Longitudinal Cadaver-Based Training Curriculum for Musculoskeletal Ultrasound-Guided Procedures Among Physical Medicine and Rehabilitation Residents.

ABSTRACT: Musculoskeletal ultrasound has become a fundamental diagnostic and treatment tool in the field of physical medicine and rehabilitation. However, there is no standardized curriculum for teaching and practicing musculoskeletal ultrasound during physical medicine and rehabilitation residency. The objective of this study was to describe a longitudinal curriculum using unembalmed fresh frozen cadavers to teach physical medicine and rehabilitation residents ultrasound-guided procedures. This protocol can help guide residents to begin learning how to independently identify important musculoskeletal structures and perform some of the most common musculoskeletal procedures relevant to clinical practice. Residents performed a procedure on average 6.99 times per block, and residents' self-reported confidence in various aspects of ultrasound practice significantly improved after this curriculum ( P < 0.005). Hence, a cadaver-based training curriculum may be a worthwhile tool for preparing physical medicine and rehabilitation residents to perform musculoskeletal ultrasound-guided procedures in the clinical setting.

A First Estimate of the Annual Prevalence of Basivertebral Nerve Ablation Candidates in a Spine Clinic.

BACKGROUND: Emerging literature supports the use of basivertebral nerve ablation (BVNA) for a specific cohort of patients with chronic low back pain and Type 1 or Type 2 Modic changes from vertebral levels L3-S1. The early literature warrants further evaluation. Studies establishing the efficacy of BVNA use highly selective patient criteria. OBJECTIVE: Provide a first estimate of the prevalence of BVNA candidates in a spine clinic over a year using the foundational studies patient selection criteria? METHODS: A retrospective review of four fellowhsip trained spine physiatrists patient encounters at a large academic medical center using relevant ICD-10 codes to isolate chronic low back pain without radiating symptoms from January 1, 2019 to January 1, 2020. Charts were then reviewed by a team of physicians for exclusionary criteria from the foundational studies which have demonstrated benefit from BVNA. MRI's from qualifying charts which did not meet exclusionary criteria were then independently reviewed by four physician for localization and characterization of Modic changes. RESULTS: The relevant diagnostic codes query yielded 338 unique patient records. Based on exclusionary criteria or lack of imaging availability, 318 charts were eliminated. The remaining 20 charts qualified for imaging review. There were 11 charts in which there was 100% agreement between all reviewers regarding the presence and either Type 1 or Type 2 Modic changes between vertebral levels L3 to S1. Accordingly, the prevalence of eligibility for BVNA was 3% (11/338, 95% CI 1-5%). CONCLUSION: The population which may benefit from BVNA is small. Our study demonstrated that over a year, the prevalence for BVNA candidacy using the foundational studies criteria was 3% (95% CI 1% - 5%). While physicians may be tempted to use less stringent selection criteria in practice, upon doing so they cannot cite the foundational studies as evidence for the outcomes they expect to achieve. Those outcomes will require more studies which formally assess the benefits of BVNA when selection criteria are relaxed.

Epidural Steroid Injections.

Epidural steroid injections (ESI) can be an effective treatment of radicular pain, while also providing potential for functional improvement. There are 3 main interventional approaches including: interlaminar (IL), transforaminal (TF), and caudal. The risks and efficacy data vary between these routes of injection and the underlying pathology with the TF route having the most robust efficacy data. However, selecting an injection approach should be based on a patient's clinical presentation, pathology, anatomy, consideration of the natural course of pain, and the unique risks and benefits of the particular technique.

Development of a Cadaver Laboratory Curriculum for Interventional Spine Procedures for Physical Medicine and Rehabilitation Residents.

ABSTRACT: There is no standardized curriculum for teaching interventional spine procedures during residency. The objective of this protocol was to share a curriculum using a cadaver laboratory for teaching Physical Medicine and Rehabilitation residents interventional spine procedures, which can be an effective and safe medium to train residents. This protocol provides a checklist that can guide the residents while they are in the cadaver laboratory with a focus on some of the most common lumbar procedures. Twelve physical medicine and rehabilitation resident's confidence in their ability to maneuver the x-ray image intensifier (C-arm), identify spine anatomy under fluoroscopy, and drive the needle improved after the training curriculum (P < 0.005). Although the cadaver laboratory curriculum is not a replacement for the required Accreditation Council for Graduate Medical Education training, it may serve as a tool to improve resident preparedness for spine procedures.

Effect of Social Determinants of Health Interventions on Adults Living With Disabilities: A Scoping Review.

OBJECTIVE: To investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18 living with disabilities and receiving long-term services and supports (LTSS) in noninstitutional settings. DATA SOURCES: A review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted of literature from PubMed, PsycINFO, REHABDATA, and Web of Science Core Collection published between January 1997 and July 2020. STUDY SELECTION: Search terms were based on the primary SDoH domains identified by the Centers for Medicare and Medicaid's Accountable Health Communities Model. A total of 5082 abstracts were screened based on identification criteria of persons age 18 and above living in non-institutional, community-based settings receiving LTSS. DATA EXTRACTION: During Level 2 review, articles were reviewed based on population focus, type of LTSS (personal assistance services, home care, adult day care, home modification, durable medical equipment, community transition services, caregiver supports and/or prevention services related to home- and community-based care), SDoH intervention and association with health outcomes, population health and/or cost. A total of 1037 abstracts underwent Level 2 review, yielding 131 publications or 1.3% for full review. DATA SYNTHESIS: Studies (n=33) designed a priori to test outcomes of interventions were rated according to Grading Recommendations Assessment Development and Evaluation (GRADE) criteria. Qualifying articles that did not include interventions (n=98) were included in our summary of the literature but were not assessed by GRADE. CONCLUSIONS: The preponderance of research surrounding SDoH and health outcomes has focused on older adults living with disabilities, and most interventions scored low or very low using GRADE criteria. Evidence is limited to the extent SDoH interventions are measured against outcomes for persons of all ages living with disabilities. Robust evaluation of models that feature SDoH interventions in partnership with community-based organizations is recommended as home and community-based care infrastructure expands in response to the American Rescue Plan Act of 2021.

Correlation Between Neurologic Impairment Grade and Ambulation Status in the Adult Spina Bifida Population.

OBJECTIVE: The aim of the study was to identify which neurologic impairment scales correlate with ambulation status in adults with spina bifida. DESIGN: A retrospective chart review was performed on patients seen at the University of Pittsburgh Medical Center Adult Spina Bifida Clinic. Findings were graded using several neurologic impairment scales: two versions of the National Spina Bifida Patient Registry classification, the International Standards for Neurological Classification of Spinal Cord Injury motor level, and the Broughton Neurologic Impairment Scale. Ambulation ability was ranked using the Hoffer classification system. RESULTS: Data collected from 409 patient records showed significant correlations between Hoffer ambulation status and all neurologic impairment scales evaluated. The strongest correlation was noted with the Broughton classification (rs = -0.771, P < 0.001). High correlations were also noted with both versions of the National Spina Bifida Patient Registry: strength 3/5 or greater (rs = -0.763, P < 0.001), and strength 1/5 or greater (rs = -0.716, P < 0.001). For the International Standards for Neurological Classification of Spinal Cord Injury motor level, only a moderate correlation was observed (rs = -0.565, P < 0.001). CONCLUSIONS: Multiple grading scales can be used to measure motor function in adult spina bifida patients. Although the Broughton classification seems to be the most highly correlated with ambulation status, the less complex National Spina Bifida Patient Registry scale is also highly correlated and may be easier to administer in busy clinic settings. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Explain the clinical significance of identifying ambulation status and maximizing ambulation potential in adults with spina bifida; (2) Describe each of the neurologic grading scales examined in this study, identifying potential shortcomings in applying them to the adult spina bifida population; and (3) Administer the National Spina Bifida Patient Registry (NSBPR) impairment scale motor assessment in a standard adult spina bifida outpatient clinic visit. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Characterizing the role of haloperidol for analgesia in the Emergency Department.

The purpose of this study was to characterize emergency department (ED) physicians' beliefs and current practices regarding the use of haloperidol for the management of acute and acute on chronic pain. METHODS: A survey regarding haloperidol use was distributed by email to attending physicians, resident physicians, nurse practitioners, and physician assistants at emergency medicine departments in the Indiana University Health System and at St Joseph Mercy Ann Arbor. RESULTS: Of the 129 responses received, the majority (89.1%) of providers had used haloperidol for control of pain in the ED. The most common reason that respondents used haloperidol to treat pain was that they did not want to use an opioid or other agent (91.3%). The majority of providers (73.9%) believed that haloperidol was effective because there is a psychiatric component to pain, while over half of respondents (58.3%) chose haloperidol as they believed it to have analgesic properties. When haloperidol was used as a first line medication, providers felt that it was effective in controlling pain about 69.0% of the time without the need for further medication. The most common presentations for use were for unspecified abdominal pain, headache, and gastroparesis. CONCLUSION: ED providers reported using haloperidol most often as a second line treatment to manage both acute and acute on chronic pain. When haloperidol was used as a first line agent, providers claimed that additional medicines were not usually required. Haloperidol may provide an effective alternative to opioids in treatment of acute pain and acute exacerbations of chronic pain in the ED.

Co-morbidities Associated With Early Mortality in Adults With Spina Bifida.

OBJECTIVE: The aims of this quality improvement project were to identify secondary conditions and medical co-morbidities in adult patients with spina bifida and to determine which factors were associated with an earlier age of death. DESIGN: Retrospective chart review of 487 patients who attended the University of Pittsburgh Medical Center Adult Spina Bifida Clinic between August 1, 2005, and June 6, 2017, was conducted. RESULTS: Of 487 patients who had received care at the University of Pittsburgh Medical Center Adult Spina Bifida Clinic, 48 were deceased. The most commonly reported causes of death included infection, respiratory failure, renal failure, shunt malfunction, and metastatic cancer. Underlying co-morbidities and secondary conditions included hydrocephalus, Chiari II malformation, tethered cord, scoliosis, and abnormal renal function. In deceased patients, earlier age of death was significantly associated with myelomeningocele subtype and the presence of hydrocephalus and Chiari II malformation. CONCLUSIONS: Clinicians treating individuals with spina bifida should be aware of the potential for earlier mortality in individuals with myelomeningocele, hydrocephalus, and Chiari II malformation, especially with regard to infection, respiratory failure, renal failure, shunt malfunction, and cancer. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Discuss the importance of recognizing co-morbidities in adult individuals with spina bifida; (2) Describe secondary conditions and medical co-morbidities associated with spina bifida; and (3) Identify which conditions are associated with earlier age of death in adult individuals with spina bifida. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.