Evidence of Beneficial Effect of Physical Therapy After Lower-Extremity Trauma

Article Outline

• Abstract
• Methods
  • Study Population
  • Procedures
  • Characterizing Patients and Their Injuries
  • Measures of Physical Impairment and Functional Limitation
  • Unmet Need for PT
  • Data Analysis
• Results
  • Patient Demographics
  • Effect of Having Unmet Need for PT Services on Improvement in Measures of Physical Impairment and Functional Limitations
• Discussion
  • Study Limitations
• Conclusions
• Acknowledgments
• References
• Copyright

Abstract 

Castillo RC, MacKenzie EJ, Archer KR, Bosse MJ, Webb LX, for the LEAP Study Group. Evidence of beneficial effect of physical therapy after lower-extremity trauma.

Objective

To examine the effect of physical therapy (PT) use on a range of measures of physical impairment in a cohort of patients with lower-extremity trauma.

Design

Longitudinal, observational study of patients with severe lower-extremity trauma. Patients were interviewed by a research coordinator and examined by an orthopedic surgeon and a physical therapist during initial admission and at 3, 6, 12, and 24 months postdischarge.

Setting

Eight level I trauma centers.

Participants

Patients (N=382) whose legs were salvaged after limb-threatening trauma to the lower limb.

Interventions

Not applicable.

Main Outcome Measures

Unmet need for PT was assessed from 2 perspectives: an orthopedic surgeon and a physical therapist independently evaluated each patient and were asked whether the patient would benefit from PT. Patients classified by these health professionals as needing PT services over a given period and who reported receiving no PT at the end of that period were classified as having unmet need as evaluated by the orthopedic surgeon or physical therapist for that follow-up period. Multiple variable regression techniques were used to compare improvement in 5 measures of physical impairment and functional limitation between the met and unmet need groups over the periods of 3 to 6, 6 to 12, and 12 to 24 months: percentage of impairment in knee and ankle range of motion (ROM), reciprocal stair climbing pattern, gait deviations when walking, self-selected walking speed greater than 1.2m/s (4ft/s), and the mobility subscores of the FIM instrument.

Results

Patients with unmet need for PT as assessed by a physical therapist were statistically significantly less likely to improve in all 5 of the selected domains of physical impairment and functional limitation than patients whose PT need was met. These results remained constant after adjustment for patient sociodemographic, personality, and social resources, as well as injury and treatment characteristics, reported pain intensity, and impairment level at the beginning of the study period. Patients with unmet need for PT as evaluated by an orthopedic surgeon were significantly worse off than patients with met need in only 1 of the 5 selected measures (ROM).

Conclusions

The results are consistent with a beneficial effect of PT after lower-extremity trauma. The results point to a need for improved standards for the prescription of PT services, and highlight the importance of involving a PT professional in the prescribing process.

Key Words: Lower extremity, Physical therapy, Rehabilitation

List of Abbreviations: AIS, Abbreviated Injury Scale, AOR, adjusted odds ratio, LBP, low back pain, LEAP, Lower Extremity Assessment Project, PT, physical therapy, RCT, randomized controlled trial, ROM, range of motion

DESPITE THE FACT that PT services are routinely prescribed after lower-extremity trauma, there is little evidence that these services are beneficial to the patient. Furthermore, there is no consensus regarding the effectiveness of PT services for musculoskeletal conditions in general.¹ Systematic literature reviews, RCTs, and observational studies provide little or insufficient evidence of improved outcomes after arthroscopic partial menisectomy², ³ or among patients with anterior cruciate ligament injuries,⁴ shoulder injuries,⁵, ⁶, ⁷ patellofemoral pain,⁸, ⁹ or sciatica.¹⁰ On the other hand, beneficial effects have been shown for patients after total hip arthroplasty¹¹ and patients with chronic LBP,¹², ¹³, ¹⁴ subacute LBP in occupational settings,¹³ whiplash,¹⁵, ¹⁶, ¹⁷ chronic neck pain,¹⁴, ¹⁸ stroke-related extremity impairment,¹⁹, ²⁰, ²¹ and hip fractures.²²

Systematic reviews find notable limitations in the quality and reporting of RCTs, as well as potential publication bias.¹⁰, ¹², ¹⁸ The current PT literature lacks standardized outcome measures and intervention techniques, effective health care provider blinding, and adequate reporting of missing data.⁹, ¹³, ¹⁸, ²³ Meta-analysis studies suggest that these limitations may lead to an overestimation of treatment effects.¹³ However, an underestimation of beneficial effects is possible because of patient self-selection into PT use. Self-selection is likely a response to the patient's level of impairment. Even in RCTs, it has been noted that about one third of the subjects switch treatment groups, thus self selecting into the treatment pathway they believe is more appropriate and casting doubt on the results of the intent-to-treat analysis.²⁴ Despite methodologic limitations, evidence-based practice guidelines for musculoskeletal rehabilitation recommend therapeutic exercise for chronic, subacute, and postsurgical LBP; knee osteoarthritis; chronic neck pain; and therapeutic ultrasound for calcific tendonitis of the shoulder,¹⁸ whereas early mobilization is recommended for acute upper-extremity and lower-extremity limb injuries.²⁵

Overall, the efficacy and effectiveness of rehabilitation services remains questionable, but orthopedic surgeons routinely prescribe PT after lower-extremity trauma.²⁶, ²⁷, ²⁸, ²⁹ Because of high rates of PT use, predictors for physician referral and appropriateness of these referrals have been examined in the literature. Current evidence suggests insurance status, physician and patient characteristics, difficulty in clinical treatment of the patient, and social relations with physical therapists affect physician referral patterns.²⁹, ³⁰, ³¹, ³²

In a previous study, we classified patients from a longitudinal study of outcomes after lower-extremity trauma³³ as having met or unmet need for PT as assessed by an orthopedic surgeon or a physical therapist.³⁴ The current study examines the effect of PT use on a range of measures of physical impairment in a cohort of patients with lower-extremity trauma. We hypothesized that patients assessed to need PT who went on to receive these services would experience improved recovery compared with patients with unmet need. We further hypothesized that these differences would persist in multiple variable regression models adjusting for patient sociodemographic, injury, and treatment characteristics, as well as baseline pain impairment, physical impairment, and activity limitations.

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Methods 

Study Population 

The present study used a secondary analysis of data collected as part of a larger, multicenter study, the LEAP.³³, ³⁵ The LEAP study was designed to compare clinical and functional outcomes after amputation versus reconstruction among patients sustaining severe lower-extremity trauma, and was conducted at 8 level I trauma centers (Carolinas Medical Center, Cleveland MetroHealth Medical Center, Harborview Medical Center, North Carolina Baptist Hospital, R. Adams Cowley Shock Trauma Center, Tampa General Hospital, University of Texas Southwestern Medical Center, Vanderbilt University Medical Center). A total of 601 eligible patients between the ages of 16 and 69 years and admitted for treatment of severe lower-extremity trauma below the distal femur were recruited into the LEAP study. Inclusion and exclusion criteria for entry into the study have been reported earlier.³⁵ Briefly, these criteria included Gustilo IIIC and IIIB fractures of the tibia and ankle, selected Gustilo IIIA fractures with vascular involvement, degloving and crush soft tissue injuries, or a combination of these injuries that placed the patient at significant risk for amputation. These criteria were established to identify patients at risk of amputation who did not have significant injuries to the central nervous system or a preexisting mental health problem that would compromise recovery. Patients were enrolled in the study over a 40-month period (March 1994–June 1997) and followed prospectively at 3, 6, 12, and 24 months postinjury. A CONSORT style diagram of the study recruitment and attrition was published previously.³⁵

Of the 601 participants in the LEAP study, 32 with bilateral injuries and 184 treated with amputations were excluded from this analysis. The current analysis focuses on 385 patients with unilateral study injuries treated by reconstruction (including 202 patients with tibia fractures, 68 with vascular injuries and knee disarticulations, and 115 with foot/ankle/pilon fractures). Follow-up rates at 3, 6, 12, and 24 months were 92%, 92%, 90%, and 82%, respectively. Because this analysis relies on comparisons across time intervals, patients could be included only if they were followed at 2 consecutive time points. Of the 385 eligible patients, 334 (86.8%) were available at the 3-month to 6-month interval, 335 (87%) were available at the 6-month to 12-month interval, and 321 (83.4%) were available at the 12-month to 24-month interval. Patients lost to follow-up were more likely to be nonwhite and less educated than followed patients.³⁵

Procedures 

During the initial hospitalization, data were collected to classify the extent of injury to the lower extremity and other body systems. In addition, detailed information about the treatment of the lower extremity was recorded prospectively, and general characteristics about the hospital stay were abstracted from the medical record. Prior to discharge from the hospital, each patient was independently evaluated by a physical therapist and the treating orthopedic surgeon, and interviewed by the study coordinator. At each follow-up, the patient was brought back to the hospital and asked to participate in (1) an orthopedic evaluation conducted by the treating orthopedic surgeon to ascertain the occurrence of complications, status of the involved limbs, and subjective assessment of its cosmetic appearance, clinical recovery, and functional recovery; (2) an evaluation by a physical therapist to ascertain the extent of physical impairment, pain, and functional limitation; and (3) an interview conducted by the site coordinator to measure the patient's perception of his/her functional status and overall sense of well being, use of services, and perceived need for additional services. This study was reviewed and approved by the institutional review boards of each participating institution. Informed consent was obtained from each patient participating in the study.

Characterizing Patients and Their Injuries 

Extensive data were collected about the patient's environment, demographics, and health habits preinjury, including income level, years of education, age, existing chronic conditions, race, sex, alcohol and drug consumption, health insurance, personality type, health status at baseline (including ability to climb stairs, run, walk, and exercise), previous lower-extremity injuries, availability of social support, and self-efficacy for return to work.³⁵ All lower-extremity injuries were prospectively classified at the time of admission and soft-tissue coverage using standard classification criteria from limb salvage indices proposed in the literature. For the analysis, injuries were summarized according to (1) type and extent of bony injury using the AO classification of tibia fractures,³⁶ the Hannover Fracture Scale,³⁷ the Limb Salvage Index,³⁸ and the Predictive Salvage Index³⁹; (2) the extent of skin, neurovascular, muscle, and tendon injury using the AO classification of soft-tissue injury of tibia, the Hannover Fracture Scale, the Limb Salvage Index, and the Predictive Salvage Index; (3) plantar sensation and shock as defined by the Mangled Extremity Severity Score⁴⁰; and (4) overall tibia fracture assessment using the Gustilo classification.⁴¹ Associated injuries were classified using the AIS⁴² and the Injury Severity Scale score⁴³; 2 scores denoting the maximum AIS severity of contralateral and ipsilateral injuries were also computed. Postacute pain levels were measured at the baseline interview and at 3 months after initial hospital discharge using a visual analog scale recording pain at the time of the interview.

Measures of Physical Impairment and Functional Limitation 

Five widely used measures of physical impairment and activity limitation were used in this analysis. Independence in transfers, walking, and stair climbing was measured using the FIM instrument.⁴⁴ The FIM is a measure of functional independence with respect to a specific task, such as walking, with scores ranging from 1 (total assistance) to 7 (total independence). The 3 domains were added to form a single score ranging from 3 to 21. Self-selected walking speed was measured by asking the participant to walk 45m (150ft) on a level surface.⁴⁵ A threshold of self-selected walking speed greater than 1.2m/s (4ft/s) was used in this study.⁴⁶ During the walking speed test, gait deviations were monitored by a physical therapist, and participants were found to have gait asymmetry if they had 1 or more of the following common deviations: Trendelenburg gait, trunk asymmetry, leg circumduction, hip hike, knee hyperextension, no heel strike, toe drag, uneven step length, or an otherwise unexplained limp.⁴⁷ Hip flexion and extension, knee flexion, and ankle dorsiflexion and plantarflexion were measured using a standard goniometric technique.⁴⁸ An ROM impairment score was constructed using the American Medical Association's Guides to the Evaluation of Permanent Impairment.⁴⁹ Ascending and descending stair climbing patterns (reciprocal vs not reciprocal) were assessed using a standard 12-step test.⁵⁰ Stair climbing, walking speed, FIM instrument, and ROM were measured at 3, 6, 12, and 24 months. Gait deviations while speed-walking were measured at 6, 12, and 24 months.

Unmet Need for PT 

The measurement of unmet need for PT used in this analysis has been described in detail in a previous article.³⁴ Briefly, we divided our follow-up into 3 periods postinjury: 3 to 6 months, 6 to 12 months, and 12 to 24 months. All available data were used at each time point. Unmet need for PT was assessed from 2 perspectives. First, orthopedic surgeons evaluating the patient as part of the follow-up were asked whether they felt the patient would benefit from PT between now and the next follow-up visit. Second, a physical therapist conducting a separate evaluation was asked whether the patient would need PT between now and the next follow-up visit. Patients who were classified by the health professionals as needing PT services over a given period and who reported receiving no PT at the end of that period (next follow-up time point) were classified as having unmet need. Table 1 shows the number of patients classified as needing PT as perceived by the orthopedic surgeon and the physical therapist, as well as the percent of these patients for whom this perceived need was unmet. These data were published previously and are reprinted with permission.³⁴

Table 1. Patients With Need for PT as Assessed by a Physical Therapist or Orthopedic Surgeon (N=385)^⁎

Data Analysis 

The main goal of the analysis was to assess differences in improvement on 5 measures of physical impairment and activity limitations between patients with met and unmet need for PT. Multiple variable regression was used for continuous measures of improvement (FIM score, ROM), whereas multiple variable logistic regression was used for categorical measures of improvement (reciprocal stair climbing pattern, gait deviations when walking, and walking speed greater than 1.2m/s). In these analyses, the dependent variable was the measure of improvement, and the population was limited to those who were classified as needing therapy over that specific period. Robust estimation techniques available in SAS Proc Robustreg^a and SAS Proc Genmod^a were used for all regression analyses. The influence option in SAS Proc reg^a and the output statement in SAS Proc logistic^a were used to explore influential data points. Analyses were compared with and without influential data points. None of the reported analyses included data points sufficiently influential to require exclusion from the model. Before proceeding with estimation of the regression models, exploratory techniques were used to examine the relationship between improvement and each of the hypothesized covariates. All of the patient, treatment, and injury characteristics described were evaluated in the model, including investigation of possible interaction terms. Because previous analyses had shown that there were significant differences between patients with met and unmet need, particular care was taken to incorporate into the multiple variable models all sociodemographic, personality, and social support measures known to predict unmet need.³⁴

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Results 

Patient Demographics 

Demographics for this population have been described in detail elsewhere.³⁵ Patients ranged in age at time of admission from 17 to 69 years, with a mean age ± SD of 35.6±12.4 years. Most patients were men (77%), white (72%), and between the ages of 20 and 45 years (71%). Socioeconomic status indicators for this cohort were lower than for the general population. Seventy percent graduated from high school (vs 86% nationally; P<.05). One fourth lived in households with incomes below the federal poverty line, compared with 16% nationally (P<.05). The percentage with no health insurance (38%) was also higher than in the general population (20%; P<.05). The percentage of heavy drinkers was over 2 times higher than reported nationally (P<.01).

Effect of Having Unmet Need for PT Services on Improvement in Measures of Physical Impairment and Functional Limitations 

Multiple variable regression models were developed for the improvement in each of the 5 measures of physical impairment and functional limitations over the periods of 3 to 6, 6 to 12, and 12 to 24 months. Correlations between the 5 measures of impairment were low to moderate, ranging from 0.2 to 0.5. Baseline and 24-month levels for the overall study population for all 5 measures are shown in table 2. All multiple variable models adjust for patient insurance status, educational level, preinjury fitness level, smoking history, self-efficacy for return to work, practical social support, severity of muscle injury, site and extent of bone injury, pain intensity, and impairment level at the first time point of the selected period.

Table 2. Impairment Status for Overall Study Population at Baseline (3 or 6mo) and 24 Months

Table 3 shows the additive regression effect of having unmet need for PT on improvement in ROM. Patients with unmet need assessed by the physical therapist experienced statistically significantly less improvement than patients with met need over the periods of 3 to 6 months and 6 to 12 months, but not the 12 to 24 months. Patients with unmet need assessed by the orthopedic surgeon experienced statistically significantly less improvement than patients with met need at the 6-month to 12-month period only (see table 3). Although the average study participant improved over all time points, the average patient with unmet need experienced negative improvement (ie, got worse) in ROM during the 6-month to 12-month period.

Table 3. Additive Regression Effect of Having Unmet Need for PT on Improvement in Percentage of Disability in ROM (range, 0–100)^⁎

NOTE. Values are mean ± SD.

Table 4 shows the additive regression effect of having unmet need for PT on improvement in FIM score. Patients with unmet need assessed by the physical therapist experienced statistically significantly less improvement than patients with met need over the 6-month to 12-month period only.

Table 4. Additive Regression Effect of Having Unmet Need for PT on Improvement in FIM Score^⁎

NOTE. Values are mean ± SD.

Table 5 shows the AORs of having improvement in reciprocal stair climbing pattern. Separate models are presented for unmet need as assessed by the physical therapist and the orthopedic surgeon. Patients with unmet need assessed by the physical therapist were less than half as likely to improve over the periods of 3 to 6 months and 12 to 24 months than patients with met need (P<.05), and less than 60% as likely to improve over the 6-month to 12-month period (P<.10). Patients with unmet need assessed by the orthopedic surgeon were between 65% and 88% as likely to improve as patients with met need, but these trends were not statistically significant.

Table 5. AOR With 95% Confidence Interval of Improvement in Reciprocal Stair Climbing Pattern Given Presence or Absence of PT Need^⁎

Table 6 shows the AORs of having improvement in gait deviations while walking. Separate models are presented for unmet need as assessed by the physical therapist and the orthopedic surgeon. Measures of improvement were only available at the periods of 6 to 12 months and 12 to 24 months. Patients with physical therapist–assessed unmet need were statistically significantly less likely to improve over both of these periods. Patients with orthopedic surgeon–assessed unmet need were also less likely to improve, but these trends were not statistically significant.

Table 6. AOR With 95% Confidence Interval of Improvement in Gait Deviations While Walking Given Presence or Absence of PT Need^⁎

Abbreviation: NA, not available.

Table 7 shows the AORs of having improvement in achieving self-selected walking speed of 1.2m/s or faster. Separate models are presented for unmet need as assessed by the physical therapist and the orthopedic surgeon. Patients with physical therapist–assessed unmet need were statistically significantly less likely to improve over all 3 periods, whereas patients with orthopedic surgeon–assessed unmet need appeared to improve at similar rates than patients with met need.

Table 7. AOR With 95% Confidence Interval of Improvement in Maximum Walking Speed Greater or Equal to 4 Feet a Second Given Presence or Absence of Physical Therapy Need^⁎

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Discussion 

Patients with unmet need for PT as assessed by a physical therapist were significantly less likely to improve in all 5 of the selected domains of physical impairment than patients whose PT need was met. Continuous measures, ROM, and FIM scores were less likely to improve during the 6-month to 12-month period, whereas functional improvement in walking speed, gait pattern, and stair climbing were less likely during the 12-month to 24-month period. These results held true even after adjustment for patient sociodemographic, personality, and social resources, as well as injury and treatment characteristics, reported pain intensity, and impairment level at the beginning of the study period. Patients with unmet need for PT as evaluated by an orthopedic surgeon were also less likely to improve, but the effect sizes were generally smaller and only statistically significant for ROM during the 6-month to 12-month period. Overall, patients with unmet need for PT were less likely to improve than patients with met need. This overall effect was mostly observed with impairments from 3 to 12 months and with functional tasks during all 3 periods. These results emphasize the need to focus attention on physical impairments early and activity limitations throughout the recovery period.

The results appear to support a beneficial effect of PT after lower-extremity trauma among patients who are diagnosed as benefiting from these services by a health care professional. These results are consistent with previously reported studies showing a beneficial effect of PT in other clinical settings, including total hip arthroplasty,¹¹ chronic LBP,¹², ¹³, ¹⁴ whiplash,¹⁵, ¹⁶, ¹⁷ chronic neck pain,¹⁴, ¹⁸ stroke-related extremity impairment,¹⁹, ²⁰, ²¹ and hip fractures.²² Furthermore, the results suggest that physical therapists may be more likely than orthopedic surgeons to identify patients who could benefit from such services. These differences cannot be explained simply by variations in willingness to prescribe these services. Although orthopedic surgeons were less likely to recommend PT services over the 12-month to 24-month period, they were no less likely to do so during the first year of follow-up. However, the differences between the 2 assessments are apparent during the entire study period.

Study Limitations 

A number of important limitations of this study must be noted. First, the multiple variable regressions used to assess the effect of having unmet need for PT were meant to adjust for the effect of patient and injury characteristics known to correlate with unmet need. It is possible, however, that there were differences between the patients with met and unmet need that were not accounted for by the variables collected in this study, and that these differences may account for some of the effect attributed to unmet need. For example, patients may differ in their willingness to engage in therapy, and these differences may correlate with both assessment of need and outcome. Only a randomized trial of PT regimens would be able to address these biases properly. Second, in some cases, the same physical therapist who evaluated the patient for PT need may have performed the subsequent PT assessment. It is possible that this process may have introduced measurement bias if the physical therapist was more likely to perceive improvement in patients who complied with the recommendation to seek PT services. Third, patients lost to follow-up were not lost at random,³⁵ although the observed effects were seen throughout the study period and follow-up rates were greater than 90% during the first year. Fourth, a number of analyses were performed, thus increasing the possibility that some or all of the observed statistically significant results may be a result of chance alone. Finally, when making generalizations from these results to the wider trauma population, it is important to consider the role of polytrauma. In this study, patients with moderate to severe brain and spine injuries were excluded, making it difficult to make any generalizations about these results to populations with central nervous system injuries.

This study also benefited from a number of strengths. First, data were gathered prospectively, with both PT need and use data, as well as impairment measures available at 3 time points over 2 years. Second, 5 different measures of physical impairment were available, as well as the need assessment of 2 different clinicians for each patient. Finally, the study collected a wealth of data on each patient, allowing adjustment for a relatively high number of patient, injury, and treatment characteristics.

Orthopedic surgeons are more likely to refer patients to rehabilitation than primary care physicians, which suggests more knowledge of physical therapists and the services they provide.²⁹ Little is known regarding the criteria used by orthopedic surgeons in assessing and diagnosing therapeutic need. Current evidence suggests factors other than the characteristics of physical impairment, such as insurance status, physician and patient demographics, and social relations with physical therapists, affect physician referral patterns.²⁹, ³⁰, ³¹, ³² The results from this study not only find a beneficial effect of PT for patients with lower-extremity trauma but also suggest that physical therapists may be more adept than orthopedic surgeons in recognizing patients who could benefit from therapy. Further research is needed to identify the reasons for the observed differences between unmet need identified by orthopedic surgeons and physical therapists, and particularly to identify the criteria used to diagnose need. Overall, the results highlight the importance of ensuring that patients who are diagnosed as needing PT receive such services, and suggest the physical therapist perspective may provide an important contribution to the recovery process.

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Conclusions 

The results are consistent with a beneficial effect of PT after lower-extremity trauma, and suggest physical therapists may be more likely than orthopedic surgeons to identify patients who could benefit from such services. The results point to a need for improved standards for the prescription of PT services, and highlight the importance of involving a PT professional in the prescribing process.

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Acknowledgments 

The LEAP Study Group is Ellen J. MacKenzie, PhD, Michael J. Bosse, MD, James F. Kellam, MD, Andrew R. Burgess, MD, Lawrence X. Webb, MD, Marc F. Swiontkowski, MD, Roy Sanders, MD, Alan L. Jones, MD, Mark P. McAndrew, MD, Brendan Patterson, MD, Melissa L. McCarthy, ScD, Thomas G. Travison, PhD, and Renan C. Castillo, MS.

We acknowledge the tireless efforts of the study coordinators and physical therapists at each of the 8 LEAP study sites. Their dedication to the study's objectives and their commitment to quality data collection were essential to the success of the study. They include Julie Agel, ATC, Jennifer Avery, PT, Denise Bailey, PT, Wendall Bryan, Debbie Bullard, Carla Carpenter, PT, Elizabeth Chaparro, RN, Kate Corbin, MD, Denise Darnell, RN, BSN, Stephanie Dickason, PT, Thomas DiPasquale, DO, Betty Harkin, PT, Michael Harrington, PT, Dolfi Herscovici, DO, Amy Holdren, RNC, ANP, MSN, Linda Howard, PT, Sarah Hutchings, BS, Marie Johnson, LPN, Melissa Jurewicz, PT, Donna Lampke, PT, Karen Lee, RN, Marianne Mars, PT, Maxine Mendoza Welch, PA, J. Wayne Meredith, MD, Nan Morris, PT, Karen Murdock, PT, Andrew Pollak, MD, Pat Radey, RN, Sandy Shelton, PT, Sherry Simpson, PT, Steven Sims, MD, Douglas Smith, MD, Adam Starr, MD, Celia Wiegman, RN, John Wilber, MD, Stephanie Williams, PA, Philip Wolinsky, MD, Mary Woodman, BA, and Michelle Zimmerman, RN.

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