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Our objective was to provide expert consensus on best practices for anatomy teaching and training on ultrasound-guided botulinum neurotoxin type A (BoNT-A) injection for specialists involved in treating spasticity and dystonia. Nine experts (three neurologists; six physical medicine and rehabilitation physicians) participated in a three-round modified Delphi process. Over three rounds, experts reached consensus on 15 of 16 statements describing best practices for anatomy and BoNT-A injection training. They unanimously agreed that knowledge of the target audience, including their needs and current competency, is crucial when designing training programs. Experts also agreed that alignment between instructors is essential to ensure consistency of approach over time and between regions, and that training programs should be simple, adaptable, and "hands-on" to enhance engagement and learning. Consensus was also reached for several other key areas of training program development. The best-practice principles identified by expert consensus could aid in the development of effective, standardized programs for anatomy teaching and BoNT-A injection training for the purposes of treating spasticity and dystonia. This will enhance the exchange of knowledge, skills, and educational approaches between global experts, allowing more specialists to treat important movement disorders and ultimately improving patient outcomes.

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Issue: While over one-quarter of adult Americans have a disability, there is a paucity of disability-specific curricula in American medical schools and residency programs. Potential consequences of this educational dearth include persistent inaccessibility of health care facilities and delivery of inequitable health care to individuals with disabilities. Evidence: Several working groups have proposed disability-specific competencies for health professions education and means by which to integrate them into existing curricula. A limited number of medical schools and residency programs have formally introduced disability-specific materials into their curricula. To our knowledge, however, there are no generalist (internal medicine or family medicine) residency programs that offer specialized training in the clinical care of people with disabilities. Implications: Offering generalist physicians the opportunity to acquire the clinical and cognitive skills required to provide thorough and equitable health care to people with disabilities is critically important. There are too few physiatrists to see to their care needs. In this manuscript, we present a novel concentration in an Internal Medicine residency program in the care of individuals with a variety of disabilities. Our hope is that this work will initiate discussions among educational leaders about how to address the lack of graduate medical education-level training in disability care. We also hope it will afford program directors the opportunity to implement similar concentrations and tracks and will eventually produce a generation of generalists who are well-equipped to help care for people with disabilities.

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BACKGROUND AND PURPOSE: Accurate identification and tailored management of patients with dysphagia is necessary to prevent complications when dysphagia is present and avoid implications of dietary restriction when unnecessary. Methods of dysphagia assessment vary, and a reassessment in the postacute period is not an established standard. The aim of this retrospective study was to compare initial dysphagia assessment with dysphagia reassessment results for stroke patients admitted to our inpatient rehabilitation facility. METHODS: We examined medical records of 226 acute stroke patients admitted to our inpatient rehabilitation facility from December 2006 to May 2007. We excluded 86 subjects, then noted the presence or absence of dysphagia based on documentation and prescribed diet and management strategies in the remaining 146 records. RESULTS: Dysphagia was identified in 94 patients (64%) assessed at our facility. Of these patients, 11% (n=10) were not previously identified in acute care (nonnegligible number, P<0.0001). Agreement regarding presence or absence of dysphagia occurred in 85%. However, prescribed diet differed in 51% (n=75), with 12% (n=18) requiring diet downgrades on admission for rehabilitation. CONCLUSIONS: The necessity of dysphagia reassessment as part of routine postacute stroke rehabilitation care is not completely established. Our study supports the need for postacute reassessment as 11% of patients with dysphagia would not have been identified without reassessment and 12% required diets more conservative than prescribed in acute care. Prospective research addressing dysphagia specific outcomes is warranted to develop efficient and high-quality standards for preventing poststroke dysphagia associated morbidity.

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