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Physiatry in Motion ISSUE 18 - SUMMER 2020

“Listening in”: natural language processing in the clinical encounter

by Nicholas S. Race, MD, PhD

Photo by Karolina Grabowska, link here.

“I just want to see patients.” Punctuated with an air of frustration, variants of this utterance routinely escape the lips of clinicians across every setting and profession within modern healthcare systems. Ire directed at documentation requirements in electronic health records (EHRs) often lies at the root of such dissatisfaction. In the years prior to their full-fledged arrival and implementation, EHRs were championed as the future of medicine. Promises included newfound efficiency alongside unprecedented access to information, accuracy of the historical record, error reduction, and integrated clinical decision support (CDS) tools. Without a doubt, some success has been had in these areas. However, on the front lines of clinical care, there are numerous perceived shortcomings in EHR implementation, efficiency, and accuracy[1, 2]. Look no further than the recent “Patients Over Paperwork” CMS federal relaxation of documentation requirements in the wake of the ongoing COVID-19 pandemic as tangible evidence of the over-burden placed on clinicians and barriers to patient care presented by modern-day EHR documentation requirements[3].

While process adherence and patient satisfaction have been reported to improve in the age of EHRs, efficiency benefits have not been realized to the same degree[4]. Indeed, it has been reported that nearly two-thirds of work day effort by practicing physicians is spent working with EHRs compared to under one-third spent face-to-face with patients[2]. Other phenomena such as copy-forwarding (and thus error-forwarding) and billing-driven documentation have been reported to compromise both the utility and data integrity of EHRs[5-8]. Dedicated efficiency training has mixed results with net perceived benefits to clinicians which, though statistically significant, are small and likely not of practical significance[9]. These problems affect not only practicing clinicians, but also trainee students and residents who have been reported to spend greater than three times as much of their work hours with EHR systems as compared to direct patient care[10]. A collection of technologies falling under the umbrella of natural language processing (NLP) may hold promise in addressing some of the current shortcomings of and perceived frustrations with EHR systems by enhancing usability, functionality, efficiency, and accuracy.

Natural Language Processing: An Overview

NLP broadly refers to computer algorithms designed to interpret communication between humans. These tools rest at the intersection between artificial intelligence and linguistics. At a basic level, the computational building blocks of NLP include text preprocessing (tokenization, part-of-speech tagging, and syntactic parsing), named entry recognition, context extraction, and association and relations extraction[11]. For the clinician, it is not so important to understand how NLP works. Rather, it is more effective to understand what NLP does and can do. At its core, NLP is built on a foundation of identifying and classifying words or phrases that represent particular concepts, and then understanding and interpreting the relationships between the recognized concepts[11]. NLP research and application development in healthcare to date has been dominated by the syntactic analysis of unstructured data (“free text”) in clinician notes and transforming them to structured, standardized data fields for improved EHR data fidelity and process optimization[12]. For example, integration of NLP into specific clinical pathways in EHRs has enabled process optimization including: automated spelling/grammar correction with context-specific expansion of acronyms, automated reading and assignment of ICD codes to radiology reports, and automated combing of clinical notes and procedure reports to assess status of colonoscopy inquiry/response/performance, among many more use cases[11]. NLP also includes optical character recognition to transform image files (ex: PDF scanned records from outside hospital) into text files which may then be parsed, searched, etc[13]. More recently, clinical decision support (CDS) tools have grown in popularity, ranging from simple outpatient reminder systems for scheduled preventative or follow-up care, to automated identification of patients with potential nosocomial infections and provision of appropriate antibiotic recommendations[11]. More specific NLP-augmented CDS use cases include reducing rates of medical imaging when not indicated[14,15], efforts to reduce adverse drug events[16-18], and improving glucose control in diabetics by modifying physician practice patterns[19]. Watson from IBM has gained recognition by building CDS with integrated NLP for unstructured datasets (the medical literature at large) to gather, interpret, and summarize rapidly evolving clinical literature to provide personalized recommendations for patient care[20]. In addition, Watson has been used to mine EHR data searching for new, previously undiscovered patterns in patients and their disease processes[11]. Such wide-ranging applications of NLP technology help illustrate diversity of opportunity for the utility of such tools in healthcare.

Speech recognition, too, falls under the purview of NLP[12,13] and is used for dictation by many clinicians. Speech recognition (SR) within healthcare-oriented NLP endeavors has to date largely been focused on dictation of clinical notes by healthcare professionals[12,13]. Some clinicians prefer dictating notes to typed entry, but evidence does not support clear perceived benefit from SR in terms of data entry efficiency, quality of care, documentation quality, or improved workflow[21]. This is understandable, as SR-mediated physician-driven documentation still requires extra time set aside during or post-encounter, consuming over half of physicians’ working time and effort[2]. Given the current state of EHR use and perception surrounding use, there remains considerable room for improvement and opportunity exists for NLP advancement to play a role. One area would be NLP/A.I.-augmented generation and interpretation of clinical documentation[12]. If further developed and implemented effectively, NLP-augmented EHRs and clinical encounters could enable a reversion of current trends and allow more clinical personnel working time and effort to be spent face-to-face with patients. NLP thus possesses wide-ranging potential to improve healthcare professionals’ interactions with EHR systems in manners ranging from streamlined workflow to next-gen CDS tools[13].

Looking Forward: NLP Augmentation of the Clinician-Patient Encounter

One area which has received significantly less attention than dictation is the use of speech recognition, voice analytics, and NLP during the physician-patient encounter. It is conceivable to imagine an artificial intelligence system equipped with such tools “listening in” to live conversations between doctors and patients as they happen. Imagine a next-generation “scribe 2.0,” an A.I./NLP-enabled transcription system and CDS tool in one. One positive impact could be automated generation of encounter documentation (even if partial) to improve clinician workflow. Somewhat to this effect, human scribes have gained popularity in recent years to streamline workflow with some success[22,23]. However, human scribes are expensive and can infringe on patient privacy and the doctor-patient relationship by introducing another human witness to the encounter[24]. A.I.-mediated data capture, of course, would obviate these hurdles by removing the additional human listener. Additional conceivable benefits of automated interview data capture for documentation generation include reduced dependence on fallible human memory, more complete record-keeping with audio backup files for medical-legal protections, and elimination of post-interaction documentation delays to communicate with allied clinicians.

The next level of value provided by NLP in live analysis of the patient interview would be beyond document generation into the realm of data analysis and interpretation. For example, it has been demonstrated that NLP technology can analyze free text across clinical notes to identify and risk-stratify patients[25,26]. The same could surely be done with clinical narratives extracted from raw recordings of clinician-patient encounters. Furthermore, much in the way clinician-generated clinical notes are mined for patterns and new discoveries in modern bioinformatics-driven research projects (ex: PPI initiation and major cardiac event risk[27]), SR-transcribed free text of patient interviews could be mined as well. Perhaps raw patient stories would provide “cleaner” unstructured data for analysis than disjointed and disparate physician-driven documentation? This is an area ripe for exploration in research and development.

Taken a step further, A.I. interpretation of the patient interview would permit analysis not only of what is said in the interview, but also how it is said. NLP-driven vocal metric analysis of quantitative speech elements from clinician-patient interview audio has demonstrated some promising ability to identify clinically relevant information. For example, NLP of speech complexity using two simple markers (maximum phrase length and use of determiners such as “which”) has predicted emergent psychosis in at-risk youth with 100% accuracy, outperforming classification from clinical interviews by mental health professionals[28]. Similarly, NLP has been used to predict mental and physical health responses to bereavement[29], adjustment to cancer[30], classification of suicide notes[31], discrimination between healthy age-related memory loss and mild cognitive impairment[32], and screening for drug abuse[33]. Specific to PM&R, imagine if passive recording/analysis of brain injury/stroke patient speech patterns were able to identify subtle changes with prognostic value for recovery potential, diagnostic value for development of specific complications, direct/target pharmacologic or speech therapist interventions. More broadly, in nearly any acute rehabilitation patient, NLP-based assessment of patient adjustment to newfound disability / functional impairment could prove useful in the manner it already has for adjustment to cancer[30]. Ultimately, the hope would be for refinement and validation of these approaches alongside development of novel NLP use cases to be integrated seamlessly and productively for actionable CDS tools that aide physician decision-making in real time[34]. However, the number of tasks, pathway integrations, and barriers to adoption are vast. As such, the success of NLP endeavors will be dependent on coordinated efforts across the medical community at large if a practical, scalable impact is to be made.

Technical, Financial, and Systemic Barriers to NLP-augmented Documentation and Encounters

Barriers to widespread adoption and integration of A.I. / NLP – augmented clinical encounter technologies are vast and include technical, financial, legal, ethical, and systemic challenges[12,13]. From a technical standpoint, voice recognition currently struggles in even the computationally simpler task of single-speaker dictation capture. Automated SR often requires human over-reads and performs inferiorly to experienced human medical transcriptionists[21, 35]. This owes to numerous factors, including medical jargon, abbreviation overlap, colloquialisms, homophones/homonyms, and other complex language features obfuscating automated syntactic interpretation[21,35]. Live NLP of clinical encounters would be further complicated by multiple speakers (physician and patient) and stylistic speech variables of natural conversation (ex: sarcasm, accents, figures of speech). Even the cutting edge SR tech behind Siri and Alexa from our most powerful tech companies struggle with such stylistic speech variables[36]. At the rate of technological advancement in modern society, however, it is not challenging to envision a near future when these technical hurdles exist only in history books. In spite of looming technical and interpersonal hurdles, systemic and institutional barriers are perhaps the largest consideration for the proposed NLP tool development and implementation in the clinical encounter.

The technical hurdles between the state of the current technology and a workable future product are likely best addressed by tech giants such as Amazon, Apple, Google, owing to their nearly unlimited resources and the requisite internal expertise to develop next-gen NLP tools. Systemic and structural challenges within healthcare and between the healthcare and tech industries further complicate the path forward. The tech giants, powerful and resource-rich as they are, have not historically been intimately involved in the healthcare space beyond wearable monitoring devices. As such, tech companies are the furthest from clinical encounter at present, and perhaps least likely to be invited into the room by those who “own” it: physicians, patients, and healthcare systems. The “owners” are thus the gatekeepers of the training data (real clinical encounters) necessary to develop the NLP algorithms for the clinical encounter of the future. With this in mind, partnerships between these tech giants and existing, healthcare-oriented organizations (Dragon Dictation, Epic/Cerner/Allscripts, etc.) already “in the room” may be more effective. These entities and healthcare-providing organizations need one another to succeed if development, integration, and adoption of NLP services in clinical encounters and EHRs are to be utilized effectively. However, a lack of clearly aligned goals/incentives at present is a hindrance to collaborative development and progress. The relationship between the above stakeholder entities will also be at the core of financial concerns – who is paying for it, what is the incentive, and why? Will the development be paid for, or only the finished product? Undertaking development and implementation of next-gen NLP in the clinical encounter is a high-risk, high-cost endeavor with uncertain rewards at the end. Efficacy remains largely theoretical as of now, though exciting data have been generated across numerous possible use cases as described in the previous section. To successfully develop and implement the NLP-driven clinical interaction and documentation of the future, it is clear that the relationships between large tech companies and healthcare systems will need to be redefined and developed collaboratively.

Legal, Perceptual, and Practical Barriers to Adoption of NLP-augmented Clinical Encounters

Even if the technology did exist, adoption remains a concern. Privacy and data sharing concerns, among others, would need to be addressed explicitly. Regulating how data is protected from or shared with insurers and the justice system would be critical and germane to the protection of both patients and healthcare practitioners. Interpersonal challenges include patient and physician distrust and the effects of perception of being recorded on alteration of natural behavior and speech[37]. Would the presence of a recording device fundamentally change the interaction between physicians and patients? Will patients be as forthcoming with information during clinical encounters, or would the existence of recording give perception of non-privacy as in the case of human scribes? Would physicians experience decreases in clinical efficiency due to more time spent covering oneself from a medicolegal perspective in every recorded conversation? Would the advances in NLP-augmented documentation efficiency gains offset more thorough clinical encounter (or “efficiency losses”), in a manner that improves and restores the work time allotted to direct patient care? These practical questions are all unknowns at this stage and merit deeper exploration through research. All of these hurdles would undoubtedly hinder adoption rates in a healthcare industry setting, which is historically slow to adopt new technologies, not to mention the litigious medicolegal culture in the US.

Final Thoughts

We clearly are far from a day when next-gen NLP technology revolutionizes clinical encounters, documentation, and decision making. Many hurdles must be overcome, ranging from technical to financial to legal to ethical challenges. Frankly, the healthcare system at large is not yet ready for widespread integration of NLP into the clinical practice setting. The vision of what could be, however, if the power of NLP and A.I. in the clinical encounter can be realized to their full potential, is worth the chase. If we are to assert the power and productivity offered by refined NLP and A.I. tools in the clinical encounter, strategic alignment of stakeholders across the healthcare industry, insurers, tech industry, government, and the general public is essential and must be the first step. Data describing efficacy and practical use cases of NLP in the day-to-day clinical setting are scant at present and unlikely to sway investment of time, energy, and money toward rapid private sector advancement. Perhaps the largest immediate barrier to cross is to more convincingly demonstrate efficacy in metrics ranging from patient outcomes to documentation efficiency and accuracy to clinician wellness as a result of NLP integration-driven improvements. The ability to ‘test-drive’ a functional product paired with strong efficacy data from well-designed, randomized trials against current standard processes would be most likely to rapidly align stakeholders to drive toward a NLP / A.I.-augmented future clinical encounter.

Nick is a resident at Physical Medicine and Rehabilitation Residency, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Follow him on Twitter @docdocrace.

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Medical Weight Loss and Bariatric Prehabilitation: The Logical Role for Physiatry

by Alexander Watson, MD, MBA

Photo: Hill-Rom | Liko® Lifts & Slings | Gait Training Bariatric Patient video screenshot.

At present, 'medical weight loss' is typically managed by two specialties- bariatric surgeons and internists with certifications in obesity medicine. Certainly, this distribution is justified as, for patients awaiting bariatric surgery, close oversight by their surgery team yields a clear bi-directional benefit. The team ensures the patient is achieving metrics that are good proxies for success following bariatric surgery, and the patient builds a deeper therapeutic relationship with the staff performing their life-changing procedure. Similarly, obesity medicine specialists are physicians who completed residency in Internal or Family Medicine and then either a fellowship or certification in obesity medicine. These practitioners treat the many comorbidities associated with obesity such as insulin resistance, hypertension, and even uncomplicated psychiatric illness.

These relationships are not without their limitations based on the practitioners' training and current scopes of practice. Bariatric surgeons are experts in minimizing surgical risks associated with re-routing portions of the gastrointestinal tract and managing postoperative surgical pain and nutritional deficiencies. However, surgeons may not be as well equipped to treat the more complex aspects of obesity medicine such as musculoskeletal pain, chronic injuries, or the unique aspects of tailoring an exercise and weight loss regimen to a patient with physical disabilities. Similarly, an obesity medicine specialist may have a greater understanding of the litany of comorbidities associated with metabolic disease; however, their training is also lacking in areas such as procedural interventions to address pain, assessment for- and usage of adaptive equipment, and designing physical training modalities to complement nutritional guidelines for weight loss.

Physiatrists can address these unmet needs treating bariatric patients and offload the nonsurgical care currently occupying bariatric surgeons' time. Truly, physiatry may have the ideal training breadth to complement surgeons' practices for enhanced outcomes and 'specialization of inputs'- i.e., allowing bariatric surgeons to maximize their time in the operating room (OR). In discussing the value of physiatry in the field of bariatric prehabilitation and medical weight loss, it helps to group the benefits into different domains: exercise, pain management, adaptive equipment, and supplements/nutrition.

Exercise and the bariatric patient

Most patients recognize that caloric expenditure is directly necessary for weight loss even without fully understanding the extended web of exercise's indirect benefits. If only considering weight loss, patients can benefit from sustained long-term elevations in basal metabolic rate (BMR) as a result of building lean muscle mass[1–3]. The kinematics associated with exercising a body that is obese, however, can be limiting.

Consider an individual who weighs 250 lbs. If the adipose tissue is distributed approximately proportionally across the body, even basic daily movements carry inherent "resistance training"[4]. For some movements, the increased subjective weight on joints is nonlinearly increased when compared with a lean individual, since the force that is experienced is a multiple of bodyweight. Most published data[5] relates to activities' impact on "peak tibial forces (PTF)," meaning the force felt in the tibial plateau of the knee joint. In this case, the row machine generated the lowest PTF (0.9 x bodyweight), whereas walking and jogging produce multiples of 2.5–2.8 and 3.1–4.2, respectively. Therefore, practitioners cannot hand a one-size-fits-all exercise routine to their patients, because a 250-pound individual (relative to 180 pounds) may feel approximately 300 pounds of additional impact force on their knees during jogging. Any joint that is part of the kinetic chain of a higher-impact exercise is susceptible to this exaggerated force.

Model [6] of obesity as a mediator for OA of the knee. These details may be missed by practitioners whose training does not include gait analyses and fitness/sports medicine. Weight and weight distribution become a significant concern when it impairs gait and other limb kinematics. Some malalignments may mediate the accelerated progression[7, 8] and symptomatology of osteoarthritis. Adding additional load in the form of barbells or dumbbells could then be dangerous without appropriate oversight, yet hiring a personal trainer for guidance may also be prohibitively expensive given that obesity is associated with lower socioeconomic status in many communities[9–11].

Excessive strain on joints and connective tissue is a concern when prescribing an exercise program for bariatric patients as some movements amplify the effect of bodyweight across joints. Appropriate consideration must be made when tailoring an exercise regimen for this population while understanding that functional, compound movements better simulate real-world demands and stimulate metabolic activity[12, 13]. As a result, exercises should be chosen judiciously after assessing the patients' limitations due to habitus and risks of initiating an exercise routine.

Medical clearance and "return to play" are integral skills that physicians learn during PM&R residency, and exercise participation after decades of inactivity should be treated as an extension of this. Some practitioners may utilize a validated screening tool such as the Physical Activity Readiness Questionnaire (PAR-Q)[14] to stratify risk prior to exercise; however, a majority of the baseline US population typically scores high enough to warrant additional medical clearance[15]. Therefore, stratifying risk in a medical weight loss/bariatric medicine patient population would likely be redundant.

Instead, a simple in-office physical conditioning assessment[16] that follows the updated American College of Sports Medicine's guidelines[17] could minimize the risks, including those of making assumptions when determining starting resistance weight and repetition ranges. With an assessment and expert planning, a patient would feel adequately challenged by the exercise while maintaining safety and minimizing discouragement, something unlikely to come from canned workout prescriptions.

Pain: differences in prevalence and management

There are clear associations between obesity and chronic pain with a logical positive feedback component. Worsening chronic pain limits a patient's interest and ability to exercise, despite the evidence that physical activity improves symptoms of chronic pain from many sources such as fibromyalgia[18, 19] and inflammatory arthopathies[20–22]. Due to pain-avoiding behaviors, patients' overall activity levels may decrease resulting in further weight gain and additional strain on muscles, joints, and connective tissue. Pain secondary to worsening metabolic health such as diabetic neuropathy compounds these issues as well.

Exercise itself can be a component of multi-modal treatment for chronic pain. Inflammatory arthropathies such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS) classically worsen after periods of inactivity and improve with movement. Other types of pain such as the result of osteoarthritic changes, which were traditionally seen in older adults, are occurring in younger populations as a result of the obesity epidemic[23]. Although these types of pain may acutely worsen with activity, the long-term benefits of reduced weight, strengthening of supporting structures, and alterations in inflammatory cytokines ultimately yield a net benefit in reducing pain[24] regardless of baseline degenerative changes. Due to this tradeoff, however, clinicians must be able to design exercise prescriptions for patients that minimize risk of injury and prioritize gains in strength and joint stability. As strength/balance increases, the prescription should adapt to prioritize multi-joint, compound exercises for greater caloric expenditure and cardiovascular impact.

Some patients have illnesses requiring chronic steroids, which ultimately have long-term effects on weight gain, insulin sensitivity, and bone density. As such, a tailored approach to exercise may complement the therapies and mitigate some negative side effects of steroids as has been demonstrated for other diseases[25]. Clinicians designing such regimen should understand the greater risks in this population due to diminished healing, worsened bone density, and muscle wasting seen in long-term corticosteroid use.

For patients with chronic joint pain that is distributed across a limited number of sites, peripheral joint injections with corticosteroids or hyaluronic acid[26, 27] are simple interventions to lower the hurdles to exercise. In these cases, pain may have been a barrier to participation and use of steroids, opioids, or non-steroidal anti-inflammatory drugs (NSAIDs) may diminish motivation to participate in strenuous activity or be contraindicated due to other comorbidities. In populations with obesity, however, physical landmarks for accessing joint spaces may be different from non-obese patients[28, 29], and therefore, greater experience with this population and training with ultrasound and other modalities is beneficial to minimize risks during the procedure.

Adaptive equipment

Ensuring proper joint alignment is crucial in working with patients with obesity. Given the amplified effects of weight across large joints, misalignment will have magnified effects. If a patient is asked to increase their physical activity level and, therefore, increase the frequency and force of impact on joints, the opportunity for injury is significant. For this reason, a thorough assessment for potential need of orthotics may ensure a patient is able to consistently participate in exercise without enduring repetitive stress-type injuries.

In some cases, exercise may be limited by a patient's own strength to weight ratio. If habitus is a limiting factor for exercise, gait-training devices in a physiatrist's practice could be used to offload a portion of body weight to permit engagement in a wider range of activities. Certainly, a severely obese patient may be required to lose weight through nutritional interventions and upper-body exercises if they are not able to support themselves even with the assistance of lifting devices. There will ultimately be a point when equipment such as these will open the patient up to a greater range of exercises for benefits of cross training.

Related to orthotics and weight-offloading devices, certain protective equipment such as knee braces, tendon straps, and tape that are typically employed in athletes will also have utility in bariatric populations. These could allow a bariatric patient to minimize discomfort and injury during exercise in a complementary fashion to peripheral joint injections, oral analgesics, and basic orthotics that are prescribed by a bariatric physiatrist.

Supplements and nutrition

While nutrition is not an area of expertise exclusively within physical medicine & rehabilitation, training in sports performance and optimization provides a unique insight into fuels for a healthy body and how to stoke metabolisms. A thorough understanding of performance under optimal conditions allows a physician to target these areas for long-term physical function in patients with metabolic disease.

Presently, the tool kits of many medical weight loss specialists include the same handful of medications, with any new additions limited by practitioner comfort and medication costs. As a result, blunt instruments like phentermine or drugs with longstanding safety profiles like metformin are first choices, even if their efficacy for weight loss over lifestyle modifications may be limited[29], effects of limiting post-exercise recovery may be concerning[30], or risks of pulmonary hypertension, arrhythmia, and potential abuse[31] are understood (in the case of phentermine). Newer medications such as naltrexone/bupropion and lorcaserin are predominantly used to curb appetite but are also expensive and do little to address other aspects of obesity such as exercise tolerance or mitochondrial function.

Physiatrists' greater understanding of muscle physiology and sports medicine afford them the opportunity to peer upstream in research and development at medications that may have utility in the obesity medicine population. Drugs currently in trials to combat muscle wasting and poor bone density in older adults and patients with chronic diseases[32] may one day demonstrate benefits in maintaining fat free mass while in caloric deficit. Other classes of drugs currently in development[33] may one day occupy a place in the informed obesity/bariatric medicine tool chest for their ability to promote a healthier metabolic phenotype with improved insulin sensitivity and serum lipid levels while assisting fat loss.

Volumes can be written about nutrition, but physiatry's role in the field can be as appropriate as our use of adaptive equipment or targeted pain-management modalities. A deeper understanding of nutrition and strategic employment of specific principles would garner greater yields from exercise prescriptions. For example, fasting has been demonstrated to have anti-inflammatory properties and can reduce acute/chronic pain through multiple potential mechanisms, including the endocannabinoid and endogenous opioid systems[34, 35]. Additionally, different fasting regimen have purported benefits in increasing insulin sensitivity[36–38], improving blood lipid levels, and increasing weight loss[39, 40]. Exercising in a fasted state may help maintain lean muscle during weight loss[41], possibly through elevated levels of betahydroxybutyrate (BHB)[42]. Physiatrists with insights into these relationships and the language to articulate them can achieve better outcomes for their patients. As a result, physiatrists in training would be prudent to gain additional experience with leading nutritional strategies.

Physiatrists, again, are appropriate and even ideal to be overseeing practices such as these because of our broad training backgrounds- often beginning with an internship in Internal Medicine and training in divergent disciplines including Sports Medicine and Pain Management. Residency/fellowship training with individuals optimizing for peak performance begets an understanding of pathways including mitochondrial function, nutrition, and fuel partitioning. The holistic focus of physical medicine & rehabilitation fosters a necessary appreciation for designing care plans that integrate multiple body systems to achieve quality of life and return to function.

Next Steps and Conclusion

The necessary steps to flesh out a new discipline within PM&R are numerous and would ideally happen in concert. Researchers should scrutinize some areas of general surgical dogma that may not apply in this unique population. For instance, the Enhanced Recovery After Surgery guidelines[43] recommend a sports drink on the eve of bariatric surgery- a surgery that will fundamentally change metabolic pathways from predominantly glycolytic to lipolytic, beta-oxidative, and ketogenic[44]. Theoretically there would, therefore, be a role for a preoperative ketogenic diet or fasting regimen to up-regulate lipolytic/beta-oxidative cellular machinery, an idea which has already been tested for safety/feasibility[45, 46].

Similarly, many of the exciting novel drugs in the research pipeline described earlier require years of further clinical trials before they could even be considered for these populations. This is particularly relevant given some of the potential side effects. Investigators would have to identify whether these effects are clinically significant.

Moreover, although this discussion has made a case for how physiatry would make a substantial contribution by complementing care with bariatric surgeons, further research should validate metrics to assess the impact. These metrics could include quantifying the percentage of patients that successfully qualify for bariatric surgery on schedule; rate of fat loss; maintenance of lean mass and strength; improvements in fasting glucose, hemoglobin A1C, lipid profiles; or even amount of sustained weight loss following surgery, for example.

With the unique skill set and knowledge base of a potential bariatric physiatrist, these specialists would have obvious overlap in caring for patients being treated by other physiatrists or patients on other wards in the hospital. In patients with obesity, associated comorbidities such as diabetes and hypertension are risk factors for stroke, acute cardiac pathology, amputations due to vascular disease and other orthopedic procedures. In these cases, the primary team could consult a bariatric physiatrist to optimize care much as a geriatrician is consulted to streamline care in geriatric patients while on another primary service. As the obesity epidemic worsens, physicians trained to address impediments for exercise and physical therapy would work hand-in-glove with surgeons to deliver optimized care.

Alex is a PGY-2 Physical Medicine and Rehabilitation resident at the University of Pittsburgh Medical Center.

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21. Fangtham, M., et al., Non-pharmacologic therapies for systemic lupus erythematosus. Lupus, 2019. 28(6): p. 703–712.

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Closing the loop between researchers and patients

The growing role of closed-loop neuroprosthetics in rehabilitation

by Isaiah Levy, MD

Source: Rehab Neural Engineering Labs at the University of Pittsburgh

Beep…beep…. John pauses, pondering exactly how to put into words the sensations he is feeling, and traces on the tablet the distribution of the sensation. He is a fit middle-aged man, a former marathoner, strapped into a standing frame to remain upright. He has electrode pads taped to his legs and wired to nearby computers to capture real time EMG data from his intact leg and his residual leg. He has a transtibial amputation which occurred after complications from osteomyelitis in the setting of his intensive running and injuries. A few days prior, he had two spinal cord stimulators inserted along portions of his thoracic and lumbar spine. Now, those stimulators were releasing electric discharges of varying frequencies and amplitude in order to elicit sensation. "It's like a tingling in my knee…" beep…beep… "a buzz in the back of my thigh" beep…beep… John's eyes widen just so slightly. "I feel it in my big toe!" "Which side?" the researchers ask excitedly. "My left side," he says, referring to his amputated side. The stimulator had successfully replicated natural sensation in his missing limb. For a brief moment, a sensory link previously lost was restored.

During my intern year, I had the opportunity to participate in a research elective at the Rehab Neural Engineering Labs at the University of Pittsburgh assessing the use of spinal cord stimulators in a patient with a transtibial amputation to restore sensation in the missing limb. The study aims to use the stimulators to replicate natural sensation, those of pressure and movement, that would provide feedback to patients to help improve balance control, reduce falling risk, and potentially decrease phantom limb pain. Imagine: a lower extremity prosthetic, that as pressure is applied with walking, applies electrical stimulation to the spinal cord corresponding to the force to give improved information of the ground below the patient. This study demonstrates another advance in the growing field of neuroprosthetics. Neuroprosthetics, devices using electrodes that interface directly with either the central or peripheral nervous system, have been increasingly utilized as a modality for rehabilitation in patients with amputations. A goal of utilizing neuroprosthetics over traditional prosthetic devices is to facilitate the creation of "closed-loop" devices, those that can reforge the link between sensory input and motor output to enhance control of the device. By reestablishing sensory input either peripherally or centrally, motor output can be reestablished, either as fine-tuned volitional control or via reflex arcs, to allow improved movement for patients.

Source: Rehab Neural Engineering Labs at the University of Pittsburgh

Over the last few decades, there have been remarkable advances in the field of neuroprosthetics in the pursuit of closed-looped devices. These advances have been helped by the wide range of electrode types and targets. Examples include peripheral nervous system (PNS) electrodes which can be divided into three categories: surface electrodes (cuff electrodes) which wrap around the peripheral nerve, penetrating electrodes which penetrate the epineurium and are placed inside fascicles, and regenerative electrodes which facilitate regrowth of a severed nerve around the electrode (Rijnbeek, Eleveld, & Olthuis, 2018). Central nervous system electrodes - brain-computer interfaces - range from those that monitor signals from large areas of the brain, such as scalp EEG which processes electrical activity in regions of interest, to more invasive intracortical and depth electrocorticography (ECoG) electrodes that can offer bidirectional recording and direct sensory stimulation (Adewole et al., 2016). Other novel approaches are also being developed, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) which apply non-invasive magnetic and electrical currents, respectively, to also modulate sensory feedback to patients. Additional approaches, as described above in the case of Robert, include spinal cord stimulators placed in varying positions (e.g. dorsal root ganglia) in order to provide sensory input and potentially reform spinal reflex arcs.

These neuroprosthetic applications have been utilized to improve functionality in patients with stroke (Grimm & Gharabaghi, 2016), spinal cord injury (López-Larraz et al., 2016), and amputation. In upper extremity amputees, prior studies have found that PNS-targeted neuroprosthetics evoke sensation and have shown the ability to restore stable chronic tactile perceptions in the phantom limb with subsequent improvement with tasks requiring fine motor control in the prosthetic limb (Francesco M. Petrini et al., 2019; Raspopovic et al., 2014; Tan, Schiefer, Keith, Anderson, & Tyler, 2015; Tan et al., 2014; Valle et al., 2018). In lower extremity amputees, PNS-targeted neuroprosthetics demonstrated faster walking speeds, decreased metabolic costs (as measured by O2 consumption), and decreased phantom pain (Francesco Maria Petrini et al., 2019). An important caveat for all of these studies is that sample sizes are small, and generalizability is still to be determined. However, many of these pilot studies demonstrate the potential for how neuroprosthetics may be able to improve patients' lives.

While many of these devices and interventions are still very much in an early phase of development, it is important for clinicians to be aware and knowledgeable of such studies. However, there is often a lack of knowledge of the emerging neuroprosthetic technologies that might be beneficial to patients. For example, a recent Canadian survey among neurologists and physiatrists showed most had relatively poor knowledge of numerous aspects of brain-computer interfaces, while still acknowledging high potential to improve their patients' quality of life (Letourneau et al., 2020). Patients living with disability are often more aware of many of the emerging technologies in the neuroprosthetic space that could have the potential to improve their quality of life and function. As physiatrists, it is up to us to be cognizant of the potential for such technologies and screen for potentially viable candidates for research, without relying on the patients' awareness of the emerging technology. However, it is also important to educate ourselves and patients on the risks of such technologies and to monitor our patients' and our own expectations. As physiatrists, we can help provide an important link between patients and researchers to enable the creation of devices that are patient centric. We can close the loop between the incredible work done by researchers and our patients.

Isaiah is a PGY-2 in PM&R at the University of Pittsburgh Medical Center.

References

Adewole, D. O., Serruya, M. D., Harris, J. P., Burrell, J. C., Petrov, D., Chen, H. I., … Cullen, D. K. (2016). The evolution of neuroprosthetic interfaces. Critical Reviews in Biomedical Engineering. https://doi.org/10.1615/CritRevBiomedEng.2016017198

Grimm, F., & Gharabaghi, A. (2016). Closed-Loop Neuroprosthesis for Reach-to-Grasp Assistance: Combining Adaptive Multi-channel Neuromuscular Stimulation with a Multi-joint Arm Exoskeleton. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2016.00284

Letourneau, S., Zewdie, E. T., Jadavji, Z., Andersen, J., Burkholder, L. M., & Kirton, A. (2020). Clinician awareness of brain computer interfaces: A Canadian national survey. Journal of NeuroEngineering and Rehabilitation. https://doi.org/10.1186/s12984-019-0624-7

López-Larraz, E., Trincado-Alonso, F., Rajasekaran, V., Pérez-Nombela, S., del-Ama, A. J., Aranda, J., … Montesano, L. (2016). Control of an ambulatory exoskeleton with a brain-machine interface for spinal cord injury gait rehabilitation. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2016.00359

Petrini, Francesco M., Valle, G., Strauss, I., Granata, G., Di Iorio, R., D'Anna, E., … Micera, S. (2019). Six-Month Assessment of a Hand Prosthesis with Intraneural Tactile Feedback. Annals of Neurology. https://doi.org/10.1002/ana.25384

Petrini, Francesco Maria, Bumbasirevic, M., Valle, G., Ilic, V., Mijović, P., Čvančara, P., … Raspopovic, S. (2019). Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain. Nature Medicine. https://doi.org/10.1038/s41591-019-0567-3

Raspopovic, S., Capogrosso, M., Petrini, F. M., Bonizzato, M., Rigosa, J., Pino, G. Di, … Micera, S. (2014). Bioengineering: Restoring natural sensory feedback in real-time bidirectional hand prostheses. Science Translational Medicine. https://doi.org/10.1126/scitranslmed.3006820

Rijnbeek, E. H., Eleveld, N., & Olthuis, W. (2018). Update on peripheral nerve electrodes for closed-loop neuroprosthetics. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2018.00350

Tan, D. W., Schiefer, M. A., Keith, M. W., Anderson, J. R., & Tyler, D. J. (2015). Stability and selectivity of a chronic, multi-contact cuff electrode for sensory stimulation in human amputees. Journal of Neural Engineering. https://doi.org/10.1088/1741-2560/12/2/026002

Tan, D. W., Schiefer, M. A., Keith, M. W., Anderson, J. R., Tyler, J., & Tyler, D. J. (2014). A neural interface provides long-term stable natural touch perception. Science Translational Medicine. https://doi.org/10.1126/scitranslmed.3008669

Valle, G., Mazzoni, A., Iberite, F., D'Anna, E., Strauss, I., Granata, G., … Micera, S. (2018). Biomimetic Intraneural Sensory Feedback Enhances Sensation Naturalness, Tactile Sensitivity, and Manual Dexterity in a Bidirectional Prosthesis. Neuron. https://doi.org/10.1016/j.neuron.2018.08.033

Adewole, D. O., Serruya, M. D., Harris, J. P., Burrell, J. C., Petrov, D., Chen, H. I., … Cullen, D. K. (2016). The evolution of neuroprosthetic interfaces. Critical Reviews in Biomedical Engineering. https://doi.org/10.1615/CritRevBiomedEng.2016017198

Grimm, F., & Gharabaghi, A. (2016). Closed-Loop Neuroprosthesis for Reach-to-Grasp Assistance: Combining Adaptive Multi-channel Neuromuscular Stimulation with a Multi-joint Arm Exoskeleton. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2016.00284

Letourneau, S., Zewdie, E. T., Jadavji, Z., Andersen, J., Burkholder, L. M., & Kirton, A. (2020). Clinician awareness of brain computer interfaces: A Canadian national survey. Journal of NeuroEngineering and Rehabilitation. https://doi.org/10.1186/s12984-019-0624-7

López-Larraz, E., Trincado-Alonso, F., Rajasekaran, V., Pérez-Nombela, S., del-Ama, A. J., Aranda, J., … Montesano, L. (2016). Control of an ambulatory exoskeleton with a brain-machine interface for spinal cord injury gait rehabilitation. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2016.00359

Petrini, Francesco M., Valle, G., Strauss, I., Granata, G., Di Iorio, R., D'Anna, E., … Micera, S. (2019). Six-Month Assessment of a Hand Prosthesis with Intraneural Tactile Feedback. Annals of Neurology. https://doi.org/10.1002/ana.25384

Petrini, Francesco Maria, Bumbasirevic, M., Valle, G., Ilic, V., Mijović, P., Čvančara, P., … Raspopovic, S. (2019). Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain. Nature Medicine. https://doi.org/10.1038/s41591-019-0567-3

Raspopovic, S., Capogrosso, M., Petrini, F. M., Bonizzato, M., Rigosa, J., Pino, G. Di, … Micera, S. (2014). Bioengineering: Restoring natural sensory feedback in real-time bidirectional hand prostheses. Science Translational Medicine. https://doi.org/10.1126/scitranslmed.3006820

Rijnbeek, E. H., Eleveld, N., & Olthuis, W. (2018). Update on peripheral nerve electrodes for closed-loop neuroprosthetics. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2018.00350

Tan, D. W., Schiefer, M. A., Keith, M. W., Anderson, J. R., & Tyler, D. J. (2015). Stability and selectivity of a chronic, multi-contact cuff electrode for sensory stimulation in human amputees. Journal of Neural Engineering. https://doi.org/10.1088/1741-2560/12/2/026002

Tan, D. W., Schiefer, M. A., Keith, M. W., Anderson, J. R., Tyler, J., & Tyler, D. J. (2014). A neural interface provides long-term stable natural touch perception. Science Translational Medicine. https://doi.org/10.1126/scitranslmed.3008669

Valle, G., Mazzoni, A., Iberite, F., D'Anna, E., Strauss, I., Granata, G., … Micera, S. (2018). Biomimetic Intraneural Sensory Feedback Enhances Sensation Naturalness, Tactile Sensitivity, and Manual Dexterity in a Bidirectional Prosthesis. Neuron. https://doi.org/10.1016/j.neuron.2018.08.033

Adewole, D. O., Serruya, M. D., Harris, J. P., Burrell, J. C., Petrov, D., Chen, H. I., … Cullen, D. K. (2016). The evolution of neuroprosthetic interfaces. Critical Reviews in Biomedical Engineering. https://doi.org/10.1615/CritRevBiomedEng.2016017198

Grimm, F., & Gharabaghi, A. (2016). Closed-Loop Neuroprosthesis for Reach-to-Grasp Assistance: Combining Adaptive Multi-channel Neuromuscular Stimulation with a Multi-joint Arm Exoskeleton. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2016.00284

Letourneau, S., Zewdie, E. T., Jadavji, Z., Andersen, J., Burkholder, L. M., & Kirton, A. (2020). Clinician awareness of brain computer interfaces: A Canadian national survey. Journal of NeuroEngineering and Rehabilitation. https://doi.org/10.1186/s12984-019-0624-7

López-Larraz, E., Trincado-Alonso, F., Rajasekaran, V., Pérez-Nombela, S., del-Ama, A. J., Aranda, J., … Montesano, L. (2016). Control of an ambulatory exoskeleton with a brain-machine interface for spinal cord injury gait rehabilitation. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2016.00359

Petrini, Francesco M., Valle, G., Strauss, I., Granata, G., Di Iorio, R., D'Anna, E., … Micera, S. (2019). Six-Month Assessment of a Hand Prosthesis with Intraneural Tactile Feedback. Annals of Neurology. https://doi.org/10.1002/ana.25384

Petrini, Francesco Maria, Bumbasirevic, M., Valle, G., Ilic, V., Mijović, P., Čvančara, P., … Raspopovic, S. (2019). Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain. Nature Medicine. https://doi.org/10.1038/s41591-019-0567-3

Raspopovic, S., Capogrosso, M., Petrini, F. M., Bonizzato, M., Rigosa, J., Pino, G. Di, … Micera, S. (2014). Bioengineering: Restoring natural sensory feedback in real-time bidirectional hand prostheses. Science Translational Medicine. https://doi.org/10.1126/scitranslmed.3006820

Rijnbeek, E. H., Eleveld, N., & Olthuis, W. (2018). Update on peripheral nerve electrodes for closed-loop neuroprosthetics. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2018.00350

Tan, D. W., Schiefer, M. A., Keith, M. W., Anderson, J. R., & Tyler, D. J. (2015). Stability and selectivity of a chronic, multi-contact cuff electrode for sensory stimulation in human amputees. Journal of Neural Engineering. https://doi.org/10.1088/1741-2560/12/2/026002

Tan, D. W., Schiefer, M. A., Keith, M. W., Anderson, J. R., Tyler, J., & Tyler, D. J. (2014). A neural interface provides long-term stable natural touch perception. Science Translational Medicine. https://doi.org/10.1126/scitranslmed.3008669

Valle, G., Mazzoni, A., Iberite, F., D'Anna, E., Strauss, I., Granata, G., … Micera, S. (2018). Biomimetic Intraneural Sensory Feedback Enhances Sensation Naturalness, Tactile Sensitivity, and Manual Dexterity in a Bidirectional Prosthesis. Neuron. https://doi.org/10.1016/j.neuron.2018.08.033

Team PM&R to the Rescue! A Pandemic Story

by Margaret Beckwith, MD

This story involves a fictional main character with nonfictional PM&R resident friends who provided her much needed support during the beginning of the COVID-19 pandemic in NYC. It is based on true stories submitted by residents in New York working on the front lines in March and April 2020.

The alarms started blaring from room 214 for the umpteenth time. The pleasantly demented, bubbly little old lady with her matching pink flower comb, nails, and purse was pulling off her non-rebreather mask again. Pulse oximetry was reading in the 60's. Despite her low sats, new restraint mittens, and prone positioning, this COVID patient with the smushed face cheerily asked without missing a breath, "Dear, do you think you could get me some coffee?"

"It's 3 AM and I think that's a terrible idea," I exasperatedly whispered to myself. "How about some water and if we tuck you into bed?" I proffered with artificial brightness like the fluorescent lights illuminating the hospital. The patient gave me a very unamused, mirthless expression from her adult tummy time position.

Since being pulled from PM&R residency inpatient rotations and deployed to the COVID units in New York City 6 weeks ago, I recently jumped headfirst into a fast-moving, committed relationship with coffee and I commiserated with my patient. Not only was the hospital short on staff and personal protective equipment, but coffee, the nectar of the gods, the gasoline of life, the fuel of the 24/7 world, was also now a rare commodity in the hospitals. "As soon as the kitchen opens at 6am, I'll make sure you're the first patient served piping hot coffee," I promised her as I backed out of the doorway and banked on her forgetting our conversation and my little white lie.

It was not to be. The patient was in fine form tonight. Every ten to fifteen minutes until 6am a disgruntled, indignant voice shouted from the room, "Do you have any respect your elders?! Where is my coffee?!" I had to chuckle. At least she was giving me some comic relief in-between codes tonight. It's always fascinated me what demented patients are able to remember.

Just before 6:30 AM hand off, I stopped by her room with a warm cup of Joe and asked her how her night was. She indignantly replied, "Well, you guys kept me up all night long running in and out setting alarms off!"

I walked home to my apartment as sun rays started to peak through the spaces between the skyscrapers. Filled with a good feeling I mused, "With her spunk and determination, I'm pretty sure she's going to make it. Didn't Eisenhower say, 'What counts is not necessarily the size of the dog in the fight but the size of the fight in the dog?'"

As soon as I stepped foot into my tiny city apartment, the exhaustion hit me. In the terms of my British relatives, I was “absolutely knackered” but I couldn’t sleep. My mind was racing, the inner monologues of mental chatter meddled with my head. I felt like I was drowning in a colorless, inescapable, slowly asphyxiating abyss of anxiety and fear. I shot up from my bed with my heart racing and sweaty palms realizing I had hugged my dog, my lifeline throughout residency, before fully decontaminating earlier in the morning. “Firetruck!” I cursed. This pandemic was not only turning me into a triple under-the-eye bags monster but also a potential dog murderer. Obviously if the zoo felines were infected by an asymptomatic staff member then Queen of the COVID wards over here is certainly going to infect her precious dog. How could I have been so careless and selfish? I’d only worked 80-90 hours/week over the past 5 weeks and this was considered nothing substantial by any means to the older physicians who thought duty hour limitations were for the weak and cried tears of joy when they were lifted. I took a deep breath and noticed it was not as voluminous as usual.

“Well that’s what happens when you don’t workout for a few weeks, M’dear,” one of the gobby voices in my head yelled at me. “Your lung capacity decreases!!” Another voice snarked that my facial bruising and subsequent edema from wearing my N95 12+ hours day likely loosened the seal around my mask and let the thin, ugly fingers of coronavirus slip underneath. This was it. I knew it. My time had come. By morning the coronavirus would overtake me and I’d be too weak to even reach for my phone and call 911. I’d die alone, like so many of my patients these past few weeks. One of my occult fears was about to become true.

Should I start writing my COVID letters now so that when someone finds me they have something to give my family? Do I leave a cheeky note or two for my top ten friends? How many days of food and treats should I leave out for my pet? Maybe voice recordings on my external hard drive or a little video would be better. Someone would eventually find it. My family is going to be so annoyed but not surprised that I haven't written my will yet. Whatever, they should get everything anyways. It's not like I own anything but a couple hundred thousand dollars of debt and a net negative value at the ripe old age of twenty-eight.

The ruminations became too much. I felt like I was turning into one of the nutters that everyone chats about at happy hour. "Don't plotz" the sagacious voice of one of my Jewish medical school roommates counseled me from an old memory. Yes, yes, okay, don't explode. Exceptional advice. Thanks, Brain, appreciate you being there for me. Even though I had to be back at work in less than 8 hours, sleep was unequivocally not going to be an option. I reluctantly opened up my web browser to Headspace, the meditation app that fellow residents had been raving about for the past few weeks. I have never been much of a meditator nor found an inner need for it as I've always prided myself on falling into REM sleep within 5 minutes of jumping into bed. Now was different. My toolbox of coping strategies needed to be expanded. I signed up for Headspace. I scrolled through the different meditation titles. Ha, "Love Oneself," This girl is the mother ducking boss at treating herself regularly. Don't need any help there. I continued to scroll through the remaining meditation options. "Breathe," well I definitely might need assistance with that later on tonight I thought as I inhaled another mediocre, insufficient "big" breath. "Eating with appreciation?" I think I could probably teach that course. Any warm meal that is not composed of pasta is a five-star feast in my personal Survive Residency's Nonsensical Time Constraints handbook. I took a moment to reflect on the recent generosity of food of donated meals at the hospital provided by community kindness before finally landing on the meditation series I was looking for: Managing Anxiety. Mmm, yep, bingo. Let's go. I started the series. A very polished British accent started cajoling me, "Take a deep breath." I wanted to throw my laptop across the room. Mr. Sophisticated British Man, this is probably the worst advice you could give me right now. I immediately exited out of the browser and reflexively picked up my phone like any conventional millennial under stress.

I noticed one of my co-residents had added me to an NYC PM&R resident WhatsApp group chat where residents were sharing their sentiments (the good, the bad, and the ugly!) and exchanging insight on how different hospitals were providing medical care for their COVID patients. It was almost like being part of a mini think tank! I was immediately drawn to the chat and loved that residents were leveraging their knowledge resources to facilitate the exchange of ideas in hopes of optimizing care for COVID patients across the city. It was how I always envisioned medicine; magnanimous, civilized, and educated. It was also a safe space free from unrealistic, nausea-inducing Pollyannas in ivory towers far from the front lines who were out of touch with reality and who shared impractical, worthless advice. All of us in the group chat had been pulled off of the rehab units and were deployed to the specialties/floors that needed extra hands such as internal medicine, emergency medicine, intensive care units, and COVID units. The timing of this group text was providential.

A personal, almost poetic in nature, journal entry shared by one of the residents at Montefiore caught my eye and really resonated with me:

I would definitely say that the most difficult part of being on the frontlines is the anxiety that comes with not knowing. We don't know where we will be in a few days, or in a few weeks. We don't know who among us will get sick. We don't know who of those that get sick, may end up in critical condition or die. We must check on a daily basis to see what recommendations have changed. Our friends and families ask us what is okay and what is not, and days after telling them one thing, it is disproven or reformed, which can be invalidating. Our training has embedded within us a deep-rooted conviction to practice evidence-based medicine, which relies on peer-reviewed, bona fide, reproducible data: this has completely gone out window. Treatment guidelines and best practice protocols change constantly, and often you learn that what you had been doing is ineffective or deleterious to patient outcomes. This really makes you wonder whether you did right by the scores of patients you watched die over the weeks prior. It feels as though we were stripped of our power to heal. We are a generation of physicians spoiled and entitled, reaping the benefits of knowledge passed on to us by the titanic accolades of the physician and scientist who preceded us. We take for granted the miracles of drugs, imaging, and technology. We have been forced to learn what it means to fly blind, and our errors are frequent and unforgiving. We experience now, what physicians 200 years ago experienced, when they had nothing to offer to children with strep throat or ear infections, and watched them suffer terrible morbidity from diseases that can be easily cured today with bubble gum flavored penicillin. Finally, we don't know whether people will stick with the social distancing and hygiene guidelines, which have afforded us the progress that we've made so far. This gives way to the worst thing of all: We do not know whether there will be a second wave, whether it will be as swift, deadly, and utterly overwhelming as the first. We do not know whether there will be a third fourth or fifth wave, whether it will be in 6 months, 1 year, or five years. And so, we fight on without knowing when this hell will end, and our victories are always overshadowed by skepticism, apprehension, and fear.

Many in the group chat further discussed the difficulty of coping with the newfound stresses of being thrown into deadly, unfamiliar working environments with daily policy changes, observing multiple patients pass away each day and feeling inept, coming home with even more anxiety about accidentally contaminating someone in the family despite taking 45 minutes or more to decontaminate at the hospital each day, and being unable to exercise properly with all the mandated gym closures.

I read on as various residents shared their personal stories and struggles.

In pre-COVID days, Amy Park, DO, Hofstra Northwell, lived with her elderly grandmother and would help take care of her after work. Due to concerns about her grandmother's frail health, Amy started staying in one of the local hotels to avoid accidentally exposing her grandmother to the virus. It was very mentally taxing being uprooted from both her normal PM&R activities and home life. However, Amy was able to find stalwart support from her co-residents and was able to keep in touch with family and friends via multiple video chatting platforms. Amy shared that some newfound positivity for her during these capricious times is that many old, neglected friendships were rekindled as thoughtful, selfless friends from previous chapters of her life reached out when they found out she was on the frontlines. For her, reconnecting with them was like discovering lost treasures of the sea and has been a blessing in this chaotic storm of muddled uncertainty. She has also been able to take advantage of many of the free at-home virtual workouts being offered by Peloton, DownDog, FitOnApp, Orange Theory, Les Mills, Nike Training Club, and Lifetime fitness and highly recommended them to other residents as an avenue for managing their personal stress and health. Amy ended her reflective text to the group by reminding us that just as no amount of make-up can cover up an ugly personality, our outer facades are often a mirror reflecting our inner world. With so many patients and the community relying on us, we must make it a priority to hold each other accountable for our individual well-beings on a daily basis as positivity and kindness are contagious…more contagious than COVID.

Another resident from Metropolitan Hospital Center summed up Dr. Park's words with a quote from Mark Twain and responded: Kindness is a language that the deaf can hear and the blind can see.

I found comfort in this group chat and continued reading through the words of wisdom from my peers.

Eugene Palatula, MD from New York Presbyterian empathized with Amy and said that he too was utilizing the housing services set up through his program and quarantining away from his pregnant wife and two young daughters (ages 3 & 5). For Eugene, watching patients gasping for their last breaths and dying alone due to the No Guest Policy in the COVID Units has been crushingly heartbreaking and made him feel like not only had he been stabbed in the heart but that someone was twisting the knife around in it too. He was certainly not the only healthcare worker experiencing these agonizing emotions. Given how traumatic this has been for patients, families, and healthcare workers, Eugene's hospital recently relaxed their No Guest Policy and has been permitting 1 family member with full PPE to come into the COVID wards for 5 minutes and say goodbye. Eugene highly recommended that other residents advocate for these humane policy changes at their sites. While it's been tough for Eugene to only see his healthy family on his single weekly day off through a screen glass door and/or 6' away, he takes comfort in knowing that his hello-goodbyes are only temporary and wished all of this was just a transient bad dream of mass hysteria proportions like the Tanganyika Laughter Epidemic where no one died and everyone recovered.

Maryam Hosseini, MD of Montefiore related to Eugene's situation and offered insight on her meticulous decontamination ritual for when she returns home to her young family from her COVID shifts. The entrance to her home is known as the "Dirty Area" where no one but Maryam is allowed. As such, she does all the laundry and grocery shopping in addition to working so that her other family members do not have to leave the dwelling. When Maryam returns home from work, she fastidiously wipes down everything on her that can be wiped with a Clorox wipe including her hair pins and changes her clothes in the Dirty Area. Clothes and items that can be washed are placed in a bin called the "Transition Zone." After she sanitizes her hands with alcohol, she races to the shower while her husband sprays the items in the Transition Zone with disinfectant and then washes the items with while donning gloves. Even though Maryam has always been a clean machine, COVID has taken her household cleaning to extraordinary, previously thought to be unattainable, levels. For Maryam, some of her most sanguine moments have been during daily reflections on actively being part of a team of many different specialties that were able to coalesce and work towards a common goal. She herself had learned new skills that she never foresaw herself mastering such as placing nasogastric tubes, drawing up ABGs, and proficiently changing ventilator settings. Meeting residents from other specialties that she would have otherwise never crossed paths with has been another silver lining for her.

Chanel Davidoff, MD, Hofstra Northwell chimed in about her personal strife. One of the most difficult, recurrent part of her day has been her inability to give patients' families closure on prognosis due the unpredictable spectrum of the disease. Ironically these tough conversations have also been the most rewarding. Despite feeling futile and too commonly using the phrase, "We don't know" in discussions about goals of care, anxious families have counter offered an overwhelming amount of gratitude which brightens Chanel's day. While the world is tensely awaiting a magic bullet, the next best discovery throughout this pandemic for Chanel has been Zoom happy hours where she can meet up with her friends and wearing sweatpants is fashionably acceptable. In her comical words, she exclaims," You mean, we get to hang out with friends but don't have to coordinate outfits or wear real pants? It took a pandemic to discover this genius?!" She also jokingly shared that her residency renamed the Faces Pain Scale the Fauci Pain Scale in Dr. Fauci's honor before signing off for the night.

The group chat was on fire! I could barely keep up with the constant stream of messages and it felt good to connect with other budding physiatrists.

A message that caught my eye further down in the group chat was from Malcolm Winkle, MD, SUNY Downstate, who said he had recently recovered from COVID. In March, he started having muscle aches, a mild cough, headache, and subjective fever for two days. For him, drinking significant quantities of tea and taking both ibuprofen and Tylenol helped alleviate the burden of his symptoms. After he was symptom free for 7 days and had not used antipyretics for 3 days, he was cleared to return to work immediately. He initially felt a bit ambivalent about his health clearance; on one hand he was eager to get back to the front lines and help out where he was needed most, but on the other hand, he was concerned he might be doing more harm than good given the current lack of information about post-symptom viral shedding and likelihood that he might still be contagious. Nonetheless, he returned to work and was exceptionally careful with ensuring that he followed PPE policy to a tee in order to avoid unintentionally infecting patients. Malcolm also considers himself very lucky as he has had multiple healthy, young colleagues contract more severe forms of COVID requiring multi-day hospitalizations. Together, he and his wife created a COVID decontamination protocol similar to Maryam's to prevent inadvertent spread of germs at home and so far his immediate family has been spared of COVID symptoms.

One of the last texts I read that night was from "Vitamin King," Lawrence Chang, DO of Burke Rehab who shared his hospital's updated protocol treatment regimen for COVID. In Burke's first week of hosting medical COVID units, one of their older patients started going into acute respiratory distress syndrome and was requiring 15 L of oxygen via non-rebreather mask. The local acute care hospital was completely filled and diverting patients. Given that no local ICUs had room for the patient, Burke was caught in a CATCH-22 as they had no manpower or resources to intubate and ventilate. The team of physiatrists turned COVID medical specialists quickly called the family with the grim update and let them know that CPR would not save the patient's life in the event that she coded. The family agreed that a Do Not Resuscitate order was appropriate for the situation and in line with the patient's wishes. Everyone was frustrated and felt inadequate as healthcare providers unable to heal. The doxycycline and hydroxychloroquine that the patient had already initiated the protocol for COVID pneumonia patients at that time) did not appear to be making any positive impact.

Tick, Tick, Tick. Outside of the patient's room, the clock above the nurse's station was practically deafening and counting down the time until the impending doom of the cytokine storm unleashed an untamable fireworks of inferno inside of the patient. In this emergent situation, Lawrence proposed to his colleagues that they throw a Hail Mary pass attempt at the patient and load her with 8–10g of Vitamin C. Although the patient's care team was initially hesitant, they agreed to try it after Lawrence showed them some medical literature regarding high dose Vitamin C in the treatment of COVID. When the pharmacy received this order, the immediately called the physicians. The pharmacy team was also very skeptical and reminded the physicians that there was an enormous risk for kidney stones and diarrhea. Lawrence again showed the evidence-based medical publications to the pharmacists and pointed out that diarrhea from Vitamin C was a sign of "bowel tolerance" and was physical evidence that the dose was strong enough to work at a therapeutic level. Pharmacy reluctantly gave the physicians the megadose of vitamin C. No one except Lawrence had high hopes for this pharmacotherapy and other members of the team prayed that the patient would have a somewhat peaceful death overnight.

Much to everyone's surprise and delight, the patient was doing well the next morning and had not any events overnight. Despite still being on 15 liters of oxygen via the non-rebreather, the patient stated she was feeling better and clinically she looked much better. Over the following days, the patient completed her course of antibiotics but still required the nonrebreather mask. She continued receiving 8g of Vitamin C daily for more than a week after finishing her antibiotics and was titrated down to 5L of O2 via nasal cannula and was able to participate in therapy. By day of discharge, she was down to her home COPD requirements of 2L and her Vitamin C had been titrated down to 2g daily. Looking back on the case, Lawrence was not sure if the patient's condition drastically turned around due to the combination of antibiotics and high dose vitamin C, just the antibiotics alone, pure luck, or divine intervention. Regardless of what actually saved the patient's life and helped her rehabilitate (and for the record she did not develop kidney stones), Lawrence's colleagues dubbed him "Vitamin King" and credited his quick thinking and broad knowledge of COVID therapies with saving the patient's life. Lawrence continued to advocate for aggressive nutrition rehabilitation in COVID patients with the hypothesis that either pre-COVID micronutrient deficiencies further compromised their ability to fight the infection or in their bodies' attempt to fight the infection they quickly depleted their micronutrient stores. Pending patient's individual conditions and needs, may of the Burke COVID teams started their patients on Vitamin D, Zinc, thiamine, and Coenzyme Q sometimes in conjunction with high-dose Vitamin C and sometimes without it. Lawrence's medical team had a few more patients with severe respiratory distress secondary to COVID over the next few weeks . He promptly put them on 6–8g of Vitamin C daily in addition to their antibiotics and all of those patients' oxygen requirements improved. Lawrence was thankful for working with an open-minded team in these uncertain times.

Despite the chaos and day-to-day dubiousness, one thing was for certain and reinforced over and over again in the NYC PM&R WhatsApp group text. As Eugene pointed out, emergency medicine and internal medicine attendings and residents were very appreciative and impressed with how seamlessly PM&R residents fit in and transitioned into the acute care workflow during the peak of the pandemic. Significant impacts were made by physiatrists on the front lines. As Chanel said, "Coming together as a 'COVID specialists' has been humbling and heart-warming. Adapting to a new environment is tough; but, doing it with the intention of supporting our front-line doctors has made it worthwhile. Having experience in providing vital information about functional barriers have aided tremendously in medical decision making. Yes, we are rehab specialists - but we are all physicians first."

And with that, I felt reenergized and put my phone down after setting the alarm. While taking in a refreshing wonderfully deep breath, I patted my dog on the head with newfound courage and peace as she curled up on the rug beside my bed. I settled into my soft covers as the sunlight peeped through the corners of my curtains and dozed off, exhausted but excited to be part of this experience and proud to be a physiatrist.

Special thank you to Lawrence Chang, Chanel Davidoff, Maryam Hosseini, Amy Park, Malcom Winkle, and Anonymous resident from Montefiore, for sharing their stories about working on the front lines in NYC.

Margaret Beckwith is a PGY-3 at the Physical Medicine and Rehabilitation residency of Washington University in St. Louis, MO. Find her on Twitter @Beckwith_MD.

Could Exercise Have a Role in Lymphedema Diagnosis and Tracking?

by Evelyn S. Qin, MD

Figure 1- Patient with leg lymphedema exercising on a recumbent cross-trainer Lymphedema occurs when there is damage or abnormal lymph vessels, preventing adequate lymphatic fluid drainage (1). It is a well-known and dreaded complication of cancer therapies such as lymph node dissections for breast or gynecological cancers (2,3). Lymphedema has traditionally been diagnosed based on clinically history and presentation. However, due to the profound disability and effect it has on quality of life, emphasis has been placed on early and accurate diagnosis.

There are several tools that have been used by healthcare providers to diagnose and track lymphedema. Indocyanine green (ICG) lymphography (figure 2) is an advanced imaging tool that is non-invasive, non-radioactive, and can visualize lymph flow in real time. It has been used increasingly by lymphedema specialists for lymphedema diagnosis, severity staging, treatment planning, and as well as intra-operative guidance, and post-operative management. ICG lymphography has a higher sensitivity and specificity than lymphoscintigraphy (4), the traditional gold standard for visualizing the lymphatic system. It requires an initial and delayed scan to fully visualize disease patterns. However, one of the largest frustrations with ICG scans is the long wait between initial and delayed scans and difficulty controlling for patient activity between scans. Current methods utilizes up to a 24-hours between immediate and delayed scanning (5, 6), and limits the amount of patients that can be imaged in a typical clinic day.

Figure 2 – Indocyanine Green Lymphography in a patient with right leg lymphedema. ICG dye builds up in the leg creating a stardust pattern rather than a normal linear pattern, indicating presence of lymphedema

Exercise has been shown to increase lymphatic drainage (7, 8) and is beneficial in patients with lymphedema (9, 10). A recent pilot study at the University of Iowa Hospitals and Clinics was performed to determine if controlled exercise could increase the rate at which ICG dye to plateaus with the goal of developing a standardized ICG lymphography protocol to increase the efficiency and reliability of ICG lymphography in patients with lymphedema. Patients with lymphedema exercised on a recumbent cross trainer (figure 1) with ICG lymphography scans performed after 5 minutes of exercise for a total of twenty minutes. Results showed the ICG dye plateaued after three cycles of exercise (15 minutes of exercise in total) in all patients, and the dye receded after 4 hours. Patients stated they preferred the exercise protocol over the traditional immediate and delayed scans because it shortened their office visits significantly and was not too challenging to do.

We are excited by these preliminary findings as it shows that exercise can accelerate lymph flow. This means exercise allows for more efficient and accurate ICG lymphography studies. In addition, this brings up the exciting question on the ability of exercise to help increase lymph transit during rehabilitation therapies, and the possible positive long-term affects it may have on lymph flow in patients with lymphedema.

Evelyn Qin is a PGY-2 in the Physical Medicine and Rehabilition residency at the University of Washington in Seattle. Follow her on Twitter @EvelynQinMD.

References

1. Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008;59(2):324–31.

2. Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer. 2010;116(22):5138–49.

3. Brayton KM, Hirsch AT, PJ OB, Cheville A, Karaca-Mandic P, Rockson SG. Lymphedema prevalence and treatment benefits in cancer: impact of a therapeutic intervention on health outcomes and costs. PLoS One. 2014;9(12):e114597.

4. Mihara M, Hara H, Araki J, Kikuchi K, Narushima M, Yamamoto T, et al. Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. PLoS One. 2012;7(6):e38182.

5. Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Hayashi A, Koshima I. Indocyanine Green Lymphography Findings in Primary Leg Lymphedema. Eur J Vasc Endovasc Surg. 2015;49(1):95–102.

6. Narushima M, Yamamoto T, Ogata F, Yoshimatsu H, Mihara M, Koshima I. Indocyanine Green Lymphography Findings in Limb Lymphedema. J Reconstr Microsurg. 2016;32(1):72–9.

7. Desai P, Williams AG, Jr., Prajapati P, Downey HF. Lymph flow in instrumented dogs varies with exercise intensity. Lymphat Res Biol. 2010;8(3):143–8.

8. Downey HF, Durgam P, Williams AG, Jr., Rajmane A, King HH, Stoll ST. Lymph flow in the thoracic duct of conscious dogs during lymphatic pump treatment, exercise, and expansion of extracellular fluid volume. Lymphat Res Biol. 2008;6(1):3–13.

9. Singh B, Disipio T, Peake J, Hayes SC. Systematic Review and Meta-Analysis of the Effects of Exercise for Those With Cancer-Related Lymphedema. Arch Phys Med Rehabil. 2016;97(2):302–15 e13.

10. Morris C, Wonders KY. Concise review on the safety of exercise on symptoms of lymphedema. World J Clin Oncol. 2015;6(4):43–4.

The Intricate Balancing Act of Physical Exercise During the COVID-19 Pandemic in Older Adults

by: Sam Famenini, BA

Image from All Seniors Care Living Centers. Source here.

On January 30th, 2020 - The World Health Organization set the entire world at large with their declaration proclaiming COVID-19 as an international public health emergency. For the billions of people living across the globe, life has dramatically changed. The United States of America implemented lock downs by mandating stay-at-home-orders to combat the spread of the virus. While its necessary to contain the virus, there have been many unfortunate and unintended consequences of this 'new normal'. An immediate detrimental result of these government shutdowns has been the breakdown of structure within society's daily routines. Specifically, with many mandated restrictions, more people have adopted a more sedentary lifestyle. Furthermore, the isolation from family and friends has created an increase in the rates of depression. With the increasing rates of unemployment, anxiety has also skyrocketed.

With the shutdown of gyms, parks, hiking trails and other facilities, people have subsequently reduced their physical activity. The limitations on facilities have greatly impacted those with underlying medical conditions who may benefit from physical activity the most. For example, the elderly person with severe arthritis who has difficulty walking and had been dependent on a public pool for physical exercise, has no other means of engaging in physical activity. With the closure of fitness stores, even obtaining exercise equipment has been challenging. Also at this time, millions of Americans are working from home. While these measures have provided immediate comfort during this challenging time, they have also created a much more sedentary lifestyle that has negatively impacted our physical well being.

The impact that COVID has made on the individual varies per person: a young, low-risk and healthy individual might not feel the strains of this 'new normal', as much as an older, high-risk or unhealthy patient may be currently experiencing. Recent studies have concluded that many of these high-risk, older adults admit to feeling a higher degree of fear. The fears of infection, death, and uncertainty often loom over these individuals. The resulting loss of social contacts and feelings of loneliness, depression, and helplessness are plaguing the minds of higher-risk individuals during this challenging time and further contributing to rising depression and anxiety. In addition, the loss of jobs has created financial strains which have exponentially increased rates of anxiety among the population.

This internal dilemma and mental health struggle are troubling for the older demographics of our societies. The constant struggle of balancing physical and mental wellness needs with the fear of potentially contracting COVID-19 is easily apparent. As a result, many older adults have significantly restricted their physical activity. While our higher-risk elderly populations are more prone to serious complications of the virus, the notable importance of avoiding a stationary lifestyle for their overall health cannot be ignored.

Prior to the development of the COVID-19 Pandemic, physical inactivity among older adults had been documented as the fourth highest cause for mortality worldwide and a major contributor to disability. Conversely, a sustained level of physical activity and exercise has proven to be an effective therapy for many common chronic diseases. Physical activity is essential in older individuals to at least preserve their already diminished functional reserve. Thus, continued engagement in physical activity is important for the elderly population to preserve both their physiological and psychological well-being.

My recommendations in combating this dilemma of inactivity is for healthcare leaders worldwide to get creative in promoting at-home physical activities. With the aid of technological advances, millions worldwide now have the ability to access virtual physical conditioning regimens. However, technology can present its own unique challenges for the elderly. As a community not only must we support and promote these technological advances, but we must also make them more-easily accessible and feasible for the elderly. A prime example can be noted in Tokyo, where healthcare officials found a clever way to capitalize on telehealth outreach by utilizing it to promote physical activity in Japanese elderly communities. The officials designed and implemented a telehealth program which consisted of either a video or poster that could be downloaded to one's mobile device. For those less technologically savvy, they also provided the alternative of mailing the DVDs and posters directly to seniors' residences. The home regimens provided included both stretching and strengthening exercises for the upper body, lower body, and core (Table 1). These actions further support the notion that providing creative and accessible means of maintaining strength and flexibility, while preserving safety and promoting autonomy and internal motivation, is paramount during this crisis for our elderly community.

Table 1: Aung MN, et al. Sustainable health promotion for the seniors during COVID-19 outbreak: a lesson from Tokyo.

Another innovative way to promote activity during this time can be done by encouraging participation in active exergames (active videogames)! Exergames are thought to be safe, easily utilized, and very enjoyable. Previous studies have shown that while exergames can safely enhance one's physical activity and performance of daily activities, they have also been beneficial for improving postural balance and cognitive function in the elderly. The games specifically tailored towards the elderly, (e.g. Zumba, virtual ping-pong, tennis, boxing, and yoga) provide a plethora of options with a wide appeal that may accommodate a range of baseline fitness abilities. In addition to maintaining physical activity, a single 20-minute session of a Zumba exergame has been shown to significantly decrease anxiety. Exergames can also be played together with family and friends, which is an added benefit that may simultaneously help decrease the feeling of social isolation commonly experienced during quarantine.

Image from All Seniors Care Living Centers. Source here.

Most community members do not have access to proper gym equipment at home, however there are many outlets that can provide creative substitutes. Many household items such as vegetables, rice, or water bottles can be substituted for weights for use in strength training. Additionally, exercises can be done using one's own body weight. For example, squats can be done by holding onto a chair or sitting and rising from a chair. Aerobic exercises that can be done at home include walking the stairs and dancing. Balancing exercises such as tandem gait walking can also be incorporated if safe to do so.

These unprecedented times have challenged our society as a whole to seek creative avenues of promoting our overall health and wellness. Society as a whole cannot afford to weaken physical and mental measures during this COVID-19 pandemic - specifically our higher at-risk population. I strongly recommend that individuals, leaders, and healthcare providers use their platform to encourage creative and fun methods of incorporating physical activity regimen through virtual activities to promote a healthy and well-balanced lifestyle.

Sam is a fourth year medical student at University of Maryland.

References

Aung MN, Yuasa M, Koyanagi Y, et al. Sustainable health promotion for the seniors during COVID-19 outbreak: a lesson from Tokyo. Journal of infection in developing countries. 2020;14(4):328–331. doi:10.3855/jidc.12684.

Goethals L, Barth N, Guyot J, Hupin D, Celarier T, Bongue B. Impact of Home Quarantine on Physical Activity Among Older Adults Living at Home During the COVID-19 Pandemic: Qualitative Interview Study. JMIR aging. 2020;3(1):e19007. doi:10.2196/19007.

Hall G, Laddu DR, Phillips SA, Lavie CJ, Arena R. A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another? Progress in cardiovascular diseases. April 2020.

Jiménez-Pavón D, Carbonell-Baeza A, Lavie CJ. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: Special focus in older people. Progress in cardiovascular diseases. March 2020. doi:10.1016/j.pcad.2020.03.009.

Matias T, Dominski FH, Marks DF. Human needs in COVID-19 isolation. Journal of health psychology. May 2020:1359105320925149. doi:10.1177/1359105320925149.

Nyenhuis SM, Greiwe J, Zeiger JS, Nanda A, Cooke A. Exercise and Fitness in the Age of Social Distancing During the COVID-19 Pandemic. The journal of allergy and clinical immunology In practice. April 2020. doi:10.1016/j.jaip.2020.04.039.

Peijie Chen, Lijuan Mao, George P. Nassis, Peter Harmer, Barbara E. Ainsworth, Fuzhong Li. Coronavirus disease (COVID-19): The need to maintain regular physical activity while taking precautions. Journal of Sport and Health Science. 2020;9(2):103–104. doi:10.1016/j.jshs.2020.02.001.

Viana RB, de Lira CAB. Exergames as Coping Strategies for Anxiety Disorders During the COVID-19 Quarantine Period. Games for health journal. May 2020. doi:10.1089/g4h.2020.0060.

Chronic Pain and COVID-19: A Case with Recommendations

by Micheal T. Murphy, MD

Photo by Karolina Grabowska, link here.

A 54-year-old male with a history of alcohol abuse, A.Fib on AC, CKD III, and hypertrophic nonobstructive cardiomyopathy s/p orthotopic heart transplant on chronic immunosuppression presents with centralized low back pain of one year duration. Pain is constant, deep, and achy with intermittent sharp, stabbing, burning sensation down the left leg. Back pain is worse than leg pain. Pain is worse with prolonged sitting/standing and improved with rest. Patient has failed conservative measures. Exam is significant for 4/5 weakness at left S1 myotome, + lumbar facet loading, and + left Slump. Plain films demonstrated moderate L4-L5 and L5-S1 facet osteoarthritis. An MRI of the lumbar spine ruled out osteomyelitis/discitis and demonstrated left lateral recess stenosis at L5-S1 in addition to multilevel central spinal stenosis, most pronounced at L4-L5. Patient was subsequently scheduled for and received bilateral L4-L5 and L5-S1 facet injections. Shortly thereafter, a national emergency was declared for COVID-19 and policy changes began to be implemented.

The CDC released mitigation recommendations which included limiting unnecessary visits and canceling elective and non-urgent procedures. Additionally, the CDC released consensus medical conditions thought to increase the risk for serious COVID-19 infection including but not limited to heart disease, CKD, and immunosuppression [1]. In accordance with CDC guidelines, the patient was scheduled for follow-up via TeleHealth at which time no pain relief was reported from prior facet injections. The decision was made to prescribe Norco 10/325mg and schedule the patient for an L4-L5 interlaminar epidural steroid injection once elective procedures resumed.

Chronic pain is a prevalent condition worldwide and causes suffering, limitation of daily activities and reduced quality of life. According to the United States 2012 National Health Interview Survey, 126.1 million adults reported some pain in the previous 3 months, with 25.3 million adults (11.2%) suffering from daily chronic pain and 14.4 million (6.3%) reporting “a lot” of pain most days or every day [2]. Until recently, there was no document or guidelines for the management of chronic pain patients, either during the current crisis or at the time of previous epidemic or pandemic outbreaks. Shanthanna et al compiled an expert panel of pain physicians, psychologists and researchers from North America and Europe to address this specific deficiency in the literature.

Their recommendations are based on the best available evidence and expert opinion, and can be summarized as follows: temporarily suspend all elective in-person visits and pain procedures; use TeleMedicine as a first approach; monitor and provide resources for psychological health, social circumstances, and ongoing pain; opioid prescribing without direct in-person medical evaluation is permissible; NSAIDs may be prescribed without associated increased risk for infection; prescribe steroids with caution due to potential for immune suppression; do not perform new pump/stimulator trials or implants; exercise clinical judgement on a case-by-case basis for semi-urgent procedures [3].

The American Society of Regional Anesthesia and Pain Medicine subsequently endorsed these recommendations in addition to highlighting the distinction between urgent vs semi-urgent procedures and what procedural precautions need to be taken. Comprising the urgent category were intrathecal pump (ITP) refills/malfunction and neurostimulator infection/malfunction. While new trials and implants are to be avoided, patients who recently underwent an implant procedure should have access to medical care. Procedure related complications are to initially be evaluated over telemedicine with subsequent in-person evaluation if implant infection is suspected. ITP refills and end-of-life battery replacements should be performed to avoid withdrawal symptoms. Comprising the semi-urgent category were intractable cancer pain, acute herpes zoster or intractable post-herpetic neuralgia, acute herniated disc and/or worsening lumbar radiculopathy, intractable trigeminal neuralgia, early complex regional pain syndrome, acute cluster headaches or other intractable headache condition, and other intractable medically resistant pain syndromes [3]. These cases need to be evaluated on an individual basis with shared decision making based on factors such as: the acuteness of the condition, potential for significant morbidity without intervention, the need for additional resources, the likelihood of benefit, and the potential for the patient to use emergency services [3, 6].

If a patient is determined to need an in-person meeting or procedure, ASRA recommends screening these individuals for the possibility of COVID-19. Patients can then be triaged into two groups: COVID-19 negative or low-risk patient and COVID-19 positive or high-risk patient. For both groups, following the CDC prevention and control recommendations is strongly recommended [4-5]. For the former group, the following recommendations apply: minimize patient movement within the hospital, use a clean room with no prior COVID-19 positive patients, use sterile technique when handling medication, utilize appropriate PPE for provider and patient, don and doff equipment carefully, protect equipment and minimize contact with patient as able, minimize personnel present during the procedure, and follow routine aseptic technique. For the latter group, in addition to the above recommendations, the following apply: limit these patients to urgent procedures, perform procedures in a designated COVID-19 room, and monitor these patients in an isolation room post procedure [6].

Given the fluidity of the COVID-19 pandemic, it is essential that practioners and organizations alike continue to adapt as more information and guidelines become available. Overall, the goal in our chronic pain population must be to avoid deterioration of function, reliance on opioids, and use of emergency services that would otherwise increase the risk of exposure.

Micheal is a PGY-2 resident in Physical Medicine and Rehabilitation at the University of Kansas Medical Center.

References

Centers for Disease Control and Prevention. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf. Accessed May 19, 2020.

Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. Journal of Pain 2015; 16: 769-80.

Shanthanna H, Strand NH, Provenzano DA, et al. Caring for patients with pain during the COVID-19 pandemic: Consensus recommendations from an international expert panel. Anaesthesia. 2020 Apr 7.

Centers for Disease Control and Prevention. Environmental Cleaning and Disinfection Recommendations. https://www.cdc.gov/coronavirus/2019ncov/community/organizations/cleaning-disinfection.html. Published March 6, 2020. Accessed May 19, 2020

Centers for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-riskassesmenthcp.html?fbclid=IwAR24sPRluyXo7abdKY4WfUwg4TtckmlqV9AZdMHpC80ZgDyEtqqwxb0baBo. Published March 7, 2020. Accessed May 19.

Shanthanna, Harsha, et al. “Recommendations on Chronic Pain Practice during the COVID-19 Pandemic.” American Society of Regional Anesthesia and Pain Medicine, 27 Mar. 2020, www.asra.com/page/2903/recommendations-on-chronic-pain-practice-during-the-covid-19-pandemic.

Pandemic Physiatry: Adapting to the New Normal

by Evan R. Zeldin, MD

Photo by Andrey Popov, link here.

For the last few months, we’ve watched the world transform into a place that would have been unimaginable just a few short months ago. First there was China, then Italy, and then New York. Here in North Carolina, we started to prepare once it became clear that what was happening worldwide could happen even in our rural neck of the woods. As society was beginning to close down all around us, we too made changes. We closed our clinics, we limited and then eliminated visitors to our hospitals, we masked personnel, and we moved to a modified schedule to prevent unnecessary resident and attending exposure. It seemed that the needs of a physiatrist would not be important in the acute crisis- we started to prepare for our new future to be “redeployed” into the COVID units- perhaps functioning as a modified ICU physician. We waited and waited for the worst to come. And waited.

Fortunately, it seems that society committing to social distancing and self-isolation spared us from the worst. Our hospital saw our fair share of cases but nothing close to overwhelming our healthcare system like the experiences of northern Italy or New York City. It became more and more apparent that we were going to experience what our hospital was calling a “plateau” − a steady stream of cases that our hospital system could manage.

It was therefore time for us to figure out how to return to our role as physiatrists in this new world.

We began reopening our clinics- entirely by phone at first. Then we started prioritizing the essential visits- the patients who needed to be seen in person. We learned how to minimize patient exposure to each other by limiting the numbers that could be seen each day and masking everyone in waiting rooms. Slowly but surely, more and more patients are being scheduled for in person visits – using what we have learned so far to keep both the patients and our staff safe. The experience in these clinics is surreal- temperature checks, everyone in masks, half schedules, and the fear that anyone could be transmitting a deadly illness makes for a vastly different experience than a few months ago.

In the inpatient hospital, we been starting to admit our first patients who’ve survived COVID-19 and are in desperate need of rehabilitation due to both general debility but especially pulmonary rehabilitation. These patients are required to be symptom free and have multiple negative tests before admission to our hospital. So far, these patients have been doing well, making both improvements medically and making physical gains with our therapists.

But the future is uncertain. I hope that things will get better or continue to remain with this steady plateau. As society attempts to grapple with the current situation and determine how and when to re-open, I wonder if we may return to the way things used to be – fearing that our system will be overwhelmed and therefore making us as physiatrists sidelined yet again – unable to take care of the multitude of patients who need our help now. This fear is hopefully unfounded, over the last few months both our healthcare system and our society has learned how to adapt – hopefully allowing us to be prepared for whatever comes our way. And most importantly, there are signs every day of how things are getting better in terms of current treatment but also progress towards the ultimate goal – the vaccine that ends this crisis.

But until then, we’ll continue on with the way things are, doing the best that we can as physiatrists in this new normal.

Evan is a PGY-2 resident at East Carolina University/Vidant Medical Center.