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Importance: Robotic exoskeletons leverage technology that assists people with spinal cord injury (SCI) to walk. The efficacy of home and community exoskeletal use has not been studied in a randomized clinical trial (RCT). Objective: To examine whether use of a wheelchair plus an exoskeleton compared with use of only a wheelchair led to clinically meaningful net improvements in patient-reported outcomes for mental and physical health. Design, Setting, and Participants: This RCT of veterans with SCI was conducted at 15 Veterans Affairs medical centers in the US from September 6, 2016, to September 27, 2021. Data analysis was performed from March 10, 2022, to June 20, 2024. Interventions: Participants were randomized (1:1) to standard of care (SOC) wheelchair use or SOC plus at-will use of a US Food and Drug Administration (FDA)-cleared exoskeletal-assisted walking (EAW) device for 4 months in the home and community. Main Outcomes and Measures: Two primary outcomes were studied: 4.0-point or greater improvement in the mental component summary score on the Veterans RAND 36-Item Health Survey (MCS/VR-36) and 10% improvement in the total T score of the Spinal Cord Injury-Quality of Life (SCI-QOL) physical and medical health domain and reported as the proportion who achieved clinically meaningful changes. The primary outcomes were measured at baseline, post randomization after advanced EAW training sessions, and at 2 months and 4 months (primary end point) in the intervention period. Device usage, reasons for not using, and adverse events were collected. Results: A total of 161 veterans with SCI were randomized to the EAW (n = 78) or SOC (n = 83) group; 151 (94%) were male, the median age was 47 (IQR, 35-56) years, and median time since SCI was 7.3 (IQR, 0.5 to 46.5) years. The difference in proportion of successes between the EAW and SOC groups on the MCS/VR-36 (12 of 78 [15.4%] vs 14 of 83 [16.9%]; relative risk, 0.91; 95% CI, 0.45-1.85) and SCI-QOL physical and medical health domain (10 of 78 [12.8%] vs 11 of 83 [13.3%]; relative risk, 0.97; 95% CI, 0.44-2.15) was not statistically different. Device use was lower than expected (mean [SD] distance, 1.53 [0.02] miles per month), primarily due to the FDA-mandated companion being unavailable 43.9% of the time (177 of 403 instances). Two EAW-related foot fractures and 9 unrelated fractures (mostly during wheelchair transfers) were reported. Conclusions and Relevance: In this RCT of veterans with SCI, the lack of improved outcomes with EAW device use may have been related to the relatively low device usage. Solutions for companion requirements and user-friendly technological adaptations should be considered for improved personal use of these devices. Trial Registration: ClinicalTrials.gov Identifier: NCT02658656.

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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.

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BACKGROUND: Physical medicine and rehabilitation (PM&R) is a diverse specialty, growing and evolving over a variety of subspecialty and practice focus areas. Accurate data regarding practice patterns of physiatrists are essential for updating requirements in training and certification, particularly as the Accreditation Council for Graduate Medical Education begins its process to update of the PM&R core residency training requirements. This study analyzes practice trends for nearly 98% of physiatrists in active practice, the largest study to date. OBJECTIVE: To update current demographics of physicians specializing in PM&R, including current areas of practice focus, to analyze the alignment of practice focus with subspecialty certification, and to determine the extent that electromyography is a component of current physiatric practice. DESIGN: Retrospective analysis of deidentified responses from American Board of Physical Medicine and Rehabilitation (ABPMR) board-certified PM&R physicians (diplomates) on annual enrollment in the ABPMR Continuing Certification program. PARTICIPANTS: A total of 9543 ABPMR diplomates. MAIN OUTCOME MEASURES: Demographics - age, gender, years in practice, practice setting(s) and area(s). Practice focus, subspecialty certifications. RESULTS: The majority of practicing physiatrists are men (62%) although the percentage of women in the field is growing (38%). Nearly 80% of physiatrists report more than one practice focus area, with pain medicine and sports medicine/musculoskeletal practices most commonly reported. CONCLUSIONS: This study confirms the growth trends in PM&R in pain and sports medicine but also highlights the substantial number of physiatrists focusing their practices in areas related to neurorehabilitation and medical rehabilitation. The large majority of physiatrists incorporate multiple focus areas into their practices. Electromyography is a focus for a declining percentage of practicing physiatrists.

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STUDY DESIGN: A 5-year longitudinal, retrospective, cohort study. OBJECTIVES: Develop a prediction model based on electronic health record (EHR) data to identify veterans with spinal cord injury/diseases (SCI/D) at highest risk for new pressure injuries (PIs). SETTING: Structured (coded) and text EHR data, for veterans with SCI/D treated in a VHA SCI/D Center between October 1, 2008, and September 30, 2013. METHODS: A total of 4709 veterans were available for analysis after randomly selecting 175 to act as a validation (gold standard) sample. Machine learning models were created using ten-fold cross validation and three techniques: (1) two-step logistic regression; (2) regression model employing adaptive LASSO; (3) and gradient boosting. Models based on each method were compared using area under the receiver-operating curve (AUC) analysis. RESULTS: The AUC value for the gradient boosting model was 0.62 (95% CI = 0.54-0.70), for the logistic regression model it was 0.67 (95% CI = 0.59-0.75), and for the adaptive LASSO model it was 0.72 (95% CI = 0.65-80). Based on these results, the adaptive LASSO model was chosen for interpretation. The strongest predictors of new PI cases were having fewer total days in the hospital in the year before the annual exam, higher vs. lower weight and most severe vs. less severe grade of injury based on the American Spinal Cord Injury Association (ASIA) Impairment Scale. CONCLUSIONS: While the analyses resulted in a potentially useful predictive model, clinical implications were limited because modifiable risk factors were absent in the models.

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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.

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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.

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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.

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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.

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OBJECTIVE: The design of medical board certification examinations continues to evolve with advances in testing innovations and psychometric analysis. The potential for subjectivity is inherent in the design of oral board examinations, making improvements in reliability and validity especially important. The purpose of this quality improvement study was to analyze the impact of using two examiners on the overall reliability of the oral certification examination in physical medicine and rehabilitation. DESIGN: This was a retrospective quality improvement study of 422 candidates for the American Board of Physical Medicine and Rehabilitation Part II Examination in 2020. Candidates were examined by examiner pairs, each of whom submitted independent scores. Training for all 116 examiners included examination case review, scoring guidelines, and bias mitigation. Examiner performance was analyzed for both internal consistency (intrarater reliability) and agreement with their paired examiner (interrater reliability). RESULTS: The reliability of the Part II Examination was high, ranging from 0.93 to 0.94 over three administrations. The analysis also demonstrated high interrater agreement and examiner internal consistency. CONCLUSIONS: A high degree of interrater agreement was found using a new, two-examiner format. Comprehensive examiner training is likely the most significant factor for this finding. The two-examiner format improved the overall reliability and validity of the Part II Examination.

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ABSTRACT: The Accreditation Council of Graduate Medical Education developed the Milestones to assist training programs in assessing resident physicians in the context of their participation in Accreditation Council of Graduate Medical Education-accredited training programs. Biannual assessments are done over a resident's entire training period to define the trajectory in achieving specialty-specific competencies. As part of its process of initial certification, the American Board of Physical Medicine and Rehabilitation requires successful completion of two examinations administered approximately 9 mos apart. The Part I Examination measures a single dimensional construct, physical medicine and rehabilitation medical knowledge, whereas Part II assesses the application of medical and physiatric knowledge to multiple domains, including data acquisition, problem solving, patient management, systems-based practice, and interpersonal and communication skills through specific patient case scenarios. This study aimed to investigate the validity of the Milestones by demonstrating its association with performance in the American Board of Physical Medicine and Rehabilitation certifying examinations. A cohort of 233 physical medicine and rehabilitation trainees in 3-yr residency programs (postgraduate year 2 entry) in the United States from academic years 2014-2016, who also took the American Board of Physical Medicine and Rehabilitation Parts I and II certifying examinations between 2016 and 2018, were included in the study. Milestones ratings in four distinct observation periods were correlated with scores in the American Board of Physical Medicine and Rehabilitation Parts I and II Examinations. Milestones ratings of medical knowledge (but not patient care, professionalism, problem-based learning, interpersonal and communication skills, and systems-based practice) predicted performance in subsequent Part I American Board of Physical Medicine and Rehabilitation Examination, but none of the Milestone ratings correlated with Part II Examination scaled scores.

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ABSTRACT: In 2015, the Accreditation Council for Graduate Medical Education published the Physical Medicine and Rehabilitation Milestones 1.0 as part of the Next Accreditation System. This was the culmination of more than 20 yrs of work on the part of the Accreditation Council for Graduate Medical Education to improve graduate medical education competency assessments. The six core competencies were patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. While providing a good foundation for resident assessment, the Physical Medicine and Rehabilitation Milestones 1.0 was not without faults. With input from program directors, national organizations, and the public, the Physical Medicine and Rehabilitation Milestones 2.0 strives to further advance resident assessment, providing improvements through the integration of the harmonized Milestones and the addition of a supplemental guide.

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There are more than 300,000 estimated cases of spinal cord injury (SCI) in the United States, and approximately 27,000 of these are Veterans. Immobilization from SCI results in adverse secondary medical conditions and reduced quality of life. Veterans with SCI who have completed rehabilitation after injury and are unable to ambulate receive a wheelchair as standard of care. Powered exoskeletons are a technology that offers an alternative form of limited mobility by enabling over-ground walking through an external framework for support and computer-controlled motorized hip and knee joints. Few studies have reported the safety and efficacy for use of these devices in the home and community environments, and none evaluated their impact on patient-centered outcomes through a randomized clinical trial (RCT). Absence of reported RCTs for powered exoskeletons may be due to a range of challenges, including designing, statistically powering, and conducting such a trial within an appropriate experimental framework. An RCT for the study of exoskeletal-assisted walking in the home and community environments also requires the need to address key factors such as: avoiding selection bias, participant recruitment and retention, training, and safety concerns, particularly in the home environment. These points are described here in the context of a national, multisite Department of Veterans Affairs Cooperative Studies Program-sponsored trial. The rationale and methods for the study design were focused on providing a template for future studies that use powered exoskeletons or other strategies for walking and mobility in people with immobilization due to SCI.

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Scholarly communication in science, technology, and medicine has been organized around journal-based scientific publishing for the past 350 years. Scientific publishing has unique business models and includes stakeholders with conflicting interests-publishers, funders, libraries, and scholars who create, curate, and consume the literature. Massive growth and change in scholarly communication, coinciding with digitalization, have amplified stresses inherent in traditional scientific publishing, as evidenced by overwhelmed editors and reviewers, increased retraction rates, emergence of pseudo-journals, strained library budgets, and debates about the metrics of academic recognition for scholarly achievements. Simultaneously, several open access models are gaining traction and online technologies offer opportunities to augment traditional tasks of scientific publishing, develop integrated discovery services, and establish global and equitable scholarly communication through crowdsourcing, software development, big data management, and machine learning. These rapidly evolving developments raise financial, legal, and ethical dilemmas that require solutions, while successful strategies are difficult to predict. Key challenges and trends are reviewed from the authors' perspective about how to engage the scholarly community in this multifaceted process.

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Context/Objective: The examination for Spinal Cord Injury (SCI) Medicine subspecialty certification has been administered since 1998, but published information about exam performance or administration is limited. Design: Retrospective review Setting/Participants: We examined de-identified information from the American Board of Physical Medicine and Rehabilitation (ABPMR) database for characteristics and performance of candidates (n = 566) who completed the SCI Medicine Examination over a 10-year period (2005-2014), during which the exam outline and passing standard remained consistent. Interventions: Not applicable Outcome Measures: We analysed candidate performance by candidate track, primary specialty, number of attempts, and domains being tested. We also examined candidate perception of the SCI Medicine Exam by analysing responses to a survey taken after exam completion. Results: Thirty-six percent of candidates who completed the exam during the study period took it for initial certification (23% in the fellowship track and 13% in the practice track offered during the initial "grandfathering" period) and 64% took it for maintenance of certification (MOC) in SCI Medicine. Factors associated with better exam performance included primary specialty certification in Physical Medicine and Rehabilitation (PM&R) and first attempt at passing the exam. For PM&R candidates, ABPMR Part I Examination scores and SCI Medicine Examination scores were strongly correlated. Candidate feedback about the exam was largely positive with 97% agreeing or strongly agreeing that it was relevant to the field and 90% that it was a good test of their knowledge. Conclusion: This study can inform prospective candidates for the SCI Medicine Examination as well as those guiding them. It may also provide useful information for future exam development.

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OBJECTIVE: To determine the effects of a 24-month program of Individual Placement and Support (IPS) supported employment (SE) on employment outcomes for veterans with spinal cord injury (SCI). DESIGN: Longitudinal, observational multisite study of a single-arm, nonrandomized cohort. SETTING: SCI centers in the Veterans Health Administration (n=7). PARTICIPANTS: Veterans with SCI (N=213) enrolled during an episode of either inpatient hospital care (24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of traumatic brain injury (TBI). INTERVENTION: IPS SE for 24 months. MAIN OUTCOME MEASURE: Competitive employment. RESULTS: Over the 24-month period, 92 of 213 IPS participants obtained competitive jobs for an overall employment rate of 43.2%. For the subsample of participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for an overall employment rate of 52.2%. Overall, employed participants averaged 38.2±29.7 weeks of employment, with an average time to first employment of 348.3±220.0 days. Nearly 25% of first jobs occurred within 4 to 6 months of beginning the program. Similar employment characteristics were observed in the subsample without TBI history enrolled as outpatients. CONCLUSIONS: Almost half of the veterans with SCI participating in the 24-month IPS program as part of their ongoing SCI care achieved competitive employment, consistent with their expressed preferences at the start of the study. Among a subsample of veterans without TBI history enrolled as outpatients, employment rates were >50%. Time to first employment was highly variable, but quite long in many instances. These findings support offering continued IPS services as part of ongoing SCI care to achieve positive employment outcomes.

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BACKGROUND: Pressure ulcers (PrUs) are a frequent, serious, and costly complication for veterans with spinal cord injury (SCI). The health care team should periodically identify PrU risk, although there is no tool in the literature that has been found to be reliable, valid, and sensitive enough to assess risk in this vulnerable population. OBJECTIVE: The immediate goal is to develop a risk assessment model that validly estimates the probability of developing a PrU. The long-term goal is to assist veterans with SCI and their providers in preventing PrUs through an automated system of risk assessment integrated into the veteran's electronic health record (EHR). METHODS: This 5-year longitudinal, retrospective, cohort study targets 12,344 veterans with SCI who were cared for in the Veterans Health Administration (VHA) in fiscal year (FY) 2009 and had no record of a PrU in the prior 12 months. Potential risk factors identified in the literature were reviewed by an expert panel that prioritized factors and determined if these were found in structured data or unstructured form in narrative clinical notes for FY 2009-2013. These data are from the VHA enterprise Corporate Data Warehouse that is derived from the EHR structured (ie, coded in database/table) or narrative (ie, text in clinical notes) data for FY 2009-2013. RESULTS: This study is ongoing and final results are expected in 2017. Thus far, the expert panel reviewed the initial list of risk factors extracted from the literature; the panel recommended additions and omissions and provided insights about the format in which the documentation of the risk factors might exist in the EHR. This list was then iteratively refined through review and discussed with individual experts in the field. The cohort for the study was then identified, and all structured, unstructured, and semistructured data were extracted. Annotation schemas were developed, samples of documents were extracted, and annotations are ongoing. Operational definitions of structured data elements have been created and steps to create an analytic dataset are underway. CONCLUSIONS: To our knowledge, this is the largest cohort employed to identify PrU risk factors in the United States. It also represents the first time natural language processing and statistical text mining will be used to expand the number of variables available for analysis. A major strength of this quantitative study is that all VHA SCI centers were included in the analysis, reducing potential for selection bias and providing increased power for complex statistical analyses. This longitudinal study will eventually result in a risk prediction tool to assess PrU risk that is reliable and valid, and that is sensitive to this vulnerable population.

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OBJECTIVES: To test the hypotheses that community-dwelling veterans with spinal cord injury (SCI) who receive the Wheelchair Skills Training Program (WSTP) in their own environments significantly improve their manual wheelchair-skills capacity, retain those improvements at one year and improve participation in comparison with an Educational Control (EC) group. METHODS: We carried out a randomized controlled trial, studying 106 veterans with SCI from three Veterans Affairs rehabilitation centers. Each participant received either five one-on-one WSTP or EC sessions 30-45 minutes in duration. The main outcome measures were the total and subtotal percentage capacity scores from the Wheelchair Skills Test 4.1 (WST) and Craig Handicap Assessment and Reporting Technique (CHART) scores. RESULTS: Participants in the WSTP group improved their total and Advanced-level WST scores by 7.1% and 30.1% relative to baseline (p < 0.001) and retained their scores at one year follow-up. The success rates for individual skills were consistent with the total and subtotal WST scores. The CHART Mobility sub-score improved by 3.2% over baseline (p = 0.021). CONCLUSIONS: Individualized wheelchair skills training in the home environment substantially improves the advanced and total wheelchair skills capacity of experienced community-dwelling veterans with SCI but has only a small impact on participation.

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