Relevance of learning health systems to physiatrists and its synergy with implementation science: A commentary.

As health care attempts to bridge the gap between evidence and practice, the concept of the learning health system (LHS) is becoming increasingly relevant. LHS integrates evidence with health systems data, driving health care quality and outcomes through updates in policy, practice, and care delivery. In addition, LHS research is becoming critically important as there are several initiatives underway to increase research capacity, expertise, and implementation, including attempts to stimulate increasing numbers of LHS researchers. Physical Medicine & Rehabilitation (PM&R) physicians (physiatrists), nurses, therapists (physical therapists, occupational therapists, speech therapists, clinical psychologists), and scientists are affiliated with LHSs. As LHS research expands in health care systems, better awareness and understanding of LHSs and LHS research competencies are key for rehabilitation professionals including physiatrists. To address this need, the Agency of Healthcare Research and Quality (AHRQ) identified 33 core competencies, grouped into eight domains, for training LHS researchers. The domains are: (1) Systems Science; (2) Research Questions and Standards of Scientific Evidence; (3) Research Methods; (4) Informatics; (5) Ethics of Research and Implementation in Health Systems; (6) Improvement and Implementation Science; (7) Engagement, Leadership, and Research Management; and the recently added (8) Health and Healthcare Equity and Justice. The purpose of this commentary is to define LHS and its relevance to physiatrists, present the role of implementation science (IS) in LHSs and application of IS principles to design LHSs, illustrate current LHS research in rehabilitation, and discuss potential solutions to improve awareness and to stimulate interest in LHS research and IS among physiatrists in LHSs.

Insights into optimizing phantom pain management: A human-centered approach to end-user perspectives.

BACKGROUND: This report explores and summarizes perspectives from end users on unmet needs in achieving optimal and effective phantom pain management through a human-centered design approach. OBJECTIVE: To examine current strategies, pharmacological, nonpharmacological, surgical procedures, virtual reality, and mirror therapy, and the evidence supporting them, in the management of phantom limb pain. DESIGN: This study reviewed and analyzed transcripts acquired in nonresearch contexts from the Veterans Affairs Translational Education and Mentoring Center's commercialization training program and from a Veteran Engagement Panel. Key themes were extracted using quasi-qualitative analysis of one-on-one interviews. RESULTS: Clinicians and patients report that early patient intervention and education will yield improved management of phantom limb pain, which aligns with the growing recognition of the impact of patient-centered care on overall treatment outcomes. Mirror therapy is viewed as an effective and low-risk therapy, though compliance and buy-in may be barriers to clinical practice. Patient engagement can contribute to better treatment adherence and outcomes. CONCLUSION: The study highlights implementation barriers, importance of end-user input, and the role of the Veteran Engagement Panel in providing feedback to pain researchers. The findings help explain unaddressed challenges and areas requiring further research to direct phantom pain management.

Evidence-based practice education in physical medicine and rehabilitation residency programs: A Canadian national survey.

OBJECTIVE: The current extent and quality of evidence based practice (EBP) training for physiatrists is unclear at this time. Training of EBP is also available to residents in Canada. The extent, quality and impact of the training was explored. DESIGN: Cohort study Results: about half of the Canadian programs reported a formal EBP curriculum. The most frequently reported method of providing EBP education were resident participation in journal club. CONCLUSIONS: Despite the increasing integration of EBP into residency program education, there remains a critical lack of knowledge and skills for implementation of EBP into clinical practice among Canadian PM&R residency programs.

Diagnosis and Treatment of Low Back Pain: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline.

ABSTRACT: Low back pain is a significant issue in the US Department of Veterans Affairs and Department of Defense populations as well as the general US population at large. This type of pain can be distressing to those who experience its effects, leading patients to seek relief of their symptoms. In 2022, leadership within the US Department of Veterans Affairs and US Department of Defense approved a joint clinical practice guideline for the management of low back pain. The guideline provides evidence-based recommendations for assessing and managing low back pain. Development of the guideline included a systematic evidence review, which was guided by 12 key questions. A multidisciplinary team, which included clinical stakeholders, reviewed the evidence that was retrieved and developed 39 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. The scope of the clinical practice guideline is broad; however, the authors have focused on key recommendations that are important for clinicians in the evaluation and nonoperative treatment of low back pain, including pharmacologic therapies and both noninvasive and invasive nonpharmacologic treatments.

A novel mixed reality system to manage phantom pain in-home: results of a pilot clinical trial.

Introduction: Mirror therapy for phantom limb pain (PLP) is a well-accepted treatment method that allows participants to use a mirror to visually perceive the missing limb. Mixed reality options are now becoming increasingly available, but an in-home virtual mirror therapy option has yet to be adequately investigated. Methods: We had previously developed a mixed reality system for Managing Phantom Pain (Mr. MAPP) that registers the intact limb and mirrors it onto the amputated limb with the system's visual field, allowing the user to engage with interactive games targeting different large lower limb movements. Feasibility and pilot outcomes of treating patients with lower extremity PLP by using Mr. MAPP at home for 1 month were evaluated in this study. Pain intensity and interference were assessed using the McGill Pain Questionnaire, Brief Pain Inventory, and a daily exercise diary. Function was assessed using the Patient Specific Functional Scale (PSFS). The clinical trial registry number for this study is NCT04529083. Results: This pilot study showed that it was feasible for patients with PLP to use Mr. MAPP at home. Among pilot clinical outcomes, statistically significant differences were noted in mean current pain intensity [1.75 (SD = 0.46) to 1.125 (SD = 0.35) out of 5, P = .011] and PSFS goal scores [4.28 (SD = 2.27) to 6.22 (SD = 2.58) out of 10, P = .006], with other outcome measures showing non-significant trends towards improvement. Discussion: This pilot study revealed that in-home use of Mr. MAPP has potential to provide pain relief and improve function in patients with lower extremity PLP and is feasible. Each scale used provided unique perspective on the functional impact of PLP. Further expanded studies and investigation, including a fully powered clinical trial, with these scales are warranted. Clinical Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT04529083, Identifier: NCT04529083.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Learning Health Systems Research Competencies: A Survey of the Rehabilitation Research Community.

OBJECTIVE: The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources. METHODS: The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements. RESULTS: Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed "a lot" or "some" interest in learning more, but only 19% reported "a lot" of knowledge. Respondents reported "a lot" of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). "None" or "some" knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%). CONCLUSION: Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training. IMPACT: Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

Determining Gaps in Current Physiatric Tele-Physical Assessments via a Needs Assessment Survey.

OBJECTIVES: Physical examinations are essential for in-person patient visits but remain difficult to replicate during virtual encounters. This work aims to identify gaps in the current state of telemedicine-based physical assessments by surveying physical medicine and rehabilitation physicians who perform physical examinations. DESIGN: A survey of 29 Likert-scale questions and five open-ended questions was distributed to practicing physical medicine and rehabilitation physicians. The Likert-scale questions covered remote physical assessment, access, perception/engagement, implementation/effectiveness, and administrative concerns. RESULTS: Fifty-three participants completed the survey. More than 80% of respondents suggested that while telemedicine was universally well accepted, they could not effectively perform telemedicine-based physical assessments, especially the musculoskeletal and neurological components. Remote assessment of upper and lower limb strength, reflexes, and sensation were examples of key unmet needs. Responses to open-ended questions suggested that telemedicine-based physical assessments can reduce the burden of travel and increase adherence to follow-up visits, but complex technology setup can pose difficulty for older patients and patients with cognitive deficits. CONCLUSIONS: These findings suggest that current telemedicine technology is insufficient to meet physical medicine and rehabilitation physicians' telemedicine-based physical assessments needs. Despite high levels of provider and patient engagement with telemedicine, numerous deficits remain in performing musculoskeletal and neurological examinations. These results can inform future technology developments that address these identified telemedicine-based physical assessments gaps.

Methodological Issues Relevant to Blinding in Physical Medicine and Rehabilitation Research.

ABSTRACT: Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding.

Quality of clinical practice guidelines on interventional management of low back pain: A systematic review.

OBJECTIVE: To appraise the quality of low back pain (LBP) clinical practice guidelines (CPG) that include interventional management recommendations and to associate their quality with characteristics including publication year and creating organization. TYPE: Systematic Review. LITERATURE SURVEY: LBP (subacute or chronic) CPGs in English (symptom based, governmental or professional society created, January 1990-May 2020) were found using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, ECRI, Guidelines International Network, NICE, and SIGN. METHODOLOGY: In this third order systematic review, search results were deduplicated, title and abstract screened by two independent reviewers, and full texts reviewed by four reviewers. Discrepancies were resolved by a third reviewer. Resulted CPGs were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool by four appraisers each. Association of their quality with creating organization, geographical region, and year of creation was calculated. SYNTHESIS: Seven hundred fourteen screened documents resulted in 21 final CPGs. On appraisal, average overall CPG quality was 5.2 (range 2.5-6.75). Domain 5 (applicability) had the lowest average (44%) and domain 4 (clarity of presentation) had the highest average score (82%). For overall recommendation, 16 received "yes" or "yes with modifications," six received unanimous "yes" and two unanimous "no" votes. The interrater agreement of domain scoring was excellent (0.8-1.0; p < .001). There was no association found between quality of CPG and (1) year of publication (R2  = 0.0006), (2) whether the CPG was updated or new (p = .17), and (3) region of publication (p = .37). CONCLUSIONS: The majority of the 21 CPGs identified in this systematic review were of high quality, but overall quality and recommendation ratings were variable. The quality of appraised CPGs showed no association with their characteristics. Some domains such as "applicability" scored uniformly lower, revealing opportunity for improvement in future CPG development. LBP CPGs should be scrutinized before adopting their recommendations.

Personalized 3D exergames for in-home rehabilitation after stroke: a pilot study.

PURPOSE: To describe a novel 3-dimensional (3D) exergames system and the results of a clinical feasibility study of stroke survivors needing in-home rehabilitation. MATERIALS AND METHODS: The customisable Personalized In-home eXErgames for Rehabilitation (PIXER) system captures the user's image, generates a live model, and incorporates it into a virtual exergame. PIXER provides a recording system for home exercise programs (HEPs) by adapting virtual objects, customizes the exergame and creates a digital diary. Ten persons with stroke, performed HEPs with PIXER for 1 month, and without PIXER for 2 additional months. In-game performance data, measures of physical functioning (PF) including Stroke Impact Scale (SIS), Timed Up & Go (TUG) and Goal Attainment (GA) Scale obtained at baseline, 1- and 3 months were evaluated. RESULTS: Seventy percent of participants completed the 1-month timepoint, 50% completed all timepoints. In-game data: Number of repetitions completed; Anomalies reported; and Percentage of bubbles hit showed positive trends. Compared to baseline, all SIS physical functioning (PF) scores were higher at 1 month, TUG scores showed no overall improvement and GA scale scores were 77% at 3 months. CONCLUSION: It is feasible for community-dwelling patients to perform HEP after stroke using PIXER, a novel, exergames system, and potentially improve their function.IMPLICATIONS FOR REHABILITATIONHome Exercises performed using a novel, 3-dimensional, customizable Personalized In-home eXErgames for Rehabilitation (PIXER) system is feasible for community-dwelling patients after stroke.In-game performance data obtained in this clinical pilot study showed positive trends of improvement in several study participants.PIXER has potential to improve functional outcomes for community-dwelling adults with stroke.

Clinical practice guidelines on interventional management of low back pain: A synthesis of recommendations.

OBJECTIVE: To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria. METHODOLOGY: A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation. SYNTHESIS: Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive. CONCLUSIONS: Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.

Estimating individualized treatment effects using a risk-modeling approach: an application to epidural steroid injections for lumbar spinal stenosis.

ABSTRACT: Conventional "1-variable-at-a-time" analyses to identify treatment effect modifiers are often underpowered and prone to false-positive results. This study used a "risk-modeling" approach guided by the Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement framework: (1) developing and validating a multivariable model to estimate predicted future back-related functional limitations as measured by the Roland-Morris Disability Questionnaire (RMDQ) and (2) stratifying patients from a randomized controlled trial (RCT) of lumbar epidural steroid injections (LESIs) for the treatment of lumbar spinal stenosis into subgroups with different individualized treatment effects on RMDQ scores at the 3-week follow-up. Model development and validation were conducted in a cohort (n = 3259) randomly split into training and testing sets in a 4:1 ratio. The model was developed in the testing set using linear regression with least absolute shrinkage and selection regularization and 5-fold cross-validation. The model was then applied in the testing set and subsequently in patients receiving the control treatment in the RCT of LESI. R2 values in the training set, testing set, and RCT were 0.38, 0.32, and 0.34, respectively. There was statistically significant modification ( P = 0.03) of the LESI treatment effect according to predicted risk quartile, with clinically relevant LESI treatment effect point estimates in the 2 quartiles with greatest predicted risk (-3.7 and -3.3 RMDQ points) and no effect in the lowest 2 quartiles. A multivariable risk-modeling approach identified subgroups of patients with lumbar spinal stenosis with a clinically relevant treatment effect of LESI on back-related functional limitations.

Comparison of in-person and synchronous remote musculoskeletal exam using augmented reality and haptics: A pilot study.

INTRODUCTION: Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination. OBJECTIVE: To assess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS). DESIGN: In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results. SETTING: Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network. PATIENTS: Fifteen participants with upper extremity pain and/or weakness. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated. RESULTS: The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): -0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0). CONCLUSIONS: This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated.

Clinical feasibility and preliminary outcomes of a novel mixed reality system to manage phantom pain: a pilot study.

BACKGROUND: To assess the clinical feasibility of a virtual mirror therapy system in a pilot sample of patients with phantom pain. METHODS: Our Mixed reality system for Managing Phantom Pain (Mr. MAPP) mirrors the preserved limb to visualize the amputated limb virtually and perform exercises. Seven patients with limb loss and phantom pain agreed to participate and received the system for 1-month home use. Outcome measures were collected at baseline and 1 month. RESULTS: Four (of seven recruited) participants completed the study, which was temporarily suspended due to COVID-19 restrictions. At 1 month, in-game data showed a positive trend, but pain scores showed no clear trends. Functioning scores improved for 1 participant. CONCLUSIONS: Mr. MAPP is feasible and has the potential to improve pain and function in patients with phantom pain. TRIAL REGISTRATION: Clinical Trials Registration, NCT04529083.

Evidence-Based Medicine Training in United States-Based Physiatry Residency Programs.

ABSTRACT: Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists' surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the "baseline" upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.