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BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) is associated with debilitating fatigue, dizziness, and discomfort in previously healthy adolescents. The effects of medical therapy have not been well studied in this patient population. This study assessed the relative efficacy and impact of drug therapy on the functioning and quality of life in adolescents with POTS. METHODS: A retrospective, single center, chart review analysis with a follow-up written survey was conducted on a group of 121 adolescents who had undergone autonomic reflex screening at the Mayo Clinic from 2002 to 2005 as part of an evaluation for possible POTS. RESULTS: Of 121 surveys sent, 47 adolescents returned a completed survey. In this cohort of patients, the two most commonly prescribed drug therapies were midodrine (n = 13) and ß-blockers (n = 14). Patients in the midodrine group were comparable to patients in the ß-blocker group in gender, age, pretreatment postural heart rate changes, and months from initial evaluation to survey completion. More patients treated with a ß-blocker reported improvement after visiting Mayo Clinic (100% vs 62%, P = 0.016) and more attributed their progress to medication (63.6% vs 36.4%, P = 0.011) than did those treated with midodrine. CONCLUSION: Treatment with both midodrine and ß-blockers was associated with overall improvement in POTS patients' general health; however, adolescents taking ß-blockers were more likely than those taking midodrine to credit the role of medications in their improvement. [ABSTRACT FROM AUTHOR]

Abstract: Physical Medicine and Rehabilitation (PM&R) residents must complete twelve months of fundamental skills training prior to beginning PM&R residency. The objective of this study is to determine if characteristics of the first post-graduate year (PGY-1) impact performance on American Board of PM&R (ABPMR) initial certification examinations. A retrospective review was conducted on a deidentified ABPMR database of physicians who completed PM&R residency and took the Part I Examination between 2008 and 2022. Physicians who completed categorical residency programs in PM&R had higher pass rates on Part I than physicians who completed advanced programs. Physicians who completed a categorical program had higher scaled scores on the Part II Examination than physicians who completed either a transitional or non-transitional advanced program but pass rates did not differ. Completing less than 3 months of training in internal medicine prior to starting PM&R was associated with lower Part I and Part II Examination scaled scores than completing 3 or more months. Physicians who completed six or more months of internal medicine had higher Part I and Part II Examination pass rates and scaled scores than physicians who completed six or more months in surgery., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: This is the first population-based study quantifying the incidence of nonsynostotic positional plagiocephaly and/or brachycephaly (PPB) in infancy and its association with developmental disorders., Objective: To report the incidence of PPB before age 1 year, the incidence of craniosynostosis, and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years., Design, Setting, and Participants: This was a retrospective, population-based cohort study of children in the Rochester Epidemiology Project (REP) born in Olmsted County, Minnesota, from January 1, 2008, through December 31, 2012, with follow-up through age 7 years. Data were analyzed from March 2021 to April 2024., Exposure: Physical examination detecting cranial deformity., Main Outcomes and Measures: The primary outcome was the incidence of PPB. Secondary outcomes were the incidence of craniosynostosis and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years., Results: Of 9909 infants (5084 [51.3%] male; 9205 [92.9%] born at term and 704 [7.1%] born preterm) included in the study, 575 had PPB, for a PPB incidence of 5.8% (95% CI, 5.3%-6.3%). The incidence of PPB was 5.3% (95% CI, 4.8%-5.8%) in term infants vs 11.8% (95% CI, 9.4%-14.6%) in preterm infants. The incidence of craniosynostosis was 0.16% (95% CI, 0.09%-0.26%). A developmental disorder was known or suspected in 4.2% (95% CI, 2.7%-6.2%) of infants at the time of PPB diagnosis; among 402 infants with PPB and follow-up through age 7 years, 30 (7.5%; 95% CI, 5.0%-10.7%) had a confirmed developmental disorder by 7 years of age. The prevalence of autism spectrum disorder (ASD) in children with a history of PPB who were followed up to age 7 years was 2.2% (9 of 402 children)., Conclusions and Relevance: This study found that only a small percentage of the infants had positional head deformity significant enough to be documented and/or referred for subspecialty evaluation, and only a small subset of these children went on to have a developmental disorder in childhood. This information is helpful for counseling families about their child's developmental risk at time of PPB diagnosis.

Background: In the United States, rare disease (RD) is defined as a condition that affects fewer than 200,000 individuals. Collectively, RD affects an estimated 30 million Americans. A significant portion of RD has an underlying genetic cause; however, this may go undiagnosed. To better serve these patients, the Mayo Clinic Program for Rare and Undiagnosed Diseases (PRaUD) was created under the auspices of the Center for Individualized Medicine (CIM) aiming to integrate genomics into subspecialty practice including targeted genetic testing, research, and education., Methods: Patients were identified by subspecialty healthcare providers from 11 clinical divisions/departments. Targeted multi-gene panels or custom exome/genome-based panels were utilized. To support the goals of PRaUD, a new clinical service model, the Genetic Testing and Counseling (GTAC) unit, was established to improve access and increase efficiency for genetic test facilitation. The GTAC unit includes genetic counselors, genetic counseling assistants, genetic nurses, and a medical geneticist. Patients receive abbreviated point-of-care genetic counseling and testing through a partnership with subspecialty providers., Results: Implementation of PRaUD began in 2018 and GTAC unit launched in 2020 to support program expansion. Currently, 29 RD clinical indications are included in 11 specialty divisions/departments with over 142 referring providers. To date, 1152 patients have been evaluated with an overall solved or likely solved rate of 17.5% and as high as 66.7% depending on the phenotype. Noteworthy, 42.7% of the solved or likely solved patients underwent changes in medical management and outcome based on genetic test results., Conclusion: Implementation of PRaUD and GTAC have enabled subspecialty practices advance expertise in RD where genetic counselors have not historically been embedded in practice. Democratizing access to genetic testing and counseling can broaden the reach of patients with RD and increase the diagnostic yield of such indications leading to better medical management as well as expanding research opportunities., (© 2023. The Author(s).)

Spasticity results from an abnormality of the central nervous system and is characterized by a velocity-dependent increase in muscle tone or stiffness. In children, it can cause functional impairments, delays in achieving developmental or motor milestones, participation restrictions, discomfort, and musculoskeletal differences. Unique to children is the ongoing process of a maturing central nervous system and body, which can create the appearance of worsening or changing spasticity. Treatment options include physical interventions such as stretching, serial casting, and bracing; oral and injectable medications; and neurosurgical procedures such as selective dorsal rhizotomy and intrathecal baclofen pump., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: There is a need to better understand the overall state of sub-specialization in physical medicine and rehabilitation (PM&R)., Objective: To examine the status and trends in subspecialty certification for each of the seven subspecialties approved for American Board of Physical Medicine and Rehabilitation (ABPMR) diplomates., Design/setting: Retrospective analysis of deidentified information from the ABPMR database., Participants: Physicians certified by ABPMR through 2019., Interventions: Not applicable., Main Outcome Measures: For each subspecialty, we examined: (1) the number of certificates issued to ABPMR diplomates; (2) the recertification rate; (3) the yearly trends for total active, new, and expired certificates; and (4) for ABPMR-administered subspecialties, recertification rates for those entering the subspecialty through fellowship completion versus a "grandfathered" practice pathway., Results: Of 11,421 ABPMR diplomates in the United States in 2019, a total of 3560 (31.2%) had 3985 active subspecialty certificates. Pain Medicine (PM) was the most common subspecialty certification (15.5% of all ABPMR diplomates) followed by Sports Medicine (SM, 6.6%), Brain Injury Medicine (BIM, 4.8%), Spinal Cord Injury Medicine (SCIM, 4.2%), Pediatric Rehabilitation Medicine (PRM, 2.5%), Neuromuscular Medicine (NMM, 0.7%), and Hospice and Palliative Medicine (HPM, 0.5%). For diplomates with more than one subspecialty certification, PM and SM was the most frequent combination. Both the recertification rate and the end of practice track eligibility influenced certification trends differently for individual subspecialties. The average number of new certificates added annually for every subspecialty was higher before than after the temporary practice track-based eligibility ended; the difference was statistically significant (p < .05) for SCIM, PM, SM, and NMM. The recertification rate for all subspecialties combined was 73.4%. For the subspecialties (SCIM, PRM) for which these data were available, fellowship candidates had higher recertification rates than those grandfathered through a practice track., Conclusion: This report informs stakeholders about the state and evolution of subspecialty certification in PM&R over time., (© 2022 American Academy of Physical Medicine and Rehabilitation.)

Depression, suicidal ideation, burnout, and moral injury are on the rise among physicians. Depression and suicidal ideation are mental health disorders that result from multiple interacting factors including biological vulnerabilities and acute stressors. Medical treatment for depression and suicidal ideation is critical to interrupt the potentially deadly progression to suicide that occurs when one's ability to find hope and other solutions is clouded by despair. Yet, stigma and perceived stigma of seeking treatment for mental health disorders still plagues medical providers. Transitions during medical training and practice can be particularly vulnerable time periods, though newer evidence suggests that overall, physicians are not at an increased risk of suicide compared to the general population. While burnout and moral injury are common among rehabilitation physicians, unlike depression, they are not directly associated with suicidal ideation. Opportunities for continued improvement in mental health resources and institutional support exist across the spectrum from medical student to staff physician. With wellness now increasingly supported and promoted by various medical organizations and recognition of the importance of access to effective mental health treatment, regaining hope and positivity while restoring resiliency in physicians, trainees, and medical students is possible.

Abstract: Recognizing the dearth of published research on board certification in physical medicine and rehabilitation and its subspecialties, the American Board of Physical Medicine and Rehabilitation has increased efforts to conduct and disseminate research in this area. This report summarizes key findings of peer-reviewed studies published by American Board of Physical Medicine and Rehabilitation staff and leadership in the past 6 yrs, including those conducted in partnership with other entities. The reported studies are organized in three main categories: initial certification, continuing certification, and subspecialty certification in physical medicine and rehabilitation. Related findings are further grouped into subsections that include psychometric evaluation of certification examinations, association of candidate characteristics with certification performance, relationship of certification performance to other measures, and candidate reaction and feedback. Collectively, the summarized results provide evidence that the board certification process is reliable, statistically valid, and predictive of the risk of disciplinary action in subsequent years. These studies also describe facets of our specialty including degree of subspecialization, burnout, and how people maintain certification over time. We hope that physical medicine and rehabilitation trainees, diplomates, institutions, programs, and other stakeholders find this information useful and look forward to continuing research in these and other areas in the spirit of constant evidence-based improvement and feedback to our specialty., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: The American Board of Medical Specialties Continuing Certification Program's Improvement in Medical Practice Standard requires physicians to participate in practice improvement activities. Despite this universal requirement, there has been no assessment of this requirement or its potential impact on patient care. Because of its continuing certification oversight structure, the American Board of Physical Medicine and Rehabilitation is in a unique position to provide this assessment. Review of quality improvement projects submitted to the American Board of Physical Medicine and Rehabilitation for continuing certification compliance revealed that most diplomates (70.1%) used available topic-specific options. These projects are designed to be directive and easy to use for physicians with limited quality improvement experience. Examples of topic-directed project potential impact on patient care include preventing wrong-site injections through implementing a preprocedure timeout or decreasing opioid prescribing risk through implementation of an opioid risk assessment tool. Thirty percent of submissions described improvement efforts in other areas of practice. These projects were directed toward areas of patient care including safety, communication/education, satisfaction, processes, and outcomes. This study demonstrates the efforts of physiatrists to improve care and the potential impact of these efforts on patient care and safety through participation in continuing certification., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Physicians can lose board certification through revocation related to professionalism violations or expiration due to failure to complete continuing certification requirements. The purpose of this study was to analyze the causes of board certification loss for physicians with board certification through the American Board of Physical Medicine and Rehabilitation., Design: This retrospective cohort study analyzed the certification status of 5541 American Board of Physical Medicine and Rehabilitation diplomates between 1993 and 2019 to determine reasons for certification loss. A focused analysis of diplomates with expired certificates in 2019 was conducted to further examine reasons for certificate expiration., Results: Of 5541 physicians, 496 (9%) had certification expiration due to failure to meet continuing certification requirements and 60 (1%) had certification revocation due to disciplinary actions, without regaining certification across the study years. A focused analysis of physicians with expired certificates in 2019 revealed that the majority had failed to complete multiple components of continuing certification. Practice improvement was the single most common incomplete requirement. Failure to pass the knowledge assessment was an uncommon cause for certification loss., Conclusions: Certification expiration through failure to complete all continuing certification requirements, versus revocation, is responsible for most instances of board certification loss. Practice improvement was the most common incomplete requirement., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: There is limited literature examining the reasons physical medicine and rehabilitation residents take an extended leave of absence during residency and the impact of leave on board examination performance. Such information could better inform leave policies, help guide residency program directors, and potentially destigmatize taking leave. Study objectives were to describe the characteristics of physical medicine and rehabilitation residents who take leave during residency, compare differences in part I (written) and part II (oral) certification examination performance, and determine the prevalence of delays in taking board examinations. Study methodology was a retrospective analysis of deidentified information from the American Board of Physical Medicine and Rehabilitation database between 2008 and 2020. Results indicated four reasons for extended leave of absence: medical, parental, academic/remediation, and unspecified personal reasons. Residents who took an extended leave of absence for medical or parental reasons had similar or better odds of passing their part I and part II examinations compared with those without leave. Residents who took leave for academic/remediation concerns or unspecified personal reasons had lower odds of passing their board examinations. Examination delays for those taking parental or personal health leaves did not affect board pass rates. Further investigation is needed to identify how to support residents on academic/remediation and unspecified leaves during training., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: The American Board of Physical Medicine and Rehabilitation began administering the longitudinal assessment for physical medicine and rehabilitation for continuing certification in 2020. The longitudinal assessment for physical medicine and rehabilitation digitally delivers quarterly short assessments of content and repeats missed items to facilitate learning as well as serve as a summative certification assessment. With a goal of offering content relevant to an individual's practice and learning needs, diplomates choose how to customize the domains or topic areas of their question content on an annual basis. This report describes the first year of experience with customization of longitudinal assessment for physical medicine and rehabilitation. The American Board of Physical Medicine and Rehabilitation diplomate customization data are grouped and compared in a variety of ways to ascertain whether there are differences in customization choices. While customization choices were similar across several domains, significant differences were seen when comparing groups with specific areas of practice or subspecialty certification. Smaller differences were also seen when comparing question domain allocation choice between sexes, age groups, and practice setting. The results from this first full year of experience confirm an alignment of this innovative assessment approach to individual physician practice, a significant step in improving the relevance of continuing certification overall for participating physicians., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: (+)-Epicatechin (EPI) induces mitochondrial biogenesis and antioxidant metabolism in muscle fibers and neurons. We aimed to evaluate safety and efficacy of (+)-EPI in pediatric subjects with Friedreich's ataxia (FRDA)., Methods: This was a phase II, open-label, baseline-controlled single-center trial including 10 participants ages 10 to 22 with confirmed FA diagnosis. (+)-EPI was administered orally at 75 mg/d for 24 weeks, with escalation to 150 mg/d at 12 weeks for subjects not showing improvement of neuromuscular, neurological or cardiac endpoints. Neurological endpoints were change from baseline in Friedreich's Ataxia Rating Scale (FARS) and 8-m timed walk. Cardiac endpoints were changes from baseline in left ventricular (LV) structure and function by cardiac magnetic resonance imaging (MRI) and echocardiogram, changes in cardiac electrophysiology, and changes in biomarkers for heart failure and hypertrophy., Results: Mean FARS/modified (m)FARS scores showed nonstatistically significant improvement by both group and individual analysis. FARS/mFARS scores improved in 5/9 subjects (56%), 8-m walk in 3/9 (33%), 9-peg hole test in 6/10 (60%). LV mass index by cardiac MRI was significantly reduced at 12 weeks (P = .045), and was improved in 7/10 (70%) subjects at 24 weeks. Mean LV ejection fraction was increased at 24 weeks (P = .008) compared to baseline. Mean maximal septal thickness by echocardiography was increased at 24 weeks (P = .031). There were no serious adverse events., Conclusion: (+)-EPI was well tolerated over 24 weeks at up to 150 mg/d. Improvement was observed in cardiac structure and function in subset of subjects with FRDA without statistically significant improvement in primary neurological outcomes., Synopsis: A (+)-epicatechin showed improvement of cardiac function, nonsignificant reduction of FARS/mFARS scores, and sustained significant upregulation of muscle-regeneration biomarker follistatin., (© 2020 SSIEM.)

Telemedicine uses modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing convenient, safe, and time- and cost-efficient care. The coronavirus disease 2019 pandemic has created marked nationwide changes in health care access and delivery. Elective appointments and procedures have been canceled or delayed, and multiple states still have some degree of shelter-in-place orders. Many institutions are now relying more heavily on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Telemedicine can also help reduce the surge in health care needs and visits as restrictions are lifted. In recent weeks, there has been a significant amount of information and advice on how to best approach telemedicine visits. Given the frequent presentation of individuals with musculoskeletal complaints to the medical practitioner, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve, even after coronavirus disease 2019 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. In addition to photographs, accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can self-perform., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: The study analyzed the relationship between participation in the American Board of Physical Medicine and Rehabilitation maintenance of certification program and the incidence of disciplinary actions by state medical boards over a physician's career. The hypothesis is that physicians who do not maintain their board certification have a higher likelihood of state medical board disciplinary actions., Design: This retrospective cohort study analyzed American Board of Physical Medicine and Rehabilitation maintenance of certification data from all board-certified physiatrists who were enrolled in the American Board of Physical Medicine and Rehabilitation maintenance of certification program from 1993 to 2007., Results: Matching examination and license data were available for 4794 physicians, who received a total of 212 disciplinary action reports through the Federation of State Medical Boards. The results showed that physicians who have a lapse in completing the American Board of Physical Medicine and Rehabilitation maintenance of certification program have a 2.5-fold higher incidence of receiving a disciplinary action report through the Federation of State Medical Boards (95% confidence interval = 1.76-3.63) and had higher severity violations (χ = 7.14, P < 0.05) than physicians whose certificate never lapsed., Conclusions: For physicians in physical medicine and rehabilitation, loss of board certification through failure to fulfill the maintenance of certification program requirements is associated with an increased risk of disciplinary action from a state medical licensing board.

The COVID-19 pandemic has accelerated many changes in medicine including the transition from providing care in person to providing care via technology enabled telemedicine. The benefits of telemedicine visits with a Pediatric Rehabilitation Medicine (PRM) provider, also known as telerehabilitation medicine visits, are numerous. Telerehabilitation medicine provides an opportunity to deliver timely, patient and family-centric rehabilitation care while maintaining physical distance and reducing potential COVID-19 exposure for our patients, their caregivers and medical providers. Telerehabilitation medicine also allows for access to PRM care in rural areas or areas without medical specialty, virtual in-home equipment evaluation, and reduced travel burden. Because of these and many other benefits, telerehabilitation medicine will likely become part of our ongoing model of care if barriers to telemedicine continue to be lowered or removed. This paper is intended to establish a foundation for pediatric telerehabilitation medicine visit efficiency and effectiveness in our current environment and into the future.

Background: Certification by the American Board of Physical Medicine and Rehabilitation (ABPMR) requires passing both a written multiple choice examination (Part I) and an oral examination (Part II), but it has been unclear whether the two examinations measure the same or different dimensions of knowledge., Objective: To evaluate the concordance between the Part I and Part II examinations for ABPMR initial certification with regard to candidate performance on the examinations and their subsets. Our question is whether the Part II examination provides additional assessment of a candidate beyond what Part I provides., Design: Retrospective psychometric evaluation of deidentified board examination scores., Setting: ABPMR database of Part I and Part II examination scores., Participants: Candidates for the ABPMR Part I and Part II examinations after 2005, with a more detailed analysis of candidates for the Part I examination from 2014 to 2016. Examination scores of candidates who took the Part II examination both before and after the examination was standardized in 2005 were also used for an additional analysis., Methods: Correlations, simple linear regressions, and principal components analysis., Main Outcome Measurements: Correlation coefficients, variance analysis, and unexplained variance in the principal components analysis., Results: There is a weak to moderate correlation between performance on the Part I and Part II examinations: r = 0.33, P < .001. There is an additional dimension of assessment that is demonstrated on the Part II examination, with this being primarily in the domains of systems-based practice and interpersonal communication skills., Conclusion: The Part I and Part II examinations, although with some overlap, contribute different and meaningful components to the overall evaluation of candidates for board certification in PM&R., Level of Evidence: III., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Objective: Unconscious bias may result in a prejudicial evaluation of another person and lead to unfair treatment. Potential gender bias risk exists in the scoring process on the American Board of Physical Medicine and Rehabilitation oral examination (Part II) because of the face-to-face interactions between candidates and examiners. This study was undertaken to determine whether performance on the American Board of Physical Medicine and Rehabilitation Part II examination differed based on candidate gender or configuration of examiner/candidate gender pairings. The impact of examiner unconscious bias training on candidate performance was also assessed., Design: This is a retrospective observational study of first-time Part II physical medicine and rehabilitation certification examination test takers between 2013 and 2018., Results: There were significant differences in pass rates (men 84%, women 89%) and mean scaled scores (men 6.56, women 6.81) between men and women (P < 0.001) with the biggest domain score differences in data acquisition and interpersonal and communication skills. Implementation of examiner unconscious bias training did not impact candidate performance., Conclusions: Women candidates scored higher and had a higher pass rate than men candidates overall on the American Board of Physical Medicine and Rehabilitation Part II examination. This difference does not seem to be due to scoring gender bias by the Part II examiners or due to candidate aptitude as measured on the Part I examination.

Background: Posterior lumbar vertebral endplate fracture occurs with avulsion of the ring apophysis from the posterior vertebral body. Although this has been described in adolescents and young adults, proper diagnosis is often delayed or missed entirely. Surgery may be curative., Objective: To determine the common clinical features and treatment outcomes in youth and young adults with posterior lumbar vertebral endplate fractures., Design: Retrospective case series., Setting: Academic medical institution., Patients: Patients 10 to 25 years old from 2000 through 2012 with posterior vertebral endplate fracture diagnosis., Main Outcome Measurements: Demographic characteristics, diagnostic studies, interventions, and change in symptoms postoperatively., Results: A total of 16 patients had posterior vertebral endplate fractures (8 male patients; mean age, 15.2 years)-8.3% of 192 patients with inclusion age range undergoing spinal surgery for causes unrelated to trauma, scoliosis, or malignancy. The most common signs and symptoms were low back and radiating leg pain, positive straight leg raise, hamstring contracture, and abnormal gait. Cause was sports related for 12 patients (75%). Mean (range) time to diagnosis was 13.0 (3.0-63.0) months. Diagnosis was most commonly made with lumbar magnetic resonance imaging (n = 6). Most fractures occurred at L5 (n = 8, 50%) and L4 (n = 5, 31.3%). Conservative measures were trialed before surgery. Nine patients had "complete relief" following surgery and seven "improved.", Conclusions: Posterior vertebral endplate fracture should be considered in differential diagnosis of a youth or young adult with back pain, radiating leg pain, and limited knee extension, regardless of symptom onset. For patients in whom conservative management fails, consultation with an experienced physician whose practice specializes in spine medicine is recommended., Level of Evidence: IV., (© 2018 American Academy of Physical Medicine and Rehabilitation.)

Background: Maintenance of certification (MOC) in Physical Medicine and Rehabilitation is a process of lifelong learning that begins after successfully completing an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and passing the American Board of Physical Medicine and Rehabilitation (ABPMR) Part I and Part II Examinations. We seek to identify factors predictive of successful MOC Examination performance., Objective: To identify characteristics predictive of successful completion on the ABPMR MOC Examination., Design: Retrospective review., Setting: American Board of Physical Medicine and Rehabilitation database review., Participants: 4,545 diplomates who completed the MOC Examination between January 2006 and December 2017., Methods: MOC Examination performance was the primary outcome variable. Performance on Part I and Part II Examinations were independent variables. Additional potential predictors evaluated included year of MOC cycle in which examination was taken, years of practice since residency completion, age, and subspecialty certification., Main Outcome Measures: Performance on MOC Examination., Results: Age at time of MOC Examination was inversely correlated with examination score (r = -0.14, P < .001). Similarly, as time since completion of residency training increased, MOC scores declined. Passing the Part I Examination on first attempt predicted a 98% MOC pass rate, compared to 90% for those who failed initially. MOC performance was highly correlated with Part I performance (r = 0.59, P < .001) and Part II performance (r = 0.32, P < .001). Although MOC performance was similar for those taking the examination in years 7 - 10 of their cycle (97% pass rate), those taking the examination after more than 10 years of the cycle had a significantly lower performance (85% pass rate, P < .01)., Conclusions: Better performance on the MOC Examination is associated with better performance on Part I and Part II Examinations, taking the examination earlier in the 10 year cycle, younger age, and less time since completion of training. Diplomates who are at higher risk for failing the examination may need to prepare differently for MOC Exam than those who are more likely to pass., Level of Evidence: III., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of intentional undersizing of prosthetic radial head implant diameters on joint contact pressures., Methods: Eight fresh-frozen cadaveric elbows were aligned in neutral extension and loaded with 100 N using a custom testing apparatus. Radiocapitellar contact pressures were recorded using a Tekscan thin-film pressure sensor. Prosthetic radial head replacement was performed with 2 prostheses: the Anatomic Radial Head and the Evolve Proline Radial Head prostheses. Each design was sized according to the manufacturer's recommendations and then again using 2-mm smaller radial heads., Results: Average and peak pressures were significantly higher with the Evolve than the Anatomic prostheses (P < 0.03 and 0.02, respectively). Peak pressures decreased from 4.2 ± 0.5 MPa to 2.9 ± 0.3 MPa for the Anatomic Radial Heads and from 5.6 ± 0.5 MPa to 3.9 ± 0.6 MPa when the Evolve Radial Heads were undersized by 2 mm. The mean pressures of the Anatomic Radial Heads (1.4 ± 0.1 MPa) did not change significantly with undersizing (1.3 ± 0.1 MPa, P = 0.12), whereas the mean pressures of the Evolve Radial Heads (1.6 ± 0.1 MPa) were significantly reduced with undersizing (1.4 ± 0.1 MPa, P < 0.02)., Conclusion: Both mean and peak pressures were initially high for the Evolve Radial Head sized based on the short axis diameter and were improved with further undersizing by 2 mm. Peak, but not mean, contact pressures were improved by undersizing the Anatomic prosthesis based on the long axis diameter., Clinical Relevance: These findings support the clinical recommendation of some surgeons to undersize the Evolve prosthesis by 2-mm smaller diameter than the current manufacturer's suggestion and give reason to consider doing the same for the Anatomic prosthesis.

Objective: This study sought to evaluate the impact of an interdisciplinary care model for pediatric aerodigestive patients in terms of efficiency, risk exposure, and cost., Methods: Patients meeting a standard clinical inclusion definition were studied before and after implementation of the aerodigestive program., Results: Aerodigestive patients seen in the interdisciplinary clinic structure achieved a reduction in time to diagnosis (6 vs 150 days) with fewer required specialist consultations (5 vs 11) as compared to those seen in the same institution prior. Post-implementation patients also experienced a significant reduction in risk, with fewer radiation exposures (2 vs 4) and fewer anesthetic episodes (1 vs 2). Total cost associated with the diagnostic evaluation was significantly reduced from a median of $10,374 to $6055., Conclusion: This is the first study to utilize a pre-post cohort to evaluate the reduction in diagnostic time, risk exposure, and cost attributable to the reorganization of existing resources into an interdisciplinary care model. This suggests that such a model yields improvements in care quality and value for aerodigestive patients, and likely for other pediatric patients with chronic complex conditions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Pediatric rehabilitation medicine (PRM) physicians enter the field via several pathways. It is unknown whether different training pathways impact performance on the American Board of Physical Medicine and Rehabilitation (ABPMR) PRM Examination and Maintenance of Certification (MOC) Examination., Objectives: To describe the examination performance of candidates on the ABPMR PRM Examination according to their type of training (physiatrists with a clinical PRM focus, accredited or unaccredited fellowship training, separate pediatric and physical medicine and rehabilitation residencies, or combined pediatrics/physical medicine and rehabilitation residencies) and to compare candidates' performance on the PRM Examination with their initial ABPMR certification and MOC Examinations., Design: A retrospective cohort study., Setting: American Board of Physical Medicine and Rehabilitation office., Participants: A total of 250 candidates taking the PRM subspecialty certification examination from 2003 to 2015., Methods: Scaled scores on the PRM Examination were compared to the examinees' initial certification scores as well as their admissibility criteria. Pass rates and scaled scores also were compared for those taking their initial PRM certification versus MOC., Main Outcome Measurements: Board pass rates and mean scaled scores for initial PRM Examination and MOC., Results: The 250 physiatrists who took the subspecialty PRM Examination had an overall first-time pass rate of 89%. There was no significant difference between first-time PRM pass rates or mean scaled scores for individuals who completed an Accreditation Council for Graduate Medical Education-accredited fellowship versus those who did not. First time PRM pass rates were greatest among those who were also certified by the American Board of Pediatrics (100%). Performance on Parts I and II of the initial ABPMR Certification Examination significantly predicted PRM Examination scores. There was no difference in mean scaled scores for initial PRM certification versus taking the PRM Examination for MOC., Conclusions: Several pathways to admissibility to the PRM Examination afforded similar opportunity for diplomates to gain the knowledge necessary to pass the PRM Examination. Once certified, physicians taking the PRM Examination for MOC have a high success rate of passing again in years 7-10 of their certification cycle., Level of Evidence: III., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the surgical treatment and patient outcomes of chronic elbow dislocations., Design: Retrospective review., Setting: Two tertiary referral centers., Patients/participants: All patients with surgically treated chronic elbow dislocation with no associated articular fracture from January 2009 to January 2015., Intervention: Review of patient demographics, injury chronicity, surgical technique, and patient outcomes., Main Outcome Measurement: Clinical outcomes included elbow range of motion and complications. Radiographic outcomes included the presence of heterotopic ossification. Patient-reported outcomes included the Mayo Elbow Performance Index (MEPI) and the Summary Outcome Determination (SOD)., Results: Thirty-two patients with mean follow-up of 22 months (range, 13-41 months) were included. The mean dislocation duration was 6 months (range, 1-34 months). The mean preoperative range of motion was 8 degrees (range, 0-30 degrees). There were no infections or recurrent dislocations. One patient developed transient ulnar nerve palsy postoperatively. There were no cases of new or progressive heterotopic ossification. The mean postoperative extension was 31 degrees (range, 0-75 degrees), and the mean postoperative flexion was 132 degrees (range, 95-150 degrees); the mean final arc of motion was 101 degrees (range, 50-140 degrees). The mean postoperative MEPI was 93 (range, 70-100), and the mean SOD score was 9 (range, 6-10). Using the MEPI, 97% (31/32 patients) had good or excellent outcome. There was no difference in flexion/extension arc or MEPI scores between groups of elbows older and younger than 17 years or dislocations less or more than 3 months., Conclusion: This is the largest case series of surgically treated patients with chronic elbow dislocation. Using our surgical technique, 97% of patients had good or excellent outcome with a low complication rate. Open reduction of chronic elbow dislocation can be accomplished while permitting early motion with minimal recurrent dislocation risk., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: The objective of this study was to determine if wrestling is a safe, positive athletic option for limb-deficient individuals., Design: This descriptive study consisted of an opportunity sample of limb-deficient wrestlers, aged 5 yrs and older with at least 1 yr of experience. Participants completed a questionnaire regarding health, satisfaction, and achievements. Descriptive statistics were used for analysis., Results: Sixteen male wrestlers reported nine below-the-knee, five above-the-knee, and three below-the-elbow limb deficiencies. There were nine congenital deficiencies and seven amputations acquired during childhood. Two individuals won National Collegiate Athletic Association championships, and seven competed collegiately. All reported a positive impact on quality-of-life, 87% reported no difficulty finding acceptance with the team, and 50% experienced wrestling-related residual limb complications. Associations between (1) residual limb complications before and during wrestling and (2) skin breakdown before and during wrestling did not demonstrate statistical significance (P = 0.30 and 0.1189, respectively)., Conclusions: This study suggests that wrestling is a safe, positive sport for limb-deficient individuals, that it fosters competitive equality between impaired and nonimpaired participants, and that it has a positive impact on health and quality-of-life. The incidence of residual limb complications warrants monitoring.

Chronic pain in children and adolescents can be difficult for a single provider to manage in a busy clinical setting. Part of this difficulty is that pediatric chronic pain not only impacts the child but also the families of these children. In this review article, we discuss etiology and pathophysiology of chronic pain, along with variables that impact the severity of chronic pain and functional loss. We review diagnosis and management of selected chronic pain conditions in pediatric patients, including headache, low back pain, hypermobility, chronic fatigue, postural orthostatic tachycardia syndrome, abdominal pain, fibromyalgia, and complex regional pain syndrome. For each condition, we create a road map that contains therapy prescriptions, exercise recommendations, and variables that may influence pain severity. Potential medications for these pain conditions and associated symptoms are reviewed. A multidisciplinary approach for managing children with these conditions, including pediatric pain rehabilitation programs, is emphasized. Lastly, we discuss psychological factors and interventions for pediatric chronic pain and potential complementary and alternative natural products and interventions., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Many teenagers who struggle with chronic fatigue have symptoms suggestive of autonomic dysfunction that may include lightheadedness, headaches, palpitations, nausea, and abdominal pain. Inadequate sleep habits and psychological conditions can contribute to fatigue, as can concurrent medical conditions. One type of autonomic dysfunction, postural orthostatic tachycardia syndrome, is increasingly being identified in adolescents with its constellation of fatigue, orthostatic intolerance, and excessive postural tachycardia (more than 40 beats/min). A family-based approach to care with support from a multidisciplinary team can diagnose, treat, educate, and encourage patients. Full recovery is possible with multi-faceted treatment. The daily treatment plan should consist of increased fluid and salt intake, aerobic exercise, and regular sleep and meal schedules; some medications can be helpful. Psychological support is critical and often includes biobehavioral strategies and cognitive-behavioral therapy to help with symptom management. More intensive recovery plans can be implemented when necessary., (Copyright © 2014 Mosby, Inc. All rights reserved.)

This report describes 2 cases of a posteroinferior capitellum impaction osteochondral injury with associated avulsion of the supinator crest resulting from a fall onto an extended upper extremity. The injury pattern in both cases was detected on x-ray films, although fully appreciated on computed tomographic imaging. Posterolateral rotatory instability occurred in both patients. One patient underwent early operative intervention (4 days postinjury) and returned to normal within 5 weeks. Surgery was delayed for the second patient (13 weeks), who initially experienced unfavorable outcomes, although stability was ultimately restored operatively. To our knowledge, this injury pattern has not previously been described as the focus of a report.

After obesity rates in youth reached alarming rates, public health officials recognized the need for specific physical activity guidelines for children and adolescents. Numerous health care groups and sports and fitness organizations collaborated on the development of the Physical Activity Guidelines for Americans in 2008, which have been widely endorsed and include recommendations for the pediatric population. Children and adolescents should participate in moderate-to-vigorous physical activity 1 or more hours per day and muscle and bone-strengthening activities 3 or more times per week. Physical activities should be age appropriate, enjoyable, and varied and occur beyond what is required for typical activities of daily living. Adequate exercise in youth improves strength, cardiorespiratory fitness, and body composition and therefore decreases cardiovascular risk factors. An improved cardiovascular profile provides a continued benefit in adulthood. Exercise also improves bone health, psychological well-being, cognition, and school performance and may decrease the risk of sports injury. Exercise habits established in childhood often continue into adulthood., (Copyright © 2012 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

This descriptive population study of 307 public high school students, ages 15 to 17 years, was performed to establish reference ranges for orthostatic changes in heart rate and blood pressure in adolescents, and to identify influential variables. Noninvasive measurements of blood pressure and heart rate were obtained. Reference ranges for orthostatic heart rate change in this population at 2 minutes were -2 to +41 beats per minute and at 5 minutes were -1 to +48 beats per minute. Orthostatic blood pressure changes were within the adult range for 98% of adolescents tested. One-third of participants experienced orthostatic symptoms during testing. In conclusion, this study shows that orthostatic symptoms and large orthostatic heart rate changes occur in adolescents. This suggests that the current orthostatic heart rate criterion aiding the diagnosis of adult orthostatic intolerance syndromes is likely not appropriate for adolescents and should be reevaluated.

Background: Postural orthostatic tachycardia syndrome (POTS) is associated with debilitating fatigue, dizziness, and discomfort in previously healthy adolescents. The effects of medical therapy have not been well studied in this patient population. This study assessed the relative efficacy and impact of drug therapy on the functioning and quality of life in adolescents with POTS., Methods: A retrospective, single center, chart review analysis with a follow-up written survey was conducted on a group of 121 adolescents who had undergone autonomic reflex screening at the Mayo Clinic from 2002 to 2005 as part of an evaluation for possible POTS., Results: Of 121 surveys sent, 47 adolescents returned a completed survey. In this cohort of patients, the two most commonly prescribed drug therapies were midodrine (n = 13) and beta-blockers (n = 14). Patients in the midodrine group were comparable to patients in the beta-blocker group in gender, age, pretreatment postural heart rate changes, and months from initial evaluation to survey completion. More patients treated with a beta-blocker reported improvement after visiting Mayo Clinic (100% vs 62%, P = 0.016) and more attributed their progress to medication (63.6% vs 36.4%, P = 0.011) than did those treated with midodrine., Conclusion: Treatment with both midodrine and beta-blockers was associated with overall improvement in POTS patients' general health; however, adolescents taking beta-blockers were more likely than those taking midodrine to credit the role of medications in their improvement.

A wide variety of neuromuscular diseases affect children, including central nervous system disorders such as cerebral palsy and spinal cord injury; motor neuron disorders such as spinal muscular atrophy; peripheral nerve disorders such as Charcot-Marie-Tooth disease; neuromuscular junction disorders such as congenital myasthenia gravis; and muscle fiber disorders such as Duchenne's muscular dystrophy. Although the origins and clinical syndromes vary significantly, outcomes related to musculoskeletal complications are often shared. The most frequently encountered musculoskeletal complications of neuromuscular disorders in children are scoliosis, bony rotational deformities, and hip dysplasia. Management is often challenging to those who work with children who have neuromuscular disorders.

Cartilage repair by autologous periosteal arthroplasty is enhanced by continuous passive motion (CPM) of the joint after transplantation of the periosteal graft. However, the mechanisms by which CPM stimulate chondrogenesis are unknown. Based on the observation that an oscillating intra-synovial pressure fluctuation has been reported to occur during CPM (0.6-10 kPa), it was hypothesized that the oscillating pressure experienced by the periosteal graft as a result of CPM has a beneficial effect on the chondrogenic response of the graft. We have developed an in vitro model with which dynamic fluid pressures (DFP) that mimic those during CPM can be applied to periosteal explants while they are cultured in agarose gel suspension. In this study periosteal explants were treated with or without DFP during suspension culture in agarose, which is conducive to chondrogenesis. Different DFP application times (30 min, 4 h, 24 h/day) and pressure magnitudes (13, 103 kPa or stepwise 13 to 54 to 103 kPa) were compared for their effects on periosteal chondrogenesis. Low levels of DFP (13 kPa at 0.3 Hz) significantly enhanced chondrogenesis over controls (34 +/- 7% vs 14 +/- 5%; P < 0.05), while higher pressures (103 kPa at 0.3 Hz) completely inhibited chondrogenesis, as determined from the percentage of tissue that was determined to be cartilage by histomorphometry. Application of low levels of DFP to periosteal explants also resulted in significantly increased concentrations of Collagen Type II protein (43 +/- 8% vs 10 +/- 5%; P < 0.05). New proteoglycan synthesis, as measured by 35S-sulphate uptake was increased by 30% in periosteal explants stimulated with DFP (350 +/- 50 DPM vs 250 +/- 75 DPM of 35S-sulphate uptake/microg total protein), when compared to controls though this difference was not statistically significant. The DFP effect at low levels was dose-dependant for time of application as well, with 4 h/day stimulation causing significantly higher chondrogenesis than just 30 min/day (34 +/- 7 vs 12 +/- 4% cartilage; P < 0.05) and not significantly less than that obtained with 24 h/day of DFP (48 +/- 9% cartilage, P > 0.05). These observations may partially explain the beneficial effect on cartilage repair by CPM. They also validate an in vitro model permitting studies aimed at elucidating the mechanisms of action of mechanical factors regulating chondrogenesis. The fact that these tissues were successfully cultured in a mechanical environment for six weeks makes it possible to study the actions of mechanical factors on the entire chondrogenic pathway, from induction to maturation. Finally, these data support the theoretical predictions regarding the role of hydrostatic compression in fracture healing.

A graft of periosteum from the tibia of 27 rabbits was incubated in vitro with tritiated thymidine for 24 hours and then transplanted into a full-thickness defect in the patellar groove. The rabbits were managed after the operation on continuous passive motion (CPM), and the joints excised at intervals of two to 21 days. After one week the cells had begun to synthesize glycosaminoglycan and by two weeks the tissue resembled immature hyaline cartilage. Thymidine-labeled cells were seen throughout the entire regenerated tissue. The cellular origin of the hyaline-like tissue that filled the defects was the progenitor cells of the periosteal graft.