Estado actual de la especialidad en medicina física y rehabilitación en Puerto Rico: educación, investigación científica y práctica clínica / Current status of the specialty in physical medicine and rehabilitation in Puerto Rico: education, scientific research and clinical practice

En Puerto Rico, la especialidad de medicina física y rehabilitación surgió en la década de los años cincuenta y a partir de ese momento ha progresado gracias a la creación de programas de adiestramiento de vanguardia, el establecimiento de una cultura de investigación científica y el desarrollo de la especialidad primaria y de subespecialidades como manejo de dolor, medicina del deporte, rehabilitación pediátrica, medicina neuromuscular, medicina de trauma cerebral y medicina de lesiones medulares. La práctica clínica más común es la de atención a pacientes externos con dolor, lesiones musculoesqueléticas y daños en el sistema nervioso, pero se ha presentado un aumento en los servicios de rehabilitación intensiva de pacientes que requieren hospitalización; en el uso de técnicas intervencionistas para manejo de dolor, lesiones de tejido blando y articulares, así como en el manejo de espasticidad. Actualmente, la especialidad de fisiatría en Puerto Rico enfrenta grandes retos, como lo son el control de las aseguradoras sobre los servicios que se les ofrecen a pacientes con impedimentos físicos y restricciones de participación, el incremento en la cantidad de documentos requeridos para que se aprueben estos servicios y la competencia de otros profesionales de la salud que han incursionado en el campo de rehabilitación. Las oportunidades para la especialidad incluyen el aumento de la población mayor y con discapacidad que requiere servicios de rehabilitación; el desarrollo de las prácticas de subespecialidad, y la necesidad de aumentar la evidencia científica que demuestre la efectividad de los tratamientos que se ofrecen y de apoyar las políticas públicas que aumenten el acceso a servicios de rehabilitación para personas de escasos recursos.

In Puerto Rico, the specialty in physical medicine and rehabilitation emerged in the 1950s and since then it has progressed thanks of the creation of cuttingedge training programs, the establishment of a culture of scientific research and the development of the primary specialty and subspecialties such as pain management, sports medicine, pediatric rehabilitation, neuromuscular medicine, brain trauma medicine, and spinal cord injury medicine. The most common clinical practice is the care of outpatients with pain, musculoskeletal injuries and damage of the nervous system, but there has been an increase in intensive rehabilitation services for patients who require hospitalization, in the use of interventionist techniques for the management of pain, soft tissue and joint injuries, as well as for the management of spasticity. Currently, the specialty of physiatry in Puerto Rico faces big challenges, such as the control of the insurers on the services offered to patients with physical impairments and participation restrictions, the increase in the number of documents required for the approval of these services, and the competition of other health care professionals who have ventured into the field of rehabilitation. The opportunities for the specialty include the increase in the elderly and disabled population requiring rehabilitation services, the development of subspecialty practices, and the need to increase scientific evidence that demonstrates the effectiveness of the treatments offered and to support public policies that increase the access to rehabilitation services for people with limited resources.

Normal Changes in Gait and Mobility Problems in the Elderly.

There are normal physiologic changes that occur as people age. Gait and mobility are altered with aging, and these changes are a combination of alterations in the gait pattern and in the function of organs. Changes in gait are associated with functional decline, less independence, and impaired quality of life. Reduced walking speed is the most consistent age-related change, but there are other contributors to an altered gait: impaired balance and stability, lower extremity strength, and the fear of falling.

Benefits of risk factor modification through cardiac rehabilitation.

In the last few decades cardiac rehabilitation has evolved dramatically. It consists of a multidisciplinary approach for secondary prevention and rehabilitation treatment after an individual has sustained a cardiac event. A key principle for successful cardiac rehabilitation management is the modification of risk factors which have been demonstrated to have a significant impact on overall mortality and morbidity outcomes. This article summarizes some of the evidence that supports modification of risk factors through the use of cardiac rehabilitation.

The effect of exercise in chronic low back pain: a pilot study.

OBJECTIVE: To determine if a structured exercise program promotes improved performance on activities of daily living (ADL) and pain perception in patients with chronic low back pain (CLBP). DESIGN: Prospective pilot study of patients referred to the San Juan VA Medical Center rehabilitation clinics with CLBP from January 1 to March 31, 2001, without neurological deficit or back surgery. INTERVENTION: The therapeutic program consisted of warm up/cool down calisthenics, stretching, back isometric and stabilization exercises and aerobic walking. INSTRUMENTS: Visual Analog Scale (VAS) and the Quebec Back Pain Disability Scale (QBPDS) were used to measure pain intensity and disability before and after the training period. RESULTS: Six patients completed the study. Back pain intensity and functional disability decreased immediately upon completing the program, and such changes persisted (statistically significant) upon follow up evaluation. CONCLUSION: A well guided exercise program can decrease pain intensity perception and disability in patients with CLBP.

The use of botulinum toxin in physical medicine and rehabilitation.

A review of the history and pharmacology of the botulinum neurotoxins is presented. Established mechanisms of action are discussed as well as preliminary evidence of other potential mechanisms, as related to botulinum toxins' antinociceptive properties. Methods of administration, including reconstitution, dilution, and basic injection techniques/principles are reviewed. Safety concerns are also addressed. Various applications relevant to the field of Physical Medicine & Rehabilitation are reviewed, specifically uses in the management of muscle over activity syndromes such as upper motor neuron-related spasticity, dystonias, and painful syndromes including Myofascial Pain Syndromes and headaches. Relevant literature related to these applications is reviewed and discussed. Botulinum toxin therapeutic efficacy and possible reasons for treatment failure (including development of antibody-mediated resistance) are discussed.

Provocative F waves may help in the diagnosis of thoracic outlet syndrome: a report of three cases.

To determine the value of F waves in provocative positions for the diagnosis of thoracic outlet syndrome, we performed provocative maneuvers on three patients with a clinical diagnosis of thoracic outlet syndrome. The patients had complained of intermittent upper limb pain with associated weakness and paresthesias for several years, and previous evaluations included essentially normal cervical and shoulder imaging studies and electrodiagnostic studies. Although upper limb nerve conduction studies, including ulnar and median F waves, were within normal limits, provocative F waves were obtained in the symptomatic and asymptomatic arm. When routine nerve conduction studies are normal, despite a strong clinical suspicion, provocative maneuvers may help to show subtle electrodiagnostic abnormalities to support the diagnosis of thoracic outlet syndrome.