The Effect of Elective Rotations on the Self-assessment Examination Results of Physical Medicine and Rehabilitation Residents: Implications for Minimizing Educational Resource Disparities in Taiwan.

OBJECTIVE: The aims of the study were (1) to assess whether a knowledge disparity existed between physical medicine and rehabilitation residents from community hospitals versus those from medical centers, before the introduction of short-term elective training at the end of 2008 and (2), if such disparity existed, to determine whether 1-month short-term elective training was associated with minimizing such disparity, as reflected in the self-assessment examination scores. DESIGN: Self-assessment examination scores from 2007-2016 were analyzed in each of the following three topics: (a) cardiac rehabilitation, (b) pulmonary rehabilitation, and (c) orthotics. Student's t tests were used to identify score discrepancies between both groups. RESULTS: (1) At baseline (2007-2008), trainees from community hospitals scored lower in all three topics (P < 0.05). (2) After the short-term elective training, follow-up comparisons showed no differences in either cardiac or pulmonary rehabilitation for 2009-2016. Regarding orthotics, trainees from both groups showed no significant differences for 2009-2010 and 2011-2012. Interestingly, for 2013-2014 and 2015-2016, trainees from medical centers scored higher again, but only in orthotics. CONCLUSIONS: (1) In 2007-2008, a knowledge disparity existed between physical medicine and rehabilitation residents from community hospitals and medical centers in Taiwan. (2) Short-term elective training was associated with minimizing such disparity from 2009-2016, especially in cardiac and pulmonary rehabilitation.

The Development and Evolution of Physical Medicine and Rehabilitation in Taiwan from 1958 to 2016.

The field of physical medicine and rehabilitation (PM&R) began its development in Taiwan since 1958, and has gradually evolved into a profession that provides a diversity of clinical services and educational activities. The objectives of this brief report were to (1) review its background and milestones in the past 6 decades, (2) describe the current role and function of its Academy of PM&R, (3) present the content and format of its board certification process, focusing on (a) residency training requirements, (b) self-assessment examination, board certification process, and (c) maintenance of certification through continued education. Some challenges and opportunities are also discussed toward the end of this article. It is hoped that this report may serve as a reference material for other countries as they develop or improve their PM&R residency programs.

Is higher serum total cholesterol level associated with better long-term functional outcomes after noncardioembolic ischemic stroke?

OBJECTIVE: To investigate the prognostic effects of the serum total cholesterol (TC) levels on long-term functional outcomes in patients with first-time noncardioembolic ischemic stroke. DESIGN: Cohort study. SETTING: Referral center. PARTICIPANTS: Patients (N=109) with first-time ischemic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Serial Barthel Index (BI) scores at onset; 2 weeks; and 1, 2, 4, and 6 months after stroke. We analyzed the impact of the serum TC level and other clinical factors on the repeated measurements of BI scores at these 6 time points by using a linear mixed regression model. RESULTS: Taking correlation across repeated measurement of BI scores, the TC level, baseline BI, follow-up time, and infarct size were identified as significant predictors for serial BI scores. Higher TC levels correlated with better functional outcomes. A 1-unit (mmol/L) increase in the TC caused a 3.12 (95% confidence interval [CI], .79-5.46) increase in the BI score after controlling for other clinical factors such as age, baseline functional status, and size of infarct. An elevation of 1 unit of baseline BI led to a .49 increase (95% CI, .38-.59) per unit in subsequent BI scores. A small infarct (<1cm) had higher BI scores than larger infarct by 9.09 (95% CI, 2.03-16.16). CONCLUSIONS: The serum TC level measured at the acute stage of noncardioembolic ischemic stroke is an independent predictor for long-term functional outcomes.

Dynamic aspect of functional recovery after stroke using a multistate model.

OBJECTIVE: To estimate time to functional recovery and quantify the effects of significant prognostic factors affecting the dynamic change of 3-state functional outcome after stroke. DESIGN: Modeling of clinical predictions. SETTING: Referral center. PARTICIPANTS: One hundred eleven patients with first-time ischemic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Serial Barthel Index scores at onset, 2 weeks, and 1, 2, 4, and 6 months poststroke. The severity of disability was classified into 3 functional states: poor functional state (PFS) for Barthel Index scores from 0 to 40, moderate functional state (MFS) for scores from 45 to 80, and good functional state (GFS) for scores greater than 80. A 3-state Markov regression model together with Bayesian acyclic graphic underpinning was used to estimate transition parameters and mean time to functional recovery between states and to predict the probability of functional recovery by using Gibbs sampling technique. RESULTS: The mean total recovery time was 3.1 months for patients with PFS at baseline and 1.3 months for patients with MFS at baseline. The mean recovery times to different functional states were also estimated. Age predominantly affected the probabilities of MFS to GFS transitions, younger patients had faster transition rates (rate ratio, 4.51; 95% confidence interval [CI], 2.72-7.40); but age had only borderline effects on PFS to MFS transitions. In contrast, infarct size exerted substantial effects on PFS to MFS transitions: small-size infarct correlated with a higher transition rate (rate ratio, 10.17; 95% CI, 5.25-20.13), whereas only a borderline effect on MFS to GFS transitions was found. The baseline functional state significantly affected the MFS to GFS transitions. CONCLUSIONS: By using a multistate model, overall and patient-specific mean time to functional recovery to different functional states can be estimated and the effect of clinical predictors on functional transitions can be precisely quantified to predict patient-specific probability of functional recovery.

Predictors of long-term survival after stroke in Taiwan.

OBJECTIVE: To determine the risk factors of long-term survival after stroke. DESIGN: A prospective, hospital-based cohort study. SUBJECTS: A total of 449 consecutive patients after acute stroke from 2 medical centres, within a 1-year period, were included. METHODS: Dysphagia was confirmed with the water-swallow test within the first week after stroke. Data on co-morbidities and clinical risk factors were collected through chart review. Survival curves and independent risk factors were evaluated with Kaplan-Meier analysis and multivariate Cox proportion hazards analysis, respectively. RESULTS: A total of 424 patients were followed for 10 years, and the survival was 54.2%. In univariate analysis, history of diabetes mellitus and recurrent stroke, dysphagia, urinary incontinence, cognitive impairment, tube feeding, dysarthria, and drooling were associated with higher mortality. In multivariate analysis, old age, history of recurrent stroke, and diabetes mellitus were independent predictors of long-term survival. The leading causes of death were cerebro-vascular diseases and malignancy during the 10-year post-stroke period. CONCLUSION: Dysphagia was not an independent determinant of post-stroke survival. History of recurrent stroke and diabetes mellitus were independent predictors of long-term survival. These results suggest that differential treatment strategies should be used in the different stages of stroke.

The effect of nasogastric tubes on swallowing function in persons with dysphagia following stroke.

OBJECTIVE: To determine whether the use of a nasogastric tube influences swallowing function in stroke patients with dysphagia. DESIGN: Before-after trial. SETTING: Primary care center. PARTICIPANTS: A total of 22 patients with stroke (12 men, 10 women; mean age, 69.7 y; range, 19-85 y) participated in the study. Time from onset of stroke to time of assessment averaged 20.3 days (range, 14-38 d). All participants continued to use a nasogastric tube for nutrition supply and had either minor or no aspiration of barium on videofluoroscopic examination of swallowing (VFES). INTERVENTION: The swallowing function was evaluated by VFES with thin and thick bariums (5 mL each) as a contrast medium. MAIN OUTCOME MEASURES: The oral transit, swallowing trigger, and pharyngeal transit times were measured and compared before and after the removal of the nasogastric tube. The patients were also observed for changes in velopharyngeal closure, pharyngeal contraction, epiglottic tilt, valleculae stasis, pyriform sinus stasis, penetration, and aspiration. RESULTS: Transit times were reduced by 0.2 to 0.6 seconds after removal of the nasogastric tube, but the reduction was not statistically significant. These transit times were slightly longer with thick barium than with thin barium, but were without statistical significance. Similarly, most of the patients had no change in nontemporal assessment of swallowing function after the tube was removed. CONCLUSIONS: The placement of a nasogastric tube did not affect temporal and nontemporal measurement of swallowing in stroke patients with dysphagia with or without minor aspiration.

Findings of videofluoroscopic swallowing studies are associated with tube feeding dependency at discharge in stroke patients with dysphagia.

The factors associated with tube feeding dependency in stroke patients with dysphagia have received little attention. This study aimed to identify factors independently associated with tube feeding dependency at discharge in stroke patients with dysphagia using videofluoroscopic swallowing studies (VSS) and clinical findings. One hundred eighty-one consecutive tube-fed inpatients with stroke-related dysphagia referred for VSS were enrolled in the study. Of them, 47 patients continued to require tube feeding at discharge. In the final logistic regression analysis model, advanced age, recurrent stroke, confinement to a wheelchair at discharge, long duration from stroke onset to VSS, and stasis in valleculae or pyriform sinuses and aspiration on VSS were independently associated with tube feeding dependency at discharge. This study confirms the association between findings of VSS and tube feeding dependency at discharge in stroke patients with dysphagia. Based on the final regression model, a preliminary equation was proposed to help clinicians better predict the tube feeding dependency at discharge in stroke patients with dysphagia.

Can the aspiration detected by videofluoroscopic swallowing studies predict long-term survival in stroke patients with dysphagia?

PURPOSE: This study aimed to evaluate whether the aspiration detected by videofluoroscopic swallowing study (VSS) could predict the long-term survival in stroke patients with dysphagia in the post-acute phase of stroke. METHODS: A cohort of 182 consecutive patients with stroke-related dysphagia referred for VSS from July 1994 to April 1999 was retrospectively constructed. VSS findings and clinical features in the post-acute phase of stroke were recorded. The records thus obtained were then linked to the National Death Register to track the occurrence of patient deaths until December 31, 2000. RESULTS: Of the 182 patients, 91 (50%) showed aspiration during VSS performed for a median duration of 8.4 weeks after stroke, and 76 (42%) had silent aspiration. In the post-acute phase of stroke (14.7 +/- 8.7 weeks after stroke, mean + standard deviation), 56 (31%) were tube-fed, and 88 (48%) were wheelchair-confined. A total of 65 patients died in a median follow-up duration of 30.8 months after VSS. Patients were classified into three groups based on the findings of VSS-detected aspiration or penetration, but no difference was noted in their survival curves. In the Cox stepwise regression analysis, only advanced age, recurrent stroke (hazard ratio 1.74, 95% CI 1.06-2.85), the need of tube-feeding (hazard ratio 2.07, 95% CI 1.19-3.59), and being wheelchair-confined (hazard ratio 2.83, 95% CI 1.54-5.19) during follow-up were independent predictors of long-term survival. CONCLUSIONS: VSS-detected aspiration during the post-acute phase of stroke was not predictive for the long-term survival in stroke patients with dysphagia.

Dysphagia in patients with nasopharyngeal cancer after radiation therapy: a videofluoroscopic swallowing study.

This study evaluated swallowing status and the factors influencing swallowing in patients with nasopharyngeal carcinoma (NPC) after radiation therapy. During the period from July 1995 to June 1999, this cross-sectional study used videofluoroscopic swallowing study (VFSS) to evaluate 184 NPC patients who had completed radiation therapy [113 cases had completed radiation therapy < or = 12 months prior to evaluation (acute group) and 71 cases had completed radiation therapy > 12 months prior to evaluation (chronic group)]. The numbers of patients with tumors in each of the four stages were as follows: 24 in stage I, 45 in stage II, 41 in stage III, and 74 in stage IV. Swallowing abnormalities of the acute and chronic groups were correlated with multiple variables, including gender, age, the stage of the tumor, use of either neoadjuvant chemotherapy or radiosensitizer, and radiation modality. The analytical results indicated that the chronic group had a significantly higher proportion of swallowing abnormalities. Radiation modality, chemotherapy, and tumor staging were not significantly associated with swallowing dysfunction. Trend analysis revealed a progressive deterioration of most parameters of swallowing function in this group of patients. These findings indicate that swallowing function continues to deteriorate over time, even many years after radiation therapy in patients with NPC. Our results indicate that the time elapsed since radiation therapy correlates with the severity of dysphagia in NPC patients.

Resistive inspiratory muscle training in sleep-disordered breathing of traumatic tetraplegia.

OBJECTIVE: To assess the effect of resistive inspiratory muscle training (RIMT) on the static pulmonary function and sleep-induced breathing disorder of individuals with chronic cervical cord injury. DESIGN: Before-after training. SETTING: Home-setting training program. PATIENTS: Fourteen complete traumatic tetraplegic patients (12 men, 2 women; mean age, 41.1 +/- 14y; range, 19-56y) injured for more than 6 months. INTERVENTION: Subjects participated in a 6-week RIMT program for 15 minutes twice daily at a training intensity of 60% of maximum inspiratory pressure (MIP). The participants were reevaluated at the end of 6-week training. MAIN OUTCOME MEASURES: Lung volume, peak expiratory flow (PEF), MIP, and maximum expiratory pressure (MEP) were measured by using a spirometry and inspiratory force meter, respectively. Capnography was used to monitor nocturnal pulse oxyhemoglobin saturation (SpO(2)) and end-tidal carbon dioxide tension level (ETCO(2)) of the patients. RESULTS: The maximum voluntary ventilation (MVV) and MIP of individuals with chronic cervical cord injury substantially improved after RIMT. MIP increased from -68.7 +/- 27.4cmH(2)O to -77.3 +/- 24.0cmH(2)O and MVV rose from 62.7 +/- 33.2L to 73.4 +/- 31.3L (P <.05). Despite increasing from 3.5 +/- 1.8L/s to 4.0 +/- 1.7L/s, PEF was statistically insignificant. For the individuals with improved MIP, the duration of ETCO(2) greater than 48mmHg reduced from 2.2% +/- 3.3% to 1.0% +/- 2.0% of total sleep time (P =.05) and that of SpO(2) less than 90% significantly declined from 1.8% +/- 2.8% to 1.3% +/- 2.4% of total sleep time (P <.05). CONCLUSION: These findings suggest that RIMT can enhance the respiratory muscle strength and endurance of chronic tetraplegia and further ameliorate the sleep-induced breathing disorder. Therefore, RIMT is suggested as a home program for patients with sleep-disordered breathing.