Neuro Rehabilitation Elective

Resident Education Curriculum

Description of Rotation

The Rehabilitation Center has defined its educational programs for Neurology residents. The following rotations are offered:

  1. One-month rotation electiveunder the direction of Dr Ann Tilton for neurology residents including multidisciplinary care of the patient as well as spasticity management clinics and procedural techniques such as intrathecal pump management and botulinum toxin injections.

Educational Purpose

  1. To provide an experience that will allow the resident to increase their knowledge of anatomy of the central nervous system and the clinical presentation and pathophysiology of head and spinal cord injury, peripheral and central nervous system disorders as well as spasticity and other movement disorders.
  2. To provide an experience that will allow the resident to achieve understanding of electrodiagnostic and imaging studies correlating it with the basic science of neurophysiology and clinical presentation.
  3. To learn the indications for ordering, diagnostic evaluation and interpretation of EEGs, evoked potentials (visual evoked potentials, brainstem auditory potentials, somatosensory evoked potentials), and imaging in this setting.
  4. To learn the indications and techniques required to perform management of intrathecal baclofen umps and botulinum toxin injections.
  5. To provide training and supervision that allows development of skills necessary to provide accurate diagnosis and treatment of the patients with disorders managed in the rehabilitation center and associated clinics.
  6. Understand the concept of improving function by utilizing the concept of the following domains: motor, activities of daily living, communication, cognitive and leisure.

Assessment Summary

The resident will work one-on-one with staff, and get immediate feedback about his/her performance after every patient encounter/work-up. It is expected that the resident will improve their performance based on the feedback they receive and as the rotation progresses.

Resident performance will be assessed in the six core competencies:

  1. Patient Care (PC)
  2. Medical Knowledge (MK)
  3. Interpersonal and Communication Skills (ICS)
  4. Practice Based Learning and Improvement (PBLI)
  5. Professionalism (P)
  6. Systems Based Practice (SBP)

By the end of the rotation, the resident should receive and/or complete the following assessments:

  1. Verbal feedback from preceptors
  2. Global written assessments
  3. Procedure Logs
  4. Written examination
  5. Testing of residents performance through direct observation and record review

Expectations

Rehabilitation Elective

This one-month elective must be approved in advance by the Child Neurology Section head. The resident will see and be responsible for the patients admitted to the child neurology rehabilitation center. The resident will round on each patient daily and coverage on evenings and weekends will be as per the child neurology call schedule. Participation in daily rounds with the pediatric team as well as the multidisciplinary staffing on the patients is required. Spasticity and Botulinum toxin clinic activities are required. Research projects are encouraged.

Orientation

This occurs on the first day of the rotation by the staff attending assigned to the clinic/lab. Orientation to the EMG machine will evolve over the clinical rotation.

Supervision

Residents will actively participate in the clinics/lab supervised both by Dr Tilton.

Mix of Diseases

  • Traumatic injury in young adults and children including brain, spine and orthopedic.
  • Encephalopathies – toxic, metabolic, anoxic, infectious
  • Coma; persistent vegetative state; advancing brain injury recovery
  • Motor and sensory recovery in peripheral and central nervous system disorders
  • Stroke and autoimmune disorders

Patient Characteristics

Patients will be referred to the rehabilitation center from either physicians in the outpatient department or from the inpatient hospital services for further diagnosis and management of a wide variety of rehabilitation and neurologic disorders. Children and adults of various ethnic backgrounds and socioeconomic backgrounds with acute and chronic neurological disorders will be encountered during the rehabilitation rotation.

Procedural Skill Acquisition

  1. Management of Intrathecal baclofen pumps including refills, interrogation, analysis, and reprogramming.
  2. Botulinum toxin injection with EMG guidance and stimulation techniques.
  3. Writing interpretations with clinical correlations for procedures.
  4. Management of multidisciplinary teams

Conferences

The residents should continue to attend the mandatory Neurology conferences including Neurology Grand Rounds. In addition, the residents are required to attend the weekly Tuesday 8am and Thursday 8am conferences and patient staffings.

References:

Resources recommended for learning skills:

Pediatric Neurology Principles and Practice, Fourth edition. Eds.Swaiman, KF, Ashwal, S, Ferriero, DM. Mosby and Elsevier, Philadelphia, 2006

Child Neurology, Seventh Edition, eds. Menkes, JH, Sarnat, HB, Maria,BL. Lippincott Williams and Wilkins, Philadelphia, 2006

AAN Practice Guidelines:

You schedule will be as follows:

Mon:Inpatient care and 1pm rounds conference room 6th floor Children’s Hospital

Tues:Inpatient care, 8am staffing rounds, spasticity clinic 9am, 1pm rounds conference room 6th floor Children’s Hospital

Wed:8am Morning Report, 9am Children’s Hospital Continuity Clinic for child neurology residents, 1pm lecture series, 2pm Grand Rounds, meet with Dr Tilton following Grand Rounds

Thursday AM:8am rehabilitation team staffing of patients, inpatient care, 1pm rounds conference room 6th floor Children’s Hospital

PM: Resident Lectures

Friday:8am Neuropathology conference, inpatient care, 1pm rounds conference room 6th floor Children’s Hospital

Objectives

Rehabilitation Elective

/ Teaching Methods / Assessment Strategy
Through direct observation and instruction, the resident will gain knowledge of advanced skills in comprehensive care of patients with rehabilitation needs including the importance of the multidisciplinary team / Direct patient care
Recommended readings
Staff instruction / Observation and advancing independent management of patients
Global ratings
Perform initial history and examination, present to staff, follow through with work up and management of patients during time on the rotation / Direct patient care
Recommended readings
Performance feedback / Observation of live performance
Global ratings
Perform procedures on selected patients / Direct patient care
Recommended readings
Performance Feedback / Clinical evaluation and study interpretation (observation of live performance)
Global ratings
Through management of patients in the inpatient and outpatient setting gain knowledge in the management of spasticity and movement disorders / Direct patient care
Recommended readings
Performance Feedback / Observation and advancing independent management of patients
Global ratings

MEDICAL KNOWLEDGE

Objectives / Teaching Methods / Assessment Strategy
Describe the pathophysiology head and spine injury as well as other disorders affecting the central and peripheral nervous system / Didactic Lecture
Rehabilitation staffings and conference
Neurology 1pm conference
Clinical Teaching / Global ratings
In-training examination
Describe the fundamental principles of the rehabilitation examination and apply this knowledge in completing a thorough history and neurological examination / Didactic Lecture
Rehabilitation staffings and conference
Neurology 1pm conference
Clinical Teaching / Global ratings
In-training examination
Explain central nervous system anatomical concepts in relation to disorders that result in rehabilitation needs / Didactic Lecture
Rehabilitation staffings and conference
Neurology 1pm conference
Clinical Teaching / Global ratings
In-training examination
Discuss the expanded diagnoses, treatment and management options and apply the latest knowledge to care of patients / Didactic Lecture
Rehabilitation staffings and conference
Neurology 1pm conference
Clinical Teaching / Global ratings
In-training examination
Understand and apply the knowledge of patient selection and techniques of delivery of intrathecal baclofen and botulinum toxin / Didactic Lecture
Spasticity clinic
Rehabilitation staffings and conference
Neurology 1pm conference
Clinical Teaching / Global ratings
In-training examination
Compare and contrast different management strategies for patients / Didactic Lecture
Rehabilitation staffings and conference
Neurology 1pm conference
Clinical Teaching / Global ratings
In-training examination

INTERPERSONAL AND COMMUNICATION

Objectives / Teaching Methods / Assessment Strategy
Establish excellent rapport and communication with their patients and their families / Clinical practice
Modeling / Global ratings
360 degree evaluation
Work as an integrated member of the Rehabilitation Center and clinical neurophysiology lab / Clinical practice
Modeling / Global ratings
360 degree evaluation
Present case presentations in an organized and detailed manner / Clinical practice
Modeling / Global ratings
360 degree evaluation
Educate their patients and their families as appropriate to the clinical situation in a manner that is geared to the patients educational level / Direct patient care
Modeling / Global rating
Demonstrate the ability to provide consultants with a report that can be easily interpreted. / Clinical rounds
Modeling / Global ratings

PRACTICE BASED LEARNING AND IMPROVEMENT

Objectives / Teaching Methods / Assessment Strategy
Research clinical questions regarding their patient’s health problems using information technology to access on-line medical information to support their own education and to improve patient care and education / Electronic medical record
Medline/OVID searches- patient centered
Case presentations / Self assessment
Global ratings
Evaluate the clinical literature applying knowledge of epidemiology, biostatistics, and research study design / Teaching conferences
Journal Clubs / Global ratings of Journal club performance
Integrate the feedback they receive from Staff physicians such that their performance will improve as the rotation progresses. / Modeling / Global ratings

PROFESSIONALISM

Objectives / Teaching Methods / Assessment Strategy
Demonstrate respect, compassion, integrity, and honesty / Direct patient care
Modeling / Global ratings
Interact responsibly with patients and families taking into consideration age, disability, culture and gender issues / Modeling / Global ratings
Demonstrate exemplary interaction with their colleagues / Modeling / Global ratings
Demonstrate appropriate use of the EMR in regards to patient respect and confidentiality / Direct patient care
Modeling / Global ratings
Self-assess their performance and the means for improvement / Modeling / Global ratings
Recognize mistakes that occur and take measures to learn from them so that the do not recur / Direct patient care
Modeling / Global rating
Self assessment

SYSTEM BASED PRACTICE

Objective / Teaching Methods / Assessment Strategy
Utilize appropriate resources to better care for their patients. / Direct patient care
Review of evidence based medicine and guidelines of the AAN
Departmental conferences / Global ratings
Focused Record Review
Identify obstacles to good patient care, engaging other members of the health care team such as child-life and social work, appropriately consulting other subspecialists or generalists. / Direct patient care / Global ratings
360 degree evaluation
Communicate with the specialized services or laboratories in order to obtain timely information on their patients / Direct patient care
Modeling / Global ratings
360 degree evaluation
Consider ethical, legal, and cost-effective standards of practice / Role modeling
Clinical teaching
Focused record review / Self assessment
Focused record review

Resources:

Articles provided by Dr Tilton

Physical Medicine and Rehabilitation. Ed. R. Braddom, Elsevier, Fourth Edition, 2011.

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