Rotations
General Rehabilitation/Spinal Cord Injury – BMC General/Neuro
Location: 7W Harrison Pavilion (HP)
Address: 1 BMC Place, Boston, MA 02118
Phone: (617) 414-4154
Preceptor: Feng Wang, MD
Target PGY-year(s): 2-
Rotation Description:
In this rotation, residents provide primary medical management for patients with neurological and general rehabilitation needs in an inpatient setting. Residents observe neuropsychological testing and gain experience with pharmacologic management principles. Residents are expected to participate in community re-entry trips and home visits with the therapists. Residents also have the opportunity to particpate in continuity outpatient clinics.
Learning Objectives:
Knowledge:
1. Epidemiology of disabling neurological disorders.
2. Mechanisms of recovery, neural plasticity, learning and skill acquisition.
3. Pathogenesis and treatment of various specific impairments including spasticity, ataxia, and flaccid paralysis; sensory impairment due to blindness and deafness; neuropsychological dysfunction; incontinence; dysphagia; disorders of speech and language, perception and memory, and other cognitive functions including attention, sequencing and planning.
4. Organization of services including linkage with pediatric and geriatric services.
5. Practice across the interface between rehabilitation medicine, learning disabilities, psychiatry and neuropsychiatry and neuropsychology.
6. Burden and impact of neurological disease on families.
7. Measurement in neurological rehabilitation.
Skills:
1. Assessment of the neurologically disabled person by means of the history and neurological examination.
2. Interpretation, preferably learned through experience, of common neurological and neuro-radiological investigations and neuro-psychological tests.
3. Use of some measures of disability and handicap in common neurological disorders such as stroke and multiple sclerosis and traumatic brain injury.
4. Methods of managing neurological impairment e.g. spasticity, feeding difficulties, incontinence, neurogenically impaired respiratory function etc.
5. Management of behaviorally disturbed people with neurological impairments.
BMC Spinal Cord Injury
Location: 7W Harrison Pavilion (HP)
Address: 1 BMC Place, Boston, MA 02118
Phone: (617) 414-4154
Preceptor: Kristen Gustafson, DO
Target PGY-year(s): 2,
Rotation Description:
This is an inpatient rotation, although there are several outpatient clinic opportunities available to residents, including the seating clinic, spinal cord injury outpatient clinic, and outpatient physical therapy sessions using the FES bicycle and gait training. Newly injured patients are admitted directly from acute medical-surgical or intensive care units from the greater Boston area. Residents gain experience with medical management of acute spinal cord injuries, proper use of adaptive equipment for mobility and activities of daily living, team building and leadership skills, and quality assurance issues. Residents should participate in community re-entry trips and home visits with the therapists.
Learning Objectives:
After completing the spinal cord injury rotation, the resident should have a detailed understanding of how to evaluate and treat both acutely injured and long term spinal cord injury patients.
They should be able specifically to:
1. Complete a reflex, motor, and sensory examination to determine the level of injury according to the ASIA classification system.
2. Identify key muscles and calculate the ASIA motor score.
3. Use appropriate radiologic studies to determine spinal stability and assist in planning appropriate treatment, including both non-operative and operative management.
4. Understand the use of various spinal orthoses in providing additional support to the injured spine.
5. Understand the pathophysiology, prevention, and management of medical complications of spinal cord injury, including metabolic derangements, pressure sores, deep vein thrombosis, heterotopic ossification, autonomic dysreflexia, infections, contractures, and spasticity.
6. Manage the medically complex patient at all stages, and set appropriate rehabilitation goals in conjunction with the multidisciplinary rehabilitation team.
7. Understand pulmonary function in the spinal cord injured individual, with special attention to the management of ventilator-dependent quadriplegics
8. Describe the pathophysiology of neurogenic bladder dysfunction, understand commonly used screening and diagnostic studies, and design appropriate management strategies to prevent long term complications in upper and lower motor neuron lesions.
9. Identify reflexes employed in the management of neurogenic bowel dysfunction and devise appropriate management strategies for upper and lower motor neuron lesions.
10. Understand neurogenic sexual dysfunction, including effects on fertility, in both males and females.
11. Understand alterations in mobility after a spinal cord injury, be able to decide upon a treatment regimen employing appropriate physiatric therapeutic modalities and create written prescriptions.
12. Understand the structure and function of wheelchairs, prosthetic and orthotic, and other durable medical equipment. Be able to write appropriate equipment prescriptions.
13. Describe the use of adaptive equipment in activities of daily living and prescribe it properly.
14. Identify specific emotional and psychosocial considerations and how they may affect the spinal cord injured individual.
15. Understand various leadership styles and team dynamics.
Outpatient/EMG
Location: various places, including: Boston Medical Center, Spaulding Rehabilitation Center, Whittier Rehabilitation Hospital, Sports Medicine-Peabody, Bedford VA
Address: 1 BMC Place, Boston, MA 02118
Phone: (617) 638-7300
Preceptor: Leslie Morse, DO; Clay Miller, MD; Radha Vijayakumar, MD; Paul Liguori, MD
Target PGY-year(s): 3, 4
Rotation Description:
Residents rotate through a variety of outpatient clinics at BMC and affiliate locations. There is some flexibility in the clinics attended. Residents assigned to this rotation will also rotate at the Mass Eye and Ear Infirmary on four Thursdays during one month of their rotation. EMG experience is obtained in the outpatient clinic at BMC and at Quincy Medical Center in the EMG Lab.
Learning Objectives:
After completing the Ambulatory Rehabilitation section, the resident should be able to:
1. Perform an outpatient rehabilitation medicine functionally oriented history and physical examination.
2. Understand how medical and surgical problems can impact on an individual’s ability to fulfill her/his role(s) at home and in the community.
3. Realize how physical, occupational, and kinesiotherapy therapy services can be delivered in an outpatient setting.
4. Become proficient in the performance of procedures typically performed on outpatients,
such as trigger point, bursa, other soft tissue, and joint injections.
5. Understand how Independent Medical Examinations are performed.
6. Understand the role of personal care assistants in the independent functioning of patients.
Electrodiagnostic skills:
1. Understand operation, safety features, and calibration of electrodiagnostic equipment.
2. Understand normal functional anatomy of the upper and lower extremities.
3. Be able to plan, execute, and interpret electrodiagnostic studies appropriately.
4. Be able to write a well-organized, correct EMG report.
5. Do routine segmental motor and sensory NCS.
6. Do routine needle EMG.
7. Understand the clinical and neurophysiologic diagnosis of cervical and lumbar radiculopathies.
8. Understand the electrodiagnosis of axonal and demyelinating neuropathies, and of the major nerve entrapment syndromes.
9. Distinguish normal, “myopathic” and “neuropathic” changes with needle EMG.
10. Perform late response studies including blink reflexes, H reflexes and F responses, and be familiar with the diagnostic meaning of abnormal studies.
11. Do repetitive stimulation studies.
12. Do advanced nerve conduction studies including spinal nerve/root stimulation and some acquaintance with the principles of collision, Max-Min conduction velocity and refractory period.
13. Do quantitative EMG studies including some acquaintance with single fibre and macro EMG.
14. Residents are expected to be able to properly care for all wires and electrodes used in electrodiagnostic testing. Disposable needles are used for elecromyography and must be
placed in a needle receptacle after use. Recording leads should be neatly folded and taped so that the machine is ready for the next study.
BMC Outpatient
Location: various BMC outpatient clinics in the Boston Medical Center system) and affiliate locations
Address: 1 BMC Place, Boston, MA 02118 and affiliates
Phone: (617) 638-7300
Preceptor: BMC outpatient attendings.
Target PGY-year(s): 2, 3, 4
Rotation Description:
Residents rotate through a variety of outpatient clinics at BMC and affiliate locations. There is some flexibility in the clinics attended. Clinics available include: PM&R, Neurology, Rheumatology, Oncology, Urology, Physical Therapy, Prosthetics and Orthotics.
Learning Objectives:
After completing the Ambulatory Rehabilitation section, the resident should be able to:
1. Perform an outpatient rehabilitation medicine functionally oriented history and physical examination.
2. Understand how medical and surgical problems can impact on an individual’s ability to fulfill her/his role(s) at home and in the community.
3. Realize how physical, occupational, and kinesiotherapy therapy services can be delivered in an outpatient setting.
4. Become proficient in the performance of procedures typically performed on outpatients, such as trigger point, bursa, other soft tissue, and joint injections.
5. Understand how Independent Medical Examinations are performed.
6. Understand the role of personal care assistants in the independent functioning of patients.
BMC Consults
Location: Harrison and East Newton Pavilions (HP & ENP)
Address: 1 BMC Place, Boston, MA 02118
Phone: (617) 638-7300
Preceptor: Simona Manasian, MD
Target PGY-year 4
Rtation Description:
In this rotation, residents provide PM&R consultation for other services throughout BMC. Along with the attending physician, residents attend Trauma Rounds in the surgical intensive care unit and Neurosurgical Conference with the neurosurgical staff. The resident may attend outpatient clinics and perform EMG’s. Residents will assess a wide variety of conditions including TBI, SCI, stroke, fractures, joint replacement, and amputations.
Learning Objectives:
1. Evaluate patients in a comprehensive yet concise manner and present appropriate recommendations to maximize functional potential, including therapeutic exercise, physical modalities, medical interventions, and durable medical equipment.
2. Develop a familiarity with the medical and rehabilitation issues of the diseases and conditions managed, with a thorough understanding of the nature of the surgical and medical management, as well as expected outcomes and complications.
3. Understand different levels of rehabilitative care and correctly assign patients to appropriate facilities based on levels of care.
4. Provide useful information to referring services as well as discharge planning personnel .
5. Communicate with personnel from other services in an effective manner. Written and oral communication must be
clear and precise.
6. Provide effective leadership in order to coordinate treatment plan.
7. Understand case management roles and responsibilities.
Whittier Rehabilitation Hospital
Location: 76 Summer Street
Address: Haverhill, MA 01830
Phone: (978) 372-8000
Preceptor: Paul Liguori, MD
Target PGY- 2
Rotation Description:
The Whittier Rehabilitation Hospital provides a setting where patients who are not able to return to their previous level of independence can receive nursing and rehabilitation treatments in preparation for discharge. A wide range of diagnoses and service needs are represented.
Learning Objectives:
Knowledge:
1. Become familiar with the operation of the inpatient rehabilitation service .
2. Learn the Medicare rules and regulations that apply in the Transitional Care Setting
3. Become proficient in the assessment of social supports and determinants of discharge destination in the elderly population.
4. Understand the effects of medications and environment on the elderly patient.
5. Epidemiology of disability in the elderly.
6. Understanding of how individuals function in families and in society.
7. Principles of primary, secondary and tertiary prevention of disability.
8. Knowledge of the preventive management of medical complications of musculoskeletal and neurological impairments, including falls, skin ulcers, contractures, nutritional complications etc.
9. Knowledge of the medical, surgical, nursing and therapeutic management of the above complications.
10. Nutritional and energy needs of severely disabled people, including nutritional supplementation.
11. Methods of monitoring progress in people with progressive disability using appropriate instruments to measure health gain or deterioration.
12. Biomechanical and kinesiological aspects of human function, including the physiology of exercise and the use of mechanical devices, aids and appliances to improve function or promote independence of disabled people.
13. Environmental factors, including access to buildings and other architectural aspects which are important in minimizing handicap.
14. Systems for the delivery of health and social care, and the economics of health care as it affects both society and the individual.
15. The principles and practice of management, and the application of these principles to problems of the delivery of services to disabled people.
16. Principles of counseling, development of interpersonal skills and group dynamics.
Skills:
1. The medical assessment of disabled people referred for rehabilitation.
2. Collaboration with a multidisciplinary team in selecting the appropriate form of ongoing management according to the capabilities and needs of the disabled person.
3. Screening assessment of the impact of disease and disability on everyday life.
4. Detailed clinical assessments relevant to the comprehensive evaluation of disabled people in an inpatient setting.
5. Health promotion needs and medical management of people with chronic and progressive disability (particularly promotion of tissue viability, nutrition and feeding, continence, physical function, tone and posture, management of pain, mood, behavior).
6. Assessing and meeting the needs of people in the terminal phase of chronic disabling conditions.
7. Identification of careers’ needs, including respite arrangements.
8. Effective working within multi-professional teams in different roles, including that of team leader.
9. Organization and chairing of multidisciplinary case conferences or other meetings involving the disabled person and their family.
10. Advocacy role on behalf of disabled people, particularly to break down administrative barriers between different service providers.
11. Contribution to the appropriate negotiating of goals, application of resources and review of achievements in different settings (inpatient and community).
12. Effective communication with relatives.
Sports Medicine
Location: Sports Medicine North
Address: 1 Orthopedic Dr 2nd fl., Peabody, MA
Phone: (978) 818-6350
Preceptor: Clay Miller, MD
Target PGY-year(s): 3, 4
Rotation Description:
This rotation includes exposure to musculoskeletal medicine, management of simple fractures (casting, bracing, and taping), performing arts medicine, and team sports coverage, as well as opportunity to perform EMGs.
Learning Objectives:
Injuries resulting from sporting activities are a major cause of short term disability and time lost from work. All rehabilitation medicine trainees should be familiar with the basic principles of the assessment and management of injuries to the musculoskeletal system through their training in musculoskeletal rehabilitation and perhaps further training in rheumatology or orthopedic rehabilitation.
Knowledge:
1. The biomechanics of sporting injuries.
2. The physical and psychological attributes of sportsmen/women.
3. The mechanisms of injuries in different sports, and their relevance to prevention.
4. Clinical presentation, assessment and management of acute sporting injuries.
5. Exercise physiology, the positive and negative effects of exercise, and the importance of retraining in the management of people who have sustained sporting injuries.
6. Neurological damage resulting from sporting injuries, and their short and long term importance for the athlete.
7. The employment, domestic and other social consequences of sports injuries for the athlete and society.
8. The problems of children and adolescents involved in sport, particularly those subject to over-training, fatigue and other negative influences.
9. Drugs and sport.
10. Sports and sporting activity among disabled people, including any special equipment which they may require.
Skills:
1. Assessment and rehabilitation of people injured while undertaking sporting activities.
2. Measurement of physical fitness.
3. Assessing the physical and psychological consequences of failure of the acute injury to resolve to the satisfaction of the athlete.
4. Understanding the motivation of athletes and how this can help, or occasionally hinder, rehabilitation after injury.
5. Dealing with disabled people who have been injured while undertaking a sporting activity.
Elective
Location: Boston Medical Center or Affiliate
Address: 1 BMC Place, Boston, MA 02118
Phone: (617) 638-7300
Preceptor: (Elective preceptor)
Target PGY-year(s): 3, 4
Rotation Description:
Residents are allowed to arrange their own outpatient/inpatient experience with preceptor(s) in an area of interest. Residents should make arrangements for the rotation several months in advance. Rotations must be approved by the Residency Program Director.
Learning Objectives
Rotation goals are dependent on the specific rotation arranged.
Bedford VA
Location: Edith Nourse Rogers Memorial Veterans Hospital
Address: 200 Springs Road, Bedford, MA 01730
Phone: (781) 687-2348
Preceptor: Herminia Festin, MD
Target PGY-year(s):3, 4
Rotation Description:
The resident assesses the rehabilitation needs of patients in the setting of a large VA medical center. The experience is primarily with outpatients, although the resident will occasionally assess inpatient needs. Goals include maximizing proficiency in EMG skills.
Learning Objectives:
1. The application of principles and techniques particular to the specialty of Physical Medicine in cases of concurrent musculoskeletal and psychiatric conditions.
2. Proficiency in Electromyography, Nerve Conduction Studies and Somatosensory tests.
3. Exposure to electrophysiological tests such as single fiber EMG, Auditory Evoked Potentials and Visual Evoked Potentials.
4. The application of principles and techniques typical of this specialty in the treatment of the elderly patient. Particular interest will be given to the cardiovascular implications in the rehabilitation of the elderly.
5. The development of understanding and perception of the musculoskeletal problems in the context of the whole person and an increase of knowledge and experience in the progression of the rehabilitation process. The stable population and the ease of the follow-up of the veteran population provide an excellent opportunity for longitudinal follow-up of a patient over many months.
6. The development of an appreciation for other members of the rehabilitation team (not limited to members of Physical Medicine and Rehabilitation Service), and the development of leadership abilities in order to become an efficient leader of that team.
7. The development of the ability to identify the physiological and psychological implications and the physical impairment imposed by an illness or injury.
8. The development of the ability to plan and prescribe a treatment plan making use of the different Physical, Occupational, Kinesiotherapy, Vocational and Psychological therapeutic disciplines in order to optimize the patient to recovery .
9. The development of understanding of the vocational implications of the physical and psychological impairment.
10. The development of an appreciation of the areas particular to Rheumatology.
In order to optimize the residents’ experience, the resident will be exposed to the different health-related professionals. The resident will not only be required to learn their specific role in the rehabilitation process, but also the principle of the specific areas of these professionals, their evaluation capabilities, their treatment possibilities and also their limitations in those areas. In addition, the resident will be required to prescribe and supervise the comprehensive treatments of these patients making use of those ancillary services. In addition to the above-mentioned learning experiences, the resident will be exposed to didactic teaching at the VA hospital. The
resident will be required to actively participate in the teaching sessions to be conducted as lectures to the hospital staff.
The residents will be closely supervised by our full-time staff, consisting of a board-certified and EMG-certified physiatrist and, in her absence, a rheumatologist, This will guarantee their proper use of the services of the department. The resident will be evaluated on the basis of their management of each patient and by means of pre-and post-tests.
West Roxbury VA
Location: Boston VA-West Roxbury Division
Address: 1400 VFW Parkway, West Roxbury, MA 02132
Phone: (617) 323-7700
Preceptor: Carlos Tun, MD; Doris Celli, MD
Target PGY-year(s): 3
Rotation Description:
Residents provide inpatient primary care and may assist with consultations. Residents are responsible for coordinating all care for their patients under the guidance and supervision of the attending physicians. Orientation to the therapy services provided at the VA includes physical therapy, occupational therapy, and kinesiotherapy.
Learning Objectives
See “General Learning Objectives in Rehabilitation Medicine”.
Pediatrics
Location: Franciscan Children’s Hospital
Address: 30 Warren Street, Brighton, MA 02135
Phone: (617) 254-3800 x5520
Preceptor: Jeffrey Foreman, MD
Target PGY 3
Rotation Description:
In this rotation, emphasis is placed on understanding normal development and how disabling conditions can affect it. Residents manage inpatients with developmental as well as acquired disabilities. In addition, follow-up clinic experience focused on childhood disabilities such as cerebral palsy, scoliosis, spina bifida, etc. is included. Spasticity management with Botox® injection is also a part of the clinical experience.
Learning Objectives:
Knowledge
1. Normal and abnormal child development, including growth, puberty, vision, hearing, gross and fine motor skills, language and communication skills, social behavior and emotional development and response to pain, illness and disability.
2. Epidemiology, natural history and various methods of management for disabling conditions of childhood, including cerebral palsy, neural tube defects, neuromuscular and musculoskeletal disorders, severe learning difficulties, juvenile rheumatoid arthritis and head injury.
3. Plasticity of the child’s brain at various ages and the degree of neurological recovery that can be anticipated in comparison with the adult brain.
4. Orthopedic complications of neuro disability and their management, particularly scoliosis, hip dislocation and joint contractures.
5. Vision and hearing impairment and its management.
6. Communication, speech and language disorders and their management.
7. General and specific learning difficulties.
8. Physical illness, including epilepsy.
9. Psychological aspects of childhood and adolescence, including problems relating to sexual development, non-compliance with treatment and medication.
10. The legal and practical framework of education, including special provisions for children with disabilities.
11. Relationships between children, their families and their social, cultural and educational environments.
Skills:
1. Neurological and orthopedic examination of children of all ages.
2. Effective communication skills with parents and children of all ages.
3. Indications for use of orthoses and other assistive devices for mobility and communication in children and their relation to growth and development.
4. Prescribing and use of medication in children.
5. Basic assessment of developmental abilities and functional skills.
BMC Resident Outpatient Clinic
• The Resident Outpatient Clinic is held each Wednesday from 9:00 AM to 12:00 Noon. Please arrive 10-15 minutes early.
• The clinic utilizes the F2 Outpatient Clinic space (which will be eventually moved to F5). We use all four of the examination rooms. Patients will be scheduled in 30-minute intervals (18 – 24 total patients per session). All of the residents assigned to rotations at BMC will participate in the clinic each week.
• The goal of this experience is for you to become proficient at diagnosing and managing rehabilitation outpatients as well as gaining experience in soft tissue and joint injections, Botox® injection and nerve blocks. You should work towards being able to see a patient (new or follow-up), including making management decisions, completing paperwork, and dictation within the allotted 30-minute per patient time frame.
Work Flow
• Patients will be escorted by the front-desk support staff to one of the examination rooms and the patient’s chart brought back to the rear desk area.
• The attending will review the chart and assign a resident to the case who will see the patient and take the history.
• After taking the history, you should leave the room so that the patient can change into a hospital gown or shorts as appropriate. (Ask the patient to open the door slightly so that you know he/she is ready to be examined.) If a female patient is being examined by a male resident, a female staff member should be present during the examination to act as an escort.
• You will examine the patient and then formulate your diagnosis and treatment plan. You will then present the case, to the supervising attending who will briefly reexamine the patient and review the diagnosis and plan.
• AFTER YOU AND THE ATTENDING FINISH WITH THE PATIENT, INSTRUCT THE PATIENT TO GET DRESSED AND THEN GO BACK OUT TO THE WAITING ROOM.
• You will write any prescriptions (medication/therapy) and fill out any requisitions for diagnostic testing which will also be reviewed by the supervising attending. You should take notes during the history/physical so that you can dictate (or input the information into Logician) the patient’s note. You will dictate/input into Logician the patient’s outpatient note before leaving the clinic.
