 Ischemic myelopathy: a review of spinal vasculature and related clinical syndromes. Sliwa JA, Maclean IC. Arch Phys Med Rehabil 1992;73:365-72. Cognitive deficits in spinal cord injury: epidemiology and outcome. Davidoff GN, Roth EJ, Richards S: Arch Phys Med Rehabil, March 1992; 73:275-284. Benefits of rehabilitation for traumatic spinal cord injury. Yarkony GM, Roth EJ, Heinemann AW, et al. Arch Neurol 1987; 44: 93-96. Functional neuromuscular stimulation for standing after spinal cord injury. Yarkony GM, Jaeger RJ, Roth EJ, Kralj AR, Quintern J: Arch Phys Med Rehabil. 1990; 71: 201-206. 375 Integrated Competency Based Curriculum 2012-2013

Functional skills after spinal cord injury rehabilitation: three-year longitudinal follow-up. Yarkony GM, Roth EJ, Heinemann AW, Lovell L, Wu Y: Arch Phys Med Rehabil, 1988; 69: 111-114. Rehabilitation technology for standing and walking after spinal cord injury. Jaeger RJ, Yarkony GM, Roth EJ: Am J Physical Med Rehabil 1989;68: 128-133. Traumatic central cord syndrome: clinical features and functional outcomes.Roth EJ, Lawler MH, Yarkony GM: Arch Phys Med Rehabil 1990; 71: 18-23. Ventilatory function in cervical and high thoracic spinal cord injury. Roth EJ, Lu A, Primack S, et al: Am J Phys Med Rehabil 1997; 76: 262-267. The halo skeletal fixator: current concepts of application and maintenance. Botte,MJ Orthopedics 1995; 18:5: 463 –471 Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury.Teasell RW. Arnold JM. Krassioukov A. Delaney GA. Arch Phys Med Rehabil 2000;81(4): 506-16 The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators. Peterson WP, Barbalata L, Brooks CA, et al. Spinal Cord 1999;37(4):284-8 Motor and sensory recovery following incomplete tetraplegia.Waters RL, et al. Arch Phys Med Rehabil 1994; 75: 306-11 Autonomic hyperreflexia with spinal cord injury: a review. Colachis SC III. J Am Paraplegia Soc 1992; 15: 171-86. Intrathecal baclofen for severe spinal spasticity. Penn RD, et al. N Engl J Med. 1989;320(23):1517-21. 18 Neuromuscular stimulation in spinal cord injury: I. restoration of functional movement of the extremities. Yarkony GM, et al. Arch Phys Med Rehabil 1992; 73: 78-86. 19 STROKE Medical complications encountered in stroke rehabilitation. Roth EJ: Phys Med Rehabil Clin North Am 1991;2(3):563-78 Does the application of constraint-induced movement therapy during acute rehabilition reduce arm impairment after ischemic stroke? Dromerick AW. Stroke 2000;31(12):2984-8 Impact of motor, cognitive, and perceptual disorders on ability to perform activities of daily living after stroke Mercier L, Audet T, Hebert R, et al. Stroke 2001;32:2602-2608 Brain plasticity and stroke rehabilitation. Johansson BB. Stroke 2000;31:223-230 A model for stroke patient management during the acute phase: outcome and economic implications. Odderson IR, McKenna BS. Stroke 1993;24:1823-1827 Intracranial aneurysms. Schievink WI. N Engl J Med 1997;226:28-40 Cerebral aneurysms and arteriovenous malformations: implications for rehabilitation. Clinchot DM, et al. Arch Phys Med Rehabil 1994; 75: 1342-51. 376 Integrated Competency Based Curriculum 2012-2013

Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Nudo RJ, Wise, BM, et al. Science 1996;272:1791-1794 Heart disease in patients with stroke: incidence, impact, and implications for rehabilitation part 1: classification and prevalence. Roth EJ: Arch Phys Med Rehabil 1993; 74:752-760. Heart disease in patients with stroke. Part II: impact and implications for rehabilitation. Roth EJ: Arch Phys Med Rehabil, January 1994; 75:94-101. Incidence of and risk factors for medical complications during stroke rehabilitation. Roth EJ, Lovell L, Harvey RL, Heinemann AW, Semik P, Diaz S. Stroke. 2001; 32:523- 529. Treatment efficacy for adults with oropharyngeal dysphagia. Miller J.Arch Phys Med Rehabil. 1994;75(11):1256-62 Factors predictive of stroke outcome in rehabilitation setting. Ween,J. Neurology 1996;47(2):388-92. Treatment-induced cortical reorganization after stroke in humans. Liepert J, et al. Stroke. 2000;31(6):1210-6. 20 Blood pressure in acute stroke: the Copenhagen stroke study. Jorgensen HS, et al. Cerebrovasc Dis. 2002;13(3):204-9. Prediction of walking function in stroke patients with initial lower extremity paralysis: the Copenhagen stroke study. Wandel A, et al. Arch Phys Med Rehabil. 2000;881(6):736-8. Neurologic and functional recovery: the Copenhagen stroke study. Jorgensen HS, et al. Phys Med Rehabil Clin N Am. 1999;10(4):887-906. What determines good recovery in patients with the most severe strokes?: the Copenhagen stroke study. Jorgensen HS, et al. Stroke 1999;30(10):2008-12. Stroke Recurrence: predictors, severity, and prognosis: the Copenhagen stroke study. Jorgensen HS, et al. Neurol 1997;48(4):891-5. Recovery of walking function in stroke patients: the Copenhagen stroke study. Jorgensen HS, et al. Arch Phys Med Rehabil. 1995;76(1):27-32. Recovery of upper extremity function in stroke patients: the Copenhagen stroke study. Nakayama H, et al. Arch Phys Med Rehabil. 1994;75(4):394-8. The influence of age on stroke outcome: the Copenhagen stroke study. Nakayama H, et al. Stroke. 1994;25(4):808-13. Intrathecal baclofen for spastic hypertonia from stroke. Meythaler JM. Stroke. 2001;32(9):2099-109. Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized, double-blind, placebo-controlled trial. Simpson DM et al Neurology. 1996;46(5):1306-10. 21 377 Integrated Competency Based Curriculum 2012-2013

PEDIATRIC REHABILITATION Cerbral palsy. Kuban, KCK, Leviton, A. New Eng J Med. 1994, 330:188-195 Prognosis for gross motor function in cerebral palsy. Rosenbaum PL, Walter SD, Hanna SE, Palisano RJ, Russell DJ, Raina P, Wood E, Bartlett DJ, Galuppi BE: JAMA 2002; 288:1357-1363. Classification and definition of disorders causing hypertonia in childhood. Sanger TD, Delgado M, et.al. Pediatrics. 2003,111:389-397. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. McLaughlin J, Bjornson K, Temkin N, et al. Dev. Med. Child Neurol. 2002; 44:17-25. A long-term follow-up study: selective posterior rhizotomy. Arens LJ, Peacock WJ, Peter J: Childs Nerv Syst. 1989; 5: 148-152. Effects of selective dorsal rhizotomy on gait in children with cerebral palsy. Boscarino LF, Ounpuu S, Davis RB III, et al: J Pediatr Orthop 1993; 13: 174-179. Selective posterior lumbosacral rhizotomy in teenagers and young adults with spastic cerebral palsy. Peter JC, Arens LJ: Br J Neurosurg. 1994;8:135-139. Cerebral palsy and rhizotomy: a three-year follow-up evaluation with gait analysis. Vaughan CL, Berman B, Peacock WJ: J Neurosurg 1991; 74:178-184. Continuous intrathecal baclofen infusion for spasticity of cerebral origin. Albright AL, Barron WB, Fasick MP, et al; JAMA 1993; 270: 2475-2477. Management of the lower extremities in children who have cerebral palsy. Bleck EE: J Bone Joint Surg 1990; 72A:140-144. Cerebral palsy orthopedic management. Renshaw TS, Green NE, Griffin PP, et al: J Bone Joint Surg, 1995;77A: 1590-1606. Walking prognosis in cerebral palsy: A 22-year retrospective analysis. Campos da Paz A, Burnett SM, Braga LW: Dev. Med. Child Neurol. 1994; 36: 130-134. Traumatic brain injury in children. Michaud LJ, Duhaime AC, Batshaw ML. Pediatr Clin North Am. 1993;40(3):553-65. Developmental perspective for the rehabilitation of children with physical disability. Molnar GE. Pediatr Ann 1988; 17: 766-76. Motorized wheelchair driving by disabled children. Buttler C, Okamoto GA, et al. Arch Phys Med Rehabil 1984; 65: 95-7. 22 Prevalence of reduced bone mass in children and adults with spastic quadriplegia. King W, Levin R, Schmidt R, et al. Dev. Med. Child Neurol. 2003; 45:12-16. Evaluation and management: obstetric brachial plexus injuries: Waters PM: J Amer Acad Orthop. 1997; 5: 205-214. Use of the green transfer in treatment of patients With spastic cerebral palsy: 17- year experience. Beach WR, Strecker WB, Coe J, et al: J Pediatr Orthop 1991; 11: 731- 736. Surgical reconstruction of the upper extremity in cerebral palsy. Goldner JL: Hand Clin 1988; 4: 223-265. 378 Integrated Competency Based Curriculum 2012-2013

Arthrodesis of the metacarpophalangeal joint of the thumb in children and adults. Goldner JL, Koman LA, Gelberman R, et al: Adjunctive Treatment of Thumb-in-Palm Deformity in Cerebral Palsy. Clin Orthop 1990; 253: 75-89. Long-term follow-up on tendon transfers to the extensors of the wrist and fingers in patients with cerebral palsy. Hoffer MM, Lehman M, Mitani M: Hand Surg 1986; 11A:836-840. Wrist fusion in cerebral palsy. Hoffer MN, Zeitzew S: J Hand Surg. 1988; 13A:667- 670. Comparison of pronator tenotomy and pronator rerouting in children with spastic cerebral palsy. Strecker WB, Emanuel JP, Dailey L, et al: J Hand Surg 1988; 13A: 540- 543. Long-term follow-up of the flexor carpi ulnaris transfer in spastic hemiplegic children. Thometz JG, Tachdjian M: J Pediatr Orthop 1988; 8:407-412. Combined split anterior tibial tendon transfer and intramuscular lengthening of the posterior tibial tendon: results in patients who have a varus deformity of the foot due to spastic cerebral palsy. Barnes MJ, Herring JA: J Bone Joint Surg 1991; 73A:734-738. Birth brachial plexus palsy. Nelson MR. Phys Med Rehabil State Of The Art Rev 2000; 14: 237-246. The life expectancy of persons with cerebral palsy. Crichton JU, Machinnon M, White CP: Dev Med and Child Neurology 1995; 37: 567-576. Obstetrical brachial plexus palsy (OBPP) outcome with conservative management. Eng, GD, et al. Muscle and Nerve 19:884-891, 1996. 23 Forced use treatment of childhood hemiparesis. Willis JK, Morello A, et al. Pediatrics 2002; 110:94-96. Brachial plexus birth injuries and current management. Shenaq SM, Berzin E, et al. Clinics in Plastic Surgery, 1998;25(4):527-536. Prognosis for ambulation in cerebral palsy. Sala DA, Grant AD. Dev Med Child Neurol, 1995;37:1020-1026. Prognosis for gross motor function in cerebral palsy: creation of motor development curves. Rosenbaum PL, et al. JAMA 2002;288(11):1357-1363. Non-accidental head injury in infants – the “shaken-baby syndrome”. Duhaime AC, et al. NEJM: 1998,;338(25):822-1829. 24 NEUROMUSCULAR AND MOTOR NEURON DISORDERS 379 Integrated Competency Based Curriculum 2012-2013

AND NEUROPATHIES The treatment of scoliosis in Duchenne muscular dystrophy. Rideau and Bach JR. Muscle Nerve. 1984;7(4):281-6. Neuromuscular disease: rehabilitation and electrodiagnosis. 3. Muscle disease. Hays RM, Kowalske KJ. Arch Phys Med Rehabil. 1995 May;76(5 Spec No):S21-5 Management of musculoskeletal complications in neuromuscular disease. Vignos PJ. Phys Med Rehab: State of The Art Reviews 1988;2:509-536 Rehabilitation of infants and children with neuromuscular disorders. Eng G, Binder H. Pediatr Ann. 1988;17(12):745, 748, 750-2 Respiratory dysfunction in muscular dystrophy and other myopathies. Lynn DJ, Woda RP, Mendell JR. Clin Chest Med 1994;15: 661-74. Critical illness myopathy and neuropathy. Latronico N, Fenzi F, Recupero D, et al. Lancet 1996; 347:1579-82 Gene therapy for muscle diseases. Coovert DD, Burghes AH. Curr Opin Neurol 1994; 7: 463-70. End of life care in Duchenne muscular dystrophy. Hilton T, Orr RD, Perkin RM, Ashwal S. Pediatr Neurol 1993;9:165-77. Clinical features and response to treatment in 67 consecutive patients with and without a monoclonal gammopathy. Chronic inflammatory demyelinating polyneuropathy: Gorson KC, Allan G, Ropper AH. Neurol 48; 321-331, 1997. The Guillain-Barre syndrome: a review Ropper, A. N Engl J Med. 1992;326(17):1130-6. Rehabilitation of Guillain-Barre syndrome. Meythaler JM, Arch Phys Med Rehabil. 1997;78(8):872-9. Neuromuscular disorders in systemic malignacies. Stubgen. Curr Opin Neurol. 1997;10(5):371-5. Neuromuscular disorders in systemic malignancy and its treatment. Stubgen. Muscle Nerve. 1995;18(6):636-48. 25 Evaluation and rehabilitation of adult motor neuron disease. Francis K, Bach J. Arch Phys Med Rehabil. 1999;80(8):951-63. Comprehensive management of amyotrophic lateral sclerosis. Carter GT, Miller RG. Phys Med Rehabil Clin North Am 1998; 9: 271-84. Exercise therapies in peripheral neuropathies. Herbison GJ, Jaweed MM, Ditunno JF Jr. Arch Phys Med Rehabil. 1983;64(5):201-5. Causes of neuromuscular weakness in the intensive care unit: a study of ninety-two patients. Lacomis D, Petrella JT, Giuliani MJ. Muscle Nerve 1998; 21: 610-7. Late effects of polio: critical review of the literature on neuromuscular function. 380 Integrated Competency Based Curriculum 2012-2013

Agre JC, Rodriquez AA, Tafel JA. Arch Phys Med Rehabil 1991; 72: 923-31 The role exercise in the patient with post-polio syndrome. Agre JC. Ann NY Acad Sci 1995; 753: 321-34 Muscular function in late polio and the role of exercise in post-polio patients. Agre JC, Rodriquez AA. Neurorehabilitation 1997; 8:107-18 Post-polio syndrome. Halstead LS. Sci Am 1998; 278(4): 42-7. 26 ELECTRODIAGNOSIS Conduction Data: Superiority of a Summary Index over Single Tests. Robinson LR, Micklesen P, Wang L: Muscle Nerve 21:1166-1171, 1998. False positive electrodiagnostic tests in carpal tunnel syndrome. Redmond MD, Rivner MH. Muscle Nerve. 1988 May;11(5):511-8. Outcome assessment for carpal tunnel surgery: the relative responsiveness of generic, arthritis-specific, disease-specific, and physical examination measures. Amadio P. J Hand Surg [Am]. 1996;21(3):338-46. Comparison of multiple frequency vibrometry testing and sensory nerve conduction measures in screening for carpal tunnel syndrome in an industrial setting. Werner RA, Franzblau A, Johnston E. Am J Phys Med Rehabil. 1995;74(2):101-6 Carpal tunnel syndrome in pregnancy: frequency, severity, and prognosis. Stolp- Smith KA, Pascoe MK, Ogburn PL Jr. Arch Phys Med Rehabil. 1998;79(10):1285-7. Predicting acute denervation in carpal tunnel syndrome. Hirsh D, Tan FC. Arch Phys Med Rehabil 1998;79(3):306-12. Cervical radiculopathy: a review. Ellenberg, M. Arch Phys Med Rehabil. 1994;75(3):342-52. Motor conduction studies in Guillain-Barre syndrome: description and prognostic value. Cornblath DR, Mellits ED, Griffin JW, et al. Ann Neurol 1988;23(4):354-9 Prognostic value of electrodiagnosis in Guillain-Barre syndrome. Miller RG, Peterson GW, Daube JR, Albers JW. Muscle Nerve. 1988;11(7):769-74. The thoracic outlet syndrome: controversies, overdiagnosis, overtreatment, and recommendations for management. Cuetter AC, Bartoszek DM. Muscle Nerve. 1989;12(5):410-9. Electrophysiologic studies of critically ill patients. Bolton CF. Muscle and Nerve 10:129-135, 1987 Approach to peripheral neuropathy and neuronopathy. Barohn RJ. Semin Neurol 1998; 18: 7-18 Neuropathic pain of peripheral origin: advances in pharmacological treatment Galer BS. Neruology 1995; 45 Suppl 9: S17-25. 27 Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications Trail. The Diabetes Control and Complications Trial Research 381 Integrated Competency Based Curriculum 2012-2013

Group. JAMA 1996; 276: 1409-15 Complications associated with sedative and neuromuscular blocking drugs in critically ill patients. Prielipp RC, Coursin DB, Wood KE, Murray MJ. Crit Care Clin 1995; 11: 983-1003 Carpal tunnel syndrome: pathophysiology and clinical neurophysiology. Clin Neurophysiol. Werner RA, Andary M. 2002;113(9):1373-81. What you always wanted to know about the history and physical examination of neck pain but were afraid to ask. Honet JC, Ellenberg MR. Phys Med Rehabil Clin N Am. 2003;14(3):473-91. Brachial plexus. Murray B, Wilbourn AJ. Arch Neurol. 2002;59(7):1186-8. Electrodiagnostic approach to the patient with suspected brachial plexopathy. Ferrante MA, Wilbourn AJ. Neurol Clin. 2002;20(2):423-50. Early electrodiagnostic findings in Guillain-Barre syndrome. Gordon PH, Wilbourn AJ. Arch Neurol. 2001;58(6):913-7. Cervical radiculopathies. Cuetter A. Neurol. 1997;48(1):295. Thoracic outlet syndromes. Wilbourn AJ. Neurol Clin. 1999;17(3):477-97, 28 OCCUPATIONAL/INDUSTRIAL MEDICINE The injured worker: assessment and treatment. Weinstein SM, Herring SA, Shelton JL.Phys Med Rehabil State Art Rev 1990; 4:361-77. Musculoskeletal and Neuromuscular Conditions of Instrumental Musicians Bejani, FJ, Kaye GM, Benham M. Arch Phys Med Rehab 1996: Vol 77:406 - 413. Optimizing outcome in the injured worker with low back pain. Nadler, SF, Stitik TP, Malanga GA. Crit Rev Phys Med Rehabil Med 1999;11:139-169. Hand Wrist Cumulative Trauma Disorders in Industry. Silverman BA et al. Br J Ind Med 43: 779-784, 1986 Epidemiologic studies of low back pain. Frymoyer JW, Pope MH, Costanza MC, et al. Spine 1980; 5:419-23. Guidelines for functional capacity evaluation of people with medical conditions. Hart DL, Isernhagen SJ, Matheson LN. J Orthop Sports Phys Ther 1993; 18:682-6. A retrospective study. III. employee-related factors. Bigos SJ, Slpengler DM, Marin NA, Zeh J, et al. Spine 1986; 11: 252-6. An ergonomic evaluation comparing desktop, notebook, and subnotebook computers. Arch Phys Med Rehabil. 2002; 83(4):492-7. Short-term effects of workstation exercises on musculoskeletal discomfort and postural changes in seated video display unit workers. Phys Therap 2002:82(6): 578- 89 Pattern of performance in workers with low back pain during a comprehensive motor performance evaluation. Menard MR, Cooke C, et al Spine 1994;19:1359-66 Incentive effects of workers’ compensation benefits: a literature synthesis. Loesser JD, Henderlite SE, et al. Med Care Res Rev. 1995; 52: 34-59. 382 Integrated Competency Based Curriculum 2012-2013

A prospective study of work perceptions and psychological factors affecting the report of back injury. Bigos SJ, Battie MC, et al. Spine 1991; 16: 1-6. Managing work disability: why first return to work is not a measure of success. Butler RJ, Johnson WG, et al. Ind Labor Relations Rev 1995; 48: 452-69. Recent trends in work-related cumulative trauma disorder of the upper extremity in the US: an evaluation of possible reasons. Brogmos GE, Sorok GS, et al. J Occup Environ Med 1996; 38: 401-11. 29 Hand wrist cumulative trauma disorder in industry. Silverstein BA, et al.Brit J Indust Med 1986; 43: 779-84. The process of recovery: Patterns in industrial back injury. Part 1. Cost and other quantitative measures of effort. Leavitt SS, Johnson TL, et al. Ind Med Sur 1971; 40: 7-14. The development of guideline factors for the evaluation of disability in neck and back injuries. Clark W, Haldeman S. Spine 1993;18: 1736-45. The diagnosis of disability: treating and rating disability in a pain clinic. Sullivan MD, Loeser JD. Arch Intern Med 1992; 152: 1829-35. Review article: randomized controlled trials in industrial low back pain relating to return to work. Part 1. Acute interventions. Scheer SJ, Radack KL, et al. Arch Phys Med Rehabil 1995; 76:966-73. 30 CANCER REHABILITATION Principles of Cancer rehabilitation. Garden FH, Grabois M, editors. Principles of Rehabilitation Medicine: State of the art rev. 1994; Chapter 71, Section 21; 971-985 Central nervous system injury by therapeutic irradiation. Dropcho EJ: Neurol Clin 1991; 9: 969-88. Neurologic pain syndromes in patients with cancer. Elliot K, Foley KM. Neurol Clin. 1989; 7: 333-60. Pain rehabilitation. 3. cancer pain, pelvic pain, and age-related considerations. Williams FH, Maly BJ. Arch Phys Med Rehabil. 1994; 75:S-15-6. The treatment of cancer pain. Foley KM. N Engl J Med 1985;313: 84-95 Brain metastases. Patchell RA. Neurol Clin. 1991; 9: 817-24. Extradural spinal cord compressions: analysis of factors determining functional prognosis: prospective study. Radiology. Kim RY, Spencer SA, et al. 1990; 176: 279- 82. Surgical treatment of pathological fractures from metastatic tumor of long bones. Mandi A, Szepesi K, et al. Orthop. 1991; 14: 43-9 31 OTHER REHABILITATION TOPICS Multiple Sclerosis Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Kurtzke JF. Neurology. 1983;33(11):1444-52. 383 Integrated Competency Based Curriculum 2012-2013

Multiple sclerosis: early prognostic guidelines. Kraft GH, Freal JE, Coryell JK, Hanan CL, Chitnis N. Arch Phys Med Rehabil. 1981;62(2):54-8. Rehabilitation in multiple sclerosis. Erickson RP, Lie MR, Wineinger MA. Mayo Clin Proc. 1989;64(7):818-28. Gabapentin for relief of upper motor neuron symptoms in multiple sclerosis. Mueller ME, Gruenthal M, Olson WL, Olson WH. Arch Phys Med Rehabil. 1997;78(5):521-4. Bladder dysfunction in multiple sclerosis: causes and treatment. Fowler, C. Int MS J 1994;1:99-107 Vesicourethral dysfunction and urodynamic findings in multiple sclerosis: a study of 149 cases. Gallien P, Robineau S, Nicolas B, et al. Arch Phys Med Rehabil. 1998;79(3):255-7. Management of multiple sclerosis. Rudick RA, Cohen JA, Weinstock-Guttman B, Kinkel RP, Ransohoff RM. N Engl J Med 1997; 337: 1604-11. Fatigue and multiple sclerosis: evidence-based management strategies for fatigue in multiple sclerosis. Multiple Sclerosis Council for Clinical Practice Guidelines.1998: Washington, DC. Fatigue therapy in Multiple Scelrosis: results of a double-blind, randomized, parallel trial of amantadine, pemoline, and placebo. Krupp LB, Coyle PK, Doscher NP, Miller A, et al. Neurol 1995; 45: 1956-61 Exercise and multiple sclerosis. Ponichtera-Mulcare JA. Med Sci Sports Exerc 1993; 25: 451-65 The impact of inpatient rehabilitation on progressive multiple sclerosis. Freeman JA, Landon DW, Hobart JC, Thompson AJ Ann Neurol 1997; 42: 236-44 Contemporary approaches to the pharmacotherapeutic management of Parkinson’s disease: an overview. Stern MB. Neurol 1997; 49: Suppl 1:S2-9. Physical therapy and parkinson’s disease: a controlled clinical trial. Comella CL, Stebbins GT, Brown-Toms N, Goetz CG. Neurol 1994; 44: 376-8 32 Peripheral Vascular Disease Pulmonary embolism in rehabilitation patients: relation to time before return to physical therapy after diagnosis of deep vein thrombosis. Kiser TS, Stefans VA. Arch Phys Med Rehabil. 1997;78(9):942-5. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. Koopman MM, Prandoni P, Piovella F, et al. N Engl J Med. 1996;334(11):682-7. Erratum in: N Engl J Med 1997;337(17):1251. 1995 American College of Chest Physicians (ACCP) consensus guidelines on antithrombotic therapy. Davidson B. Semin Thromb Hemost. 1996;22 Suppl 2:1-5; 384 Integrated Competency Based Curriculum 2012-2013

discussion 29-30. Current status of anticoagulation therapy after total hip and total knee arthroplasty. Zimlich RH, Fulbright BM, Friedman RJ. J Am Acad Orthop Surg. 1996;4(2):54-62. Prevention of thromboembolism in spinal cord injury: role of low molecular weight heparin. Green D, Chen D, Chmiel JS, et al. Arch Phys Med Rehabil. 1994;75(3):290- 2. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. Kearon C. N Engl J Med 1999;340:901-7. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. Kearon C, Ginsberg JS, Kovacs MJ, et al. N Engl J Med 2003;349(7):631-9. Prolonged thromboprophylaxis with oral anticoagulants after total hip arthroplasty. Prandoni P, Bruchi O, Sabbion P, et al. Arch Intern Med, 2002; 162:1966- 1971 Pressure Ulcers A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers. Wood JM, Evans PE 3rd, et al. Arch Dermatol 1993; 129(8):999-1009. The effectiveness of preventive management in reducing the occurrence of pressure sores. Krouskop TA, Noble PC, Garber SL and Spencer WA: Journal of Rehabilitation Research and Development, 20(1): 7483, 1983. 33 Pressure ulcers: a review. Yarkony GM. Arch Phys Med Rehabil. 1994 ;75(8):908-17. HIV/AIDS HIV- related disability: assessment and management. O’Dell ME, editor. Phys Med Rehabil: State of the Art Rev. Vol 7 (Special issue) 1993. Experience with rehabilitation in the acquired immunodeficiency syndrome. O’Connell PG, Levinston SF. Am J Phys Med Rehabil. 1991; 70: 195-200. Rehabilitation medicine consultation in person hospitalized with AIDS. O’Dell MW. Am J Phys Med Rehabil. 1993; 72: 90-6. Rehabilitation in adults with human immunodeficiency virus-related diseases. O’Dell MW, et al. Am J Phys Med Rehabil. 1992; 71: 183-90. Neurologic manifestation of HIV infection. Simpson DM, Tagliati M. Ann Intern Med. 385 Integrated Competency Based Curriculum 2012-2013

1993; 328: 1686-95. Therapy for human immunodeficiency virus infection. Hirsh MS, D’Aquila RT. N Eng J Med. 1993; 328: 1686-95. Rehabilitation dimensions of AIDS: a review. Levinson SF. Arch Phys Med Rehabil. 1991; 72: 690-6 Disability in persons hospitalized with AIDS. O’Dell MW, et al. AM J Phys Med Rehabil. 1991; 70: 91-5. Measuring health-related quality of life in HIV and AIDS. Wu AW, Rubin HR. Psychol Health. 1992; 6: 251-64.

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Index

3 E 360-degree Evaluation · 355 Educational Conferences and Workshops · 347 Electives · 321 Electrodiagnositic Medicine · 253 5 Electrodiagnostic Medicine · 24 E-mail · 361 5 C's · 19 Essential Articles in PM&R Training · 366

A G

ABPM&R – Oral Boards General Physical Medicine & Rehabilitation and Boards · 363 Therapeutics · 63 ABPMR – Written Boards Grid · 70 Boards · 362 American Academy of Physical Medicine and Rehabilitation. · 347 H Amputee Rehabilitation and Prosthetics & Orthotics and · 50, 337 Hands on Workshops · 334 Appendix · 364 Humanities in Rehabilitation Medicine · 66 Assessment Tools · 348 Association of Academic Physiatrist · 364, 366 Audience Response System · 334 I

C IF-AT · 334 Immediate Feedback – Assessment Tool · 334 Case Logs · 357 Clinic Design: · 341 Clinic logistics: · 341 J Clinical Orthopaedic Rehabilitation Second Edition · 343 Contact Information · 361 Joel A DeLisa, MD, MS · 364 Continuity clinic · 341 Joint & Connective Tissue Rehabilitation · 40, 340 Continuity Clinic Peer Lecture Schedule · 343 Current Outcomes · 361 Curriculum Committee · 358 L

Learning/Education · 342 D Lecture Techniques used · 334

Didactic · 23 Didactics · 333 M Doctor Number assignment: · 342 Domains · 23 Medical Rehabilitation · 55 Musculoskeletal Medicine · 99 Musculoskeletal Medicine – PGY2 PGY2 · 99

387 Integrated Competency Based Curriculum 2012-2013

Musculoskeletal Medicine – PGY4 REFERENCES Triple D 2004 · 364 PGY4 · 116 Rehab Administration & Practice Management · 60 Musculoskeletal, Sports and Occupational Medicine · 43 Rehabilitation Research · 58, 339 Resident Observation and Competency Assessment (RO&CA) · 352 N Resident’s responsibility: · 342 Rheumatology · 290 National Institutes of Health · 280 RO&CA · 352 Neurorehabilitation · 36 Rotations · 23, 69

O S

Objective Structures Clinical Examination · 334 SCI Rehabilitation · 31 Occupational Medicine & Electrodiagnostic Consultations · Spinal Cord Injury · 71 188 Spinal Cord Injury – PGY2 Orthotics · 50, 337 PGY2 · 71 OSCE · 334, 349 Spinal Cord Injury – PGY3 · 85 Other Learning Opportunities · 341 PGY3 · 85 Outpatient Center - Bethesda NRH Regional Rehab · 242 Sports Medicine or Orthopedic Surgery Outpatient Physician Center Specialty Clinics at NRH · 210 Orthopedic Surger · 271 Sports Medicine · 271 Standardized Patients (SP) · 350 P Stroke Recovery · 151 Stroke Recovery – PGY2 PGY2 · 151 P&O Stroke Recovery – PGY3 Orthotics · 200 PGY3 · 165 Prosthetics · 200 Pain Consultations · 224 Patient scheduling · 341 T Pediatric Rehabilitation · 47, 189, 339 PGY2 Elective PGY2 · 321 Team Appraisal of Resident · 355 PGY3 Traumatic Brain Injury · 131 Elective PGY3 · 321 Traumatic Brain Injury – PGY2 PGY4 PGY2 · 131 Elective PGY4 · 322 Traumatic Brain Injury – PGY4 Elective PGY4 or Adult Neurology at WHC · 322 PGY4 · 141 Phone: · 361 Portfolio · 357 Portfolio Items · 358 U Prosthetics · 50, 337 Unannounced quizzes · 356 US Mail · 361 Q

Quarterly Exams · 357 V

Veterans Affairs – Geriatrics · 179 R

Radiology – Visiting Nurses Association – Nascott · 200

388 Integrated Competency Based Curriculum 2012-2013

W Washington Hospital Center Consultations · 309 Written Exams · 356

389 Integrated Competency Based Curriculum 2012-2013

Figures and Tables Figure 1 - 5 C's ...... 19 Figure 2 - Sample RO&CA ...... 354 Figure 3 - Sample survey - 360o Evaluation ...... 356

Table 1 - Domains ...... 23 Table 2 - Rotation Grid as of 4/14/2009 ...... 70 Table 3 - SCI Didactic Lectures ...... 73 Table 4 - SCI Didactic Lectures ...... 87 Table 5 - List of Didactic Lectures ...... 340 Table 6 - Doctor Number assignment ...... 342 Table 7 - Continuity Clinic Lectures ...... 347 Table 8 - Other Educational Conferences and Workshops & Competencies ...... 347 Table 9 - Portfolio Items & Competencies ...... 358 Table 10 - 5 year Board Scores Part I ...... 362 Table 11 - 5 year Board Scores Part II ...... 363

390 Integrated Competency Based Curriculum 2012-2013