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Physiatry in Motion Issue 15, Summer 2019

Update from the AAP RFC Chair — Summer 2019

by Neal Rakesh, MD

Happy Summer Everyone!! We’re halfway through the year since our last conference in Puerto Rico and inching ever closer to our joint conference with The International Society of Physical and Rehabilitation Medicine (ISPRM) in Orlando. Save the date: March 4–9, 2020. This conference is set to be one of the biggest that AAP has ever had and you can bet there will be a lot of amazing things that you don’t want to miss. To prepare for this conference, your elected AAP Resident/Fellow Council (RFC) has been working on a range of exciting projects.

I am proud to announce the creation of three new RFC subcommittees:

The first is the Wellness Subcommittee that is chaired by Allison Schroeder, MD (University of Pittsburgh, PGY-4), which is focused on tackling issues centered around resident and fellow wellness. As burnout continues to be a reality in physician training and beyond, this group helps reflect on what keeps us as physicians mentally and physically well to better serve our patients. Last year Allison created the “Word of Wellness” section on AAP’s website and has some new exciting ideas in the works for this year.

The next is the Digital Outreach Subcommittee that is chaired by Barbara Kozminski, MD (incoming resident to the University of Washington in 2020). This group focuses on generating and publishing podcasts on a variety of interesting topics for AAP members. Within the past few months, a slew of new podcast series was created and produced including the Pocket Mentor, Journal Club, Physiatry Perspectives, The Road to Chair, and Career Chats. For updates when new podcasts are released, follow us on Apple Podcasts, Spotify or SoundCloud under the “Association of Academic Physiatrists.”

Finally, our newest addition is the Social Media Subcommittee. In a world that revolves around social media as a way to connect and consume information, it is essential to communicate with our members with more than just emails. This group focuses on assimilating all the exciting things that are going on within AAP and representing our diverse and dynamic field across our social media platforms. If you haven’t yet, follow us on our Instagram, Twitter, and Facebook to catch the latest updates and stay connected with your fellow physiatrists.

Medical Student Council (MSC)

Since its inception last year, the MSC has been very active with the creation of a new newsletter, a virtual grand rounds and an overhaul of AAP’s medical student mentorship program. They have also expanded AAP’s audience by producing podcasts targeted toward the physiatrists of tomorrow and increased their social media presence. Additionally, the MSC is helping to create a great program for the upcoming conference to help medical students navigate the residency application process.

American Journal of PM&R (AJPM&R) — Resident Fellow Section

Last year a new section of the AJPM&R was created to highlight the research endeavors of physiatrists in training. Since then, a new associate editor (Dinesh Kumbhare, MD, PhD) and editorial board (Allison Bean, MD, PhD; Chan Gao, MD, PhD; Allison Schroeder, MD, Patrick Spicer, MD, PhD, Martin Weaver, MD) were selected. The board has reviewed a series of submissions and the first articles are planned to be published soon. If you are interested in research and publishing articles, check out the link to see how to submit to AJPM&R’s Resident Fellow Section.

Physiatry ’20 — Resident Fellow Track

A pivotal role of the RFC is to design and produce the resident fellow track for the upcoming conference. Currently, the educational sessions and schedules are still being finalized, but you can expect a diverse mix of hands-on workshops, engaging lectures and networking events that you won’t want to miss.

We’ve had an exciting year in the RFC with lots of new ideas and fresh faces. With still a half a year to go till the next conference and a new council, the RFC has lots we are still striving to accomplish. I would like the thank everyone that has been involved in the Resident/Fellow Council, Medical Student Council, AJPM&R Resident Fellow Section, and the new RFC Subcommittees for their tireless effort. It is inspiring to be a part of such an amazing group of motivated people that strive to make our community of PM&R better for future generations. Finally, I would also like to thank the AAP staff, including Jackie Dilworth, Tiffany Knowlton and Amy Schnappinger, for all of their support and help to facilitate the creation of all of these new endeavors. I look forward to seeing everyone in Orlando in 2020!

YouTube and Sports Medicine

by Brian Sutterer, MD

It’s Christmas day and the L.A. Lakers are playing the Golden State Warriors when suddenly LeBron James goes down with an injury and the NBA community holds its breath. It’s a groin strain — LeBron is going to miss significant time. Those within PM&R probably understand what this means, but countless fans watching are left to wonder what exactly happened and that provides a unique opportunity to help educate and teach about musculoskeletal and sports medicine. This was the inspiration behind my YouTube channel, Brian Sutterer MD, where I help explain various sports medicine topics and injuries in a way that people can better learn from and understand. This approach makes learning more fun for my audience and helps to provide some exposure to medicine and what we learn about in PM&R.

There are many different social media outlets that can be used to provide education and share your experiences with others. When used appropriately they can be effective in helping promote your field and shaping your professional career. YouTube is one of the lesser used tools and the thought of recording yourself in front of a camera and microphone can seem quite intimidating at first. However, the video format provides many benefits to your audience and your own personal development. It is more personable and can make the viewer feel more of a connection with you. You also have the ability to add helpful graphics and animations in presenting your information. YouTube videos can also help you improve your communication skills for public speaking and your ability to present information in a concise and understandable way. If you can get comfortable recording yourself for the whole world to see, speaking at a conference or just talking to a patient gets much easier!

If you are interested in starting a YouTube channel, here are some key tips to help set you up for success!

1- Tell your institution what you are doing and get approval. You are your own person, but it’s crucial to have open communication with your employer or school so that you don’t cause any issues down the road.
2- Separate yourself from your employer/school. Include a simple disclaimer statement in your work so viewers know you don’t officially represent your employer or school.
3- Don’t worry about having fancy equipment to record with — focus on the content. Cell phones record perfectly good video and a cheap microphone is all you need. I did not buy a camera for over a year after starting my channel. Focus on your content and make gradual improvements to your production as you grow.
4- Be prepared for criticism. The internet can be a mean place, and YouTube is no exception. Don’t take this personal or be surprised when it happens.
5- Make it fun! If it’s not fun you won’t stay with it. Focus on topics that both interest you and help others.

Brain Sutterer is a PGY3 in the Department of Physical Medicine and Rehabilitation at Mayo Clinic. Follow him on Twitter @b_sutterer

Ability over Disability

by Laurenie Louissaint MD, MSc

“Come on guys, let’s get this game going!” shouted Team Zaryen’s head coach. I could hear the team members playfully arguing in Creole about who would score the most goals as they prepared to play. Those who wore prosthetic legs removed them and left their residual limbs bared as if to show off a war wound. Others put on a single shin guard or soccer cleat.

I had the pleasure of attending one of Team Zaryen’s scrimmages in Haiti’s capital, Port-au-Prince, back in January during a medical volunteer trip. As a former track athlete, I was left completely speechless at how amputee soccer challenged the biomechanics of running on two feet. From the way their Lofstrand crutches propelled them forward, to their remarkable upper body strength and the precision with which they all performed their cutting motions, ability, rather than disability, described this group of young Haitian men. In October 2018, they competed at the Amputee Football World Cup in Mexico and finished in the top ten with one of their youngest players winning the Golden Boot as the highest scorer.

Team Zaryen was founded in the aftermath of Haiti’s devastating earthquake in 2010 and is a demonstration of the resilience and pride of the Haitian people. An estimated 1,200–1,500 individuals underwent amputations as a result of the earthquake. Having a disability compounded with living in a developing country creates the perfect storm that ultimately leaves an individual limited, not only how they live their daily life, but also how they are able to provide for themselves. “When people see me, they see my missing leg. They see someone who always needs help. I can’t find work. I’ve been turned down for jobs that I was more than qualified for,” explained one player. Soccer gives these men a sense of purpose, strengthens their self-confidence, and is their way of defying the odds after losing a limb.

Team Zaryen’s story is one of many examples of the power of adaptive sports and its multifaceted effect on the overall health of individuals with disabilities.They provide a positive impact on outcomes related to physical health, mental health, community participation, and, in some cases, neurorecovery. (1) The camaraderie and sense of community that develops as a result of participating in adaptive sports are therapeutic. Thus, participation should be seen not only as a medical intervention but also as a rights-based issue. Who best to be at the forefront of the care of amputees but physiatrists? With our knowledge base of impairment-specific injuries and risks, we can provide appropriate treatment for the disabled athlete. Physiatrists can also provide essential leadership and support to disabled sports programs and the multidisciplinary team often involved.(2)

Physiatry is a young field, and while growing rapidly, we are a relatively small field; therefore, our representation at local and international events such as the Paralympic Games is important for those who participate in these events.(3) As technological advances and the number of individuals with disabilities who want to participate in sports continues to increase, the demand for physiatric expertise will increase as the profession becomes better known for the unique healthcare roles it serves. According to Dr. Miranda-Comas, Sports Medicine Fellowship director at Icahn School of Medicine at Mount Sinai, having a larger impact with our care begins with getting involved in local organizations.

As physiatrists, let us continue to encourage individuals with disabilities to compete in adaptive sports at the local, national, and international level so that we may have more teams like Team Zaryen, and work together to spread the hope that adaptive sports can offer.

References

  1. Blauwet CA. More Than Just a Game: The Public Health Impact of Sport and Physical Activity for People With Disabilities (The 2017 DeLisa Lecture). Am J Phys Med Rehabil. 2019 Jan;98(1):1–6.
  2. Bergeron, JW. Athletes with Disabilities. Physical Medicine and Rehabilitation Clinics. 1999 10(1):213–230.
  3. Willick S, Lexell J. Stories from Sochi: sun, sea, snow, and salt. PM R. 2014 Aug;6(8 Suppl):S76–9.

Laurenie Louissaint is a PGY1 at North Florida Regional Medical Center and future Resident in the Department of Rehabilitation and Human Performance at Icahn School of Medicine at Mount Sinai. Follow her on Twitter @Dr_knee_nie

Space: The Next Frontier in Physical Medicine and Rehabilitation

by Luke Brane, MD

This is the first part of a three-part series on Aerospace Medicine.

Flight Surgeons on the job. — nasa.gov

One might ask, “What is the purpose of discussing spaceflight in a medical publication dedicated to the trainees of Physical Medicine and Rehabilitation? What could these two things possibly have in common?” In this three-part series on space medicine, I hope to convince you that these things do have strong potential as commingled subjects, and that the time to explore this potential is now.

First, we must lay a little groundwork. Whether or not the average citizen of Earth is aware of it, we are currently experiencing a space race that is far more voracious and widespread than its predecessor of 50 years ago. In fact, the driving force behind it bears very little resemblance to the original nationalistic, superpower-sponsored race of the 60’s and 70’s, save the name and destination. This distinction does not diminish the accomplishments of the past space explorers, but demonstrates a political expediency behind the original “space race” that is not present today. The focus of the original space race was not the long-term sustainability of human space flight, but how fast milestones could be achieved. Consequently, the economic infrastructure and financial support for continued human space flight were not in place when the race was effectively “won” and the drive and public interest waned. In contrast, the current race is largely an economic one, that has more in common with the gold rush, early oil economy, or frontier expansion of the 18th and 19th centuries in North America. This race is being fueled by recent breakthroughs in associated technology that have drastically reduced the cost of launching to low Earth orbit (LEO) and beyond. In conjunction with robust competition in nearly every sector of spaceflight, from launch vehicles, to habitation, to life support systems, it is truly a new world order. The economic possibilities of opening space for industry change everything; the advances in technology and standard of living seen between the pre-industrial horse-drawn age and the post-industrial steam and combustion engine driven age pale in comparison. However, unlike the gold rush, railroad expansion and early oilmen of yore, the viability of our push into the frontier hinges on being able to figure out how to keep humans safe and healthy throughout and beyond each mission.

For those skeptical that there is not enough motivation for, or interest in the human colonization of space, here is a short, and by no means complete, list of technologies that are poised to experience a drastic leap forward with low-cost access to space: Microgravity manufacturing, aided by proximity to a near perfect vacuum, would drastically change the fields of optics, including fiber optics, as recently demonstrated aboard the ISS. A commercial entity that can capture the market on this technique will become a new industry leader. Materials science has also shown that the conditions of microgravity (uG) and vacuum allow for the formation of materials with far greater purity than can be created on Earth. This has substantial implications for everything from microchips to new materials with unique properties not achievable on Earth, like metal glass. The new potential for microencapsulation of drugs for targeted delivery, and protein crystallization could revolutionize the pharmaceutical industry. The ability of 3D tissue culture in uG could finally give the field of tissue engineering the conditions it would need to develop viable functional organ tissue. Raw materials mining could be effectively moved off planet. A single metal-rich asteroid has been estimated to contain more platinum group metals and rare earth elements (critical for many goods in our current economy — specifically electronics) than has been mined out of the Earth’s crust to date. Communications will see a drastic overhaul in the coming years as multiple companies are in the process of launching satellite fleets for the deployment of a truly world-wide web. Each one of these examples represents the collective interest of a multibillion- dollar industry, and taken in total, there is ample incentive to be first to make a game-changing breakthrough. This drive, quite different from the one that fueled the early space race, is built upon the idea of economic sustainability. If the initiative does not appear cost effective or ultimately sustainable, it will not be undertaken, but those that make it there first will be the new industry leaders. However, much of this work will eventually depend on these companies being able to safely and effectively house humans in space-based environments for considerable lengths of time, in order to complete necessary experimentation and implementation.

Astronaut performs kneeling lift with Advanced Resistive Exercise Device (ARED) device. — nasa.gov

There has been increasing interest in the effects of space flight, in particular those effects of uG on human physiology, as we have been able to extract better data following recent long duration space missions. Some of these effects were observed early on during human space flight, but their physiological cost was minimized as “temporary,” or easily recovered from after only a few weeks’ therapy upon returning to Earth. However, as missions shifted away from shorter duration rocket and shuttle missions to longer stays on various space stations, these effects became more pronounced and critical. The effects that space flight, including habitation in uG, the consequences of long-term radiation exposure, and results of living in a contrived environment, have shown enough deleterious effects that space pioneers expected to live and work in this environment for years at a time constitute a severely at-risk population. There is no denying or minimizing the impact now, the data is in, space is really hard on the human body. Consequently, if this barrier to space exploration and colonization is not adequately addressed from the outset, it could completely hamstring the push into this new frontier. Conversely, if those issues are carefully addressed and forethought is put into designing the space craft and habitation around these limitations, then those who are first to be able to inhabit space while mitigating these deleterious effects on human physiology, will profoundly corner the market on space exploration and utilization. So, if we can accept the above premises that the development of space, and subsequently its population by humans, is likely, and that the effects of space-based living on human physiology are profound and important, where does Physical Medicine and Rehabilitation fit in that picture?

My assertion is that PM&R as a field is uniquely placed to address many of the issues that will arise out of a growing population of humans traveling and working in space. This is partly because PM&R is already used to working with special populations that have unique needs and whose metrics of function might fall well outside the norms for the average population. Additionally, there will be a myriad of unique obstacles to overcome in human space flight that will require novel approaches to adapt and overcome them. As Physiatrists, adaptation and overcoming functional limitations is a large part of our focus with many of our patients. Finally, much of the research that would come out of how to address the physiologic maladaptation in space could be ported for use in our planet-side populations.[1]

Expedition 32 astronaut Sun Williams uses the COLBERT (Combined Operational Load Bearing External Resistance Treadmill) in the Tranquility node of the International Space Station in August 2012. The treadmill was named after comedian Stephen Colbert. — nasa.gov

PM&R as a field could represent a powerful adjunct to opening the frontier of human inhabited space. Aerospace medicine has traditionally focused a large part of its efforts on rigorous pre-mission screening and (appropriately) on what could kill or incapacitate an astronaut, or at the very least what might cause them to be unable to complete their mission. Many of those things are part of what-if, or worst-case scenarios. This means dealing with emergencies, malfunctions, or medical disasters. While those preparations and the training associated with it are critical to mission success, they largely account for the immediate effects. Much of what has come out of recent long-term space flight data shows gradual maladaptation of human physiology that occurs over many months, and that can ultimately result in astronauts who are no longer mission-capable, or at the very least face a protracted recovery once they return to Earth. Neither one of these options is acceptable if humans are going to be regular denizens of space. The preparations for “what-ifs,” malfunctions and medical disasters, although crucial, constitute a tiny proportion of space-faring impacts. In contrast, the long-term deleterious effects of uG, radiation, high CO2 environments, etc. will be experienced by 100% of the population traveling and working in space. We need to have a comprehensive plan for this, and it needs to be a priority for human spaceflight.

Let us take a brief look at some of the medical issues that are already well known in space medicine, with substantial crossover into the planet-side PM&R populations. This is in no way a complete list and it will only constitute a short overview. More in-depth analysis of the etiology, physiology, mitigation and treatment of these issues will be forthcoming in the next article.

The muscles of the human body take a considerable hit when subjected to long-term microgravity. The unloading of skeletal muscles for extended periods of time causes rapid atrophy, as fast as 15–26% decline in cross sectional area in just 17 days in uG.[2] Similar to the muscle mass lost in bed rest over a comparable length of time. While the mechanism between this atrophy and those muscle changes seen in critical illness myopathy (CIM) appear to be subtly different, there might be enough similarity to allow for common treatments. Studying these effects in astronauts would be advantageous as they, unlike the critically ill, are otherwise healthy, and this would limit the number of confounding factors during the study. Moreover, what becomes useful to the astronaut as prophylaxis or treatment could potentially be applied to the critically ill, or those recovering from its effects. This not only applies to skeletal muscle; the smooth muscle of the vasculature and the cardiac myocytes are also affected by not having to push against gravity to establish a blood pressure compatible with consciousness.[3] A better understanding of these effects will further inform our ability to tackle issues of heart failure and cardiac rehabilitation, orthostasis, as well as other aspects of cardiovascular and peripheral vascular disease in general.

The skeletal system of an astronaut also undergoes maladaptation as the nullification of their own body weight dysregulates the balance of the skeletal system as both a source for structural stability and as a reserve of minerals.[4] In PM&R, we see similar issues in our spinal cord injury patients and those with chronic reduced mobility. This can lead to accelerated bone loss with development of osteoporosis and calcium redistribution putting the new spinal cord injury patient and the astronaut alike at greater risk for kidney stone formation.[5, 6]

Astronauts are also plagued by many of the same issues of the urinary system that affect our populations of rehab patients. Both the uG environment (giving rise to lack of urge and causing increased risk of reflux to the kidneys) and the operational needs requiring condom catheters or the occasional catheterization for retention expose the astronaut to a heightened risk of urinary complications.[6]

The nervous system is affected in several diverse ways that we have been able to characterize. These can be sorted broadly into short term and long term in space and short term and long-term when returning to Earth. In the short term in both space and returning to gravity, profound nausea and a “vertigo-like” set of symptoms dubbed “space sickness” can render the astronaut incapable of performing necessary duties.[7] Astronauts have been known to characterize the intensity of this effect by using the number of “air sickness” bags required to contain it. This can last from a few hours to days upon entry into uG, but can then recur upon return to earth. Additionally, there is a component of sleep disruption that accompanies all those adjusting to null-gravity sleeping. This can eventually be overcome after an acclimatization period, but this can take some time.

For the more long-term developments, proprioception is markedly disrupted for returning astronauts, as the normal reference points of how to move limbs and trunk through 3 dimensions are thrown out and new reference points, sans the force of gravity, are assimilated in the brain’s mapping system. This is not helped by postural instability both due to the above-mentioned proprioceptive difficulties, but also because of the long “break” all the postural muscles have taken as they are not needed in uG.[8] This postural instability looks similar to that of populations coming off long term bed rest after a major accident or medical calamity. Memory and cognitive function (i.e., processing speed) can be impaired in long duration missions.[9] This appears to be more of a long term effect — the origins of which remain a mystery — but which could severely impact expeditionary type missions where there might be 6–9 months in space before, say, landing on Mars to begin the arduous process of setting up a base and habitats, as well as dealing with a strikingly unique environment.

As mentioned before, PM&R is used to taking on specialized populations that have different metrics for what constitutes function or what type of daily exposure their bodies might be expected to endure. Elite athletes, for example, might be in need of rehabilitative therapy even though their current functional capacity is well above average. However, for them, the rigors placed on them during their sport performance requires that functional standards be different, and their therapy is tailored accordingly. Likewise, consider professional ballet dancers — they may not be able to perform due to a limitation in function that would never be considered an impediment by average people who have never pushed their body to perform under such rigor. Similarly, space habitation will place new and different stresses on our bodies that will necessitate countermeasures, pre-, during and post-exposure, to mitigate the deleterious effects. Those teams that take care of their athletes in the off-season, who pay attention to their conditioning schedules and are conscientious about return to play when injury occurs, will have fewer games missed due to injury, and better overall performance as a team. Those who assiduously pursue the optimization of human performance and minimize degradation during space flight will realize continued success from their crews and lower failure rates overall.

ISS Expedition Commander Leroy Chiao, PhD, performs an ultrasound examination of the eye on Flight Engineer Salizhan Sharipov. — nasa.gov

So what does this all mean for the future of PM&R as it relates to spaceflight? At the beginning of this article I asserted that there was a strong potential for human spaceflight and PM&R to share a future. Another assertion was that the time to explore this is now. The reason this timing is so fortuitous is that the last several years have shown incredible changes in the space industry, with private industry taking a leading role. With that role now firmly established, and in most ways surpassing prior government abilities, we find ourselves standing on the planetary shores looking towards a new frontier that is rapidly becoming more accessible and more important in our everyday lives. Both of those changes are accelerating as we realize the economic boon to be had by colonizing space. The science and engineering technology behind it continues to be pushed ever further forward. Recognizing the importance of human physiology and building these new vehicles and habitats to specifically accommodate human sustainability will be crucial. Additionally, getting the right people involved to help mitigate and/or treat the resulting effects of space flight will be the difference between this frontier being opened to humans — forever changing our species’ trajectory, or relegated to being a thing we once did, but is now confined to the history books. I believe the field of Physical Medicine and Rehabilitation can help further develop that frontier. Adaptation and overcoming limitation is what we do.

In the following article, we will discuss in more detail the health issues that arise in long duration space flight and what has been done to date to both mitigate and treat them.

References

  1. Gerzer, R., et al., Space Physiology and Medicine in the Exploration Era. IAA Humans in Space Symposium, 2013.
  2. D.R., R. and W. J.J, Functional and structural adaptations of skeletal muscle to microgravity. The Journal of Experimental Biology, 2001(204): p. 3201–3208.
  3. Shen, M. and W.H. Frishman, Effects of Spaceflight on Cardiovascular Physiology and Health. Cardiol Rev, 2019. 27(3): p. 122–126.
  4. Vico, L. and A. Hargens, Skeletal changes during and after spaceflight. Nat Rev Rheumatol, 2018. 14(4): p. 229–245.
  5. Smith, S.M., et al., Bone metabolism and renal stone risk during International Space Station missions. Bone, 2015. 81: p. 712–720.
  6. Jones, J.A., et al., Genitourinary issues during spaceflight: a review. Int J Impot Res, 2005. 17 Suppl 1: p. S64–7.
  7. Lackner, J.R. and P. Dizio, Space motion sickness. Exp Brain Res, 2006. 175(3): p. 377–99.
  8. Clement, G. and J.T. Ngo-Anh, Space physiology II: adaptation of the central nervous system to space flight — past, current, and future studies. Eur J Appl Physiol, 2013. 113(7): p. 1655–72.
  9. Garrett-Bakelman, F.E., et al., The NASA Twins Study: A multidimensional analysis of a year-long human spaceflight. Science, 2019. 364(6436).

Luke Brane is a PGY2 in the Department of Physical Medicine and Rehabilitation at the University of Pittsburgh Medical Center (UPMC). Follow him on Twitter @LBraneMD

Tackling the Opioid Crisis: The role of Physiatry

by Robert D. Pagán-Rosado, MD

Pain affects nearly 50 million people in the United States and is the number one cause of disability in the country.[1] Approximately 12% of patients suffering from pain in the US reported chronic pain, while the rest reported short-term pain from diseases, injuries, or medical procedures. In the past years, the cost for chronic pain treatment in the United States ranges from $560 to $600 billion.[2] The leading cause of accidental mortality in the nation is drug overdose by opioid addiction, exceeding deaths caused by firearms and motor vehicle accidents.[3,4] Due to misinformation, psychosocial factors, and excessive opioid use in acute pain management, an opioid crisis has risen. While personalized medical assistance is expected from physicians, there is vast social stigma that leads to unrealistic expectations regarding pain management.[5] Many patients may still expect a detox-like experience from opioid use, thus underestimating the effect that psychosocial determinants have in their quality of life. Nonetheless, studies have reported that in some patients, use of opioids for chronic pain exacerbated symptoms and resulted in detrimental functionality.[6,7] Only by redirecting health policy towards a comprehensive, opioid-minimizing approach, can we properly address this opioid crisis.[8]

Literature has clearly shown that Physical Medicine and Rehabilitation (PM&R) is a vital component for pain management.[8] One of the most important aspects regarding physiatric care lies on its multidisciplinary approach to treat musculoskeletal and neurologic conditions. Physiatrists aim to improve quality of life and function through the use of exercise, non-opioid medications, interventional procedures, modalities, and addressing psychosocial elements that predispose patients to chronic pain. Studies have reported that when physiatrists affiliate with emergency medicine physicians to treat back pain, 80% fewer patients return within thirty days for the same chief complaint.[9] In addition, research has also shown that fewer back surgeries are performed when PM&R is consulted before elective spine surgeries.[10]

It is important to stress the main issues that prevent adequate pain management by physiatrists and perpetuate the use of opioids. First, funds for research projects based on non-pharmacological management, functionality and quality of life for pain-suffering patients was historically lacking until recently.[11] Less than 2% of a $30 billion budget for biomedical investigations was spent on pain management related projects by the National Institutes of Health (NIH) before 2018. Second, the limited amount of therapy sessions approved by health insurances and their high out-of-pocket costs lead to an underuse of these physical modalities that are fundamental for chronic pain management and function.[8,12] Moreover, low cost opioid treatment in comparison to physiatrist-led pain rehabilitation programs, as well as less access for these programs, pose a challenge for physiatrists to provide a safe option for pain management.

There are some ways the field of physiatry can tackle the opioid crisis. The first step includes incorporating medication, medical equipment, nerve blocks, exercise, neuromodulation, and behavioral treatments into pain management and research. These non-opioid interventions curtail opioid-derived mortality as well as the socioeconomic burden in the country. Second, the focus of the results in pain research must be directed toward long-term patient follow-up, function and overall quality of life. Third, community outreach programs can be designed to educate patients about non-pharmacological pain management and the role of a physiatrist-led multidisciplinary programs to address pain and the opioid crisis. Additionally, physicians should focus their treatment on not only symptoms, but also patient priorities and goals in order to significantly impact patient satisfaction.[13] A satisfied patient who feels he or she can trust a physician’s plan may be more adherent with a multidisciplinary treatment.

Finally, there is medical education that must be addressed. Graduate and post-graduate medical education should emphasize the importance of pain rehabilitation, the challenges physicians face when treating pain, and the safe use of opioids.[8] Training healthcare providers in addressing external synergistic factors that contribute to pain can also help address the opioid crisis. As physiatrists, our job is not only to relieve pain but to provide better outcomes for our patients through improved quality of life and function. We want our patients to rely on safe measures to treat pain and continue with their life goals and hobbies. This is what physiatry is all about.

References:

  1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morbidity Mortality Weekly Reports (CDC). 2018;67(36):1001–1006.
  2. de Leon-Casasola OA: Opioids for chronic pain: new evidence, new strategies, safe prescribing. Am J Med 2013;126: S3–11
  3. Paulozzi LJ: Vital signs: overdoses of prescription opioid pain relievers- United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011; 60:1487–92.
  4. Nuckols TK, Anderson L, Popescu I, et al: Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014; 160:38–47
  5. Young K, Zur J. Medicaid and the opioid epidemic: enrollment, spending, and the implications of proposed policy changes. Available at: https://www.kff. org/report-section/medicaid-and-theopioid-epidemic-enrollment-spendingand-the-implications-of-proposedpolicy-changes-issue-brief
  6. Braden JB, Young A, Sullivan MD, et al: Predictors of change in pain and physical functioning among post-menopausal women with recurrent pain conditions in the women’s health initiative observational cohort. J Pain 2012; 13:64–72
  7. Hina N, Fletcher D, Poindessous-Jazat F, et al: Hyperalgesia induced by low-dose opioid treatment before orthopaedic surgery: an observational case–control study. Eur Anaesthesiol 2015; 32:255–61
  8. Pavlinich M, Perret D, Rivers WE, Hata J, Visco C, Gonzalez-Fernandez M, Knowlton T, Whyte J. Physiatry, Pain Management and the Opioid Crisis: A Focus on Function Association of Academic Physiatrists Position Statement Addressing the Opioid Crisis. Am J Phys Med Rehabil. 2018
  9. Haig AJ, Uren B, Diaz K, et al: FastBack: The consequences of a reproducible complex consultation process on emergency department management of back pain. Orlando, Florida, Presented at the Academy Health 2012 Annual Research Meeting, June 24–26, 2012
  10. Fox J, Haig AJ, Todey B, et al: The effect of required physiatrist consultation on surgery rates for back pain. Spine 2013; 38: E178–84
  11. Help support a landmark pain research funding bill- U.S. Pain Foundation. Available at: https://uspainfoundation.org/news/help-support-landmark-pain-research-funding-bill. 2018.
  12. How much does physical therapy cost? Available at: https://www.thumbtack.com/p/ physical-therapy-cost. 2017.
  13. Tinetti, Mary, et al. “Challenges and strategies in patients’ health priorities-aligned decision-making for older adults with multiple chronic conditions.” PloS one 14.6. 2019

Robert Pagán-Rosado is a PGY1 at Hospital Episcopal San Lucas in Puerto Rico and future Resident in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic. Follow him on Twitter @rdprMD.

Introducing the AAP RFC Well-Being Sub-Committee

by Allison Schroeder, MD

Burnout is increasingly being recognized as affecting physicians and their patients, with over 50% of attending physicians registered through ABPM&R reporting symptoms of burnout [1]. Although definitions of burnout vary, they commonly include 3 things:

Previously, studies were mostly reporting on the prevalence of burnout, but recent studies, including that by Sliwa et al. have shifted to determining factors that contribute to burnout, which include increasing regulatory demands, workload and job demands, and practice inefficiency and lack of resources [1]. Now that some potential contributors to burnout have been identified, the next step is to determine how we can combat them.

Although there has not been a similar study to evaluate burnout in PM&R resident physicians, many residents recognize this as a problem. To help combat burnout and to emphasize resident well-being, the AAP RFC added a new position: the Education/Well-being Representative. This was the most sought-after position on the RFC with the highest number of applicants. Given the great talent and ideas of the applicants, the RFC decided to create a Well-Being Subcommittee.

The AAP RFC Well-Being Subcommittee’s goal is to provide information and resources to support PM&R physician wellness on a national level so that we can encourage and inspire each other to practice physical, mental, emotional, spiritual, and social wellness

Meet the team
Chair

I’m Allison Schroeder, a PGY-4 Chief Resident at the University of Pittsburgh Medical Center (UPMC) where I also serve on the UPMC GME Wellness, Environment, Learning, and Living (WELL) committee and am co-chair of the UPMC PM&R resident wellness committee. My interest in well-being started at a young age when my dad would remind her to always “keep a positive, happy attitude” and I continue to value grit, resilience, and positivity. I enjoy running and spending time outdoors to maintain balance and for stress relief.

Members

Mona Ahmed is a PGY-3 resident at the University of Alabama at Birmingham (UAB). She is the social chair of the UAB PM&R resident wellness committee and also serves on the UAB GME Wellness Subcommittee. Mona’s long term goal is to increase resident wellness by identifying and tackling systemic issues contributing to burnout. When she’s feeling down, Mona enjoys a game of racquetball, a good cheeseburger, and some sun.

Tracey Isidro is a PGY-3 at Baylor College of Medicine (BCM) where she is part of the inaugural BCM Wellness Committee. She is very passionate about wellness, and has written and spoken nationally on topics like how to be happy and healthy in medical school, lessons from intern year, wellness tips for busy individuals, how to be your best: tips on how to be successful, and spirituality and compassion in the patient-physician relationship. Outside of residency, she enjoys spending time with her family (Dad, Mom, twin sister Stacey, brother Ace, and three rescue dogs), salsa dancing, and composing piano music.

Olga Komargodski is a PGY-3 at Stony Brook University Hospital where she serves as the Patient Safety Resident. She has become interested in well-being while trying to do her best with both Residency and motherhood. Olga’s favorite hobby is writing fantasy novels, which are published in the Russian language.

Rosa Pasculli is a PGY-3 resident at NYU Rusk and co-chair of the NYU Physician Wellness Committee. Her main wellness interests are fitness and nutrition; she is a certified personal trainer and fitness nutrition specialist through the National Academy of Sports Medicine, and taught group fitness classes prior to starting residency. She loves trying new workout classes around Manhattan (favorites: 305 Fitness and Fhitting Room) and experimenting with paleo recipes.

Jasmine Harris is a PGY-4 at the Icahn SOM at Mount Sinai in New York. She is also a certified Integrative Health and Wellness coach. Her passion for well-being developed when she discovered yoga and meditative practices as a way to readily cope with the rigor and stress of medical training. In her spare time, she enjoys bringing nature indoors by caring for her more than 70 houseplants.

We are planning to provide information and resources to help improve overall well-being which will be available online and published on the AAP website. Please check out the AAP “Words of Wellness”. More content on this website will be coming soon! If your residency program has wellness initiative in place that you would like to have featured on our website and shared with other programs around the country, please contact me at aschroe1@alumni.nd.edu.

References:

  1. Sliwa JA, Clark GS, Chiodo et al. Burnout in diplomates of the american board of physical medicine and rehabilitation-prevalence and potential drivers: a prospective cross-sectional survey. PM R. 2019 Jan;11(1):83–89.

Q&A with the experts on Spinal Cord Stimulation (SCS) — A Summary For Residents & Fellows

by Vinny Francio, MD

Expert Panel:

Alexios G. Carayannopoulos, DO - Chief, Department of PM&R, Rhode Island Hospital

Jonathan M. Hagedorn, MD - Pain Faculty, Division of Pain Medicine, Mayo Clinic

Richard Kendall, MD - Professor of PM&R, University of Utah

Lynn Kohan, MD - Director of Pain Management Fellowship, University of Virginia

Suzzanne Manzi, MD - PM&R Pain Medicine, Performance Pain & Sports Medicine Houston, TX

Dawood Sayed, MD - Division Chief of Pain Medicine, Program Director of Multidisciplinary Pain Fellowship, Medical Director of The Center of Neuromodulation, The University of Kansas Health System

Byron J Schneider, MD - Assistant Professor, PM&R, Vanderbilt University Medical Center

Last month, I received an invitation from my good friend and Editor of AAP’s Physiatry in Motion, Jim Eubanks, MD, to produce an article on spinal cord stimulation (SCS). He suggested this topic since I’ve been researching SCS for my thesis and have an interest in pursuing a pain fellowship. I started brainstorming ideas on how to approach this paper in a manner that would be valuable to residents and fellows with interest in this intervention. I could think of no way better than “picking the brains” of some of the best neuromodulation experts using questions that residents and fellows emailed to me. Below is a brief summary of the discussion. Due to word count, the full-text is available at https://bit.ly/2YUGlUJ

Neuromodulation includes the application of electricity to the central or peripheral nervous system, and musculoskeletal system. For the purposes of this discussion, we will focus only on SCS, which is classically indicated for chronic neuropathic pain that is otherwise not responsive to more common conservative measures. SCS may no longer be considered a treatment of last resort. Instead, it may be used to reduce persistent opioid use and/or repeat surgical interventions that are unable to show concomitant improvement in long-term pain or function (Carayannopoulos, 2019). Dr. Manzi also provides an interesting insight: “To me, neuromodulation refers to changing the way the brain interprets pain by modulating the nervous system. Any condition that causes nerves to be affected may be a target for neuromodulation.”

Importantly, clinical success with neuromodulation techniques most likely occurs with appropriate patient selection, realistic patient expectations, proper procedural/surgical technique, adequate coverage of a patient’s individual pain pattern, and subsequent improvement of function longitudinally. As such, it is important to schedule regular follow-ups after implant to further educate patients, reprogram as necessary, and ensure adherence with therapy. In terms of successful indications, Failed Back Surgery Syndrome or FBSS with residual leg pain (see North and Kumar’s work) and Complex Regional Pain Syndrome or CRPS (Kemlar’s work) remain traditional research-backed SCS responsive conditions (Hagedorn, 2019).

Pitfalls occur with poor patient selection, unrealistic expectations or understanding of SCS capabilities, poor coverage of individual pain patterns, poor surgical technique, disregard of potential medical issues, which may in turn lead to infection or bleeding, and mechanical failure of the device, including lead fracture or migration (Carayannopoulos, 2019). Numerous medical conditions, including but not limited to bleeding risk, coagulopathy, infection, immune suppression, and/or anticoagulation use could preclude safe trial or implant and increased risk of complications or poor clinical outcomes. Behavioral or cognitive factors may also impede ability to set realistic expectations or understand the appropriate use of devices, including uncontrolled psychiatric illness, lack of social support, and high pain catastrophizing (Hagedorn, 2019; Carayannopoulos, 2019).

Discussion with the Experts

Q: When do you use SCS in your clinical practice?

Dr. Sayed: The most ideal indication is chronic intractable neuropathic pain, secondary to post-laminectomy syndrome and/or FBSS. Other indications included CRPS, peripheral neuropathy, diabetic neuropathy, post-herpetic neuralgia and chronic radiculopathy that failed conservative care. The strongest body of evidence with SCS treatment is with the first two.

Dr. Hagedorn: While I’m excited about neuromodulation and recognize its effectiveness, I still try more conservative measures first. If these are not effective or results are not long lasting, I offer neuromodulation to my patients.

Dr. Kendall: I am very conservative with my referrals for SCS. CRPS and chronic radiculopathy are the only two indications, I have seen it useful in. I am not convinced with the data on SCS for back pain, even in the post-surgery group. The fact that it is better than repeat surgery does not mean it is better than other conservative methods with lower risks.

Dr. Schneider: I most often refer for an SCS evaluation patients with recalcitrant axial spine and/or radicular pain despite a technically successful surgery, in the absence of any new pathology, and in whom there are limited other treatment options.

Q: Briefly, what are the different technique interventions for SCS?

Dr. Sayed: SCS is a two-stage procedure, first a trial, and if successful, followed by a permanent implant. Trial is most commonly performed percutaneously using fluoroscopy guidance. Permanent placement may be performed percutaneously (by interventional pain PM&R/Anesthesia physicians or surgeons), as well as surgically via a laminectomy (usually if paddle placement, performed by a spine surgeon).

Dr. Hagedorn: Non-surgically trained (Anesthesiologists, PM&R, Neurology, Psychiatry, etc.) physicians will almost exclusively perform percutaneous trials with cylindrical leads. On the other hand, neurosurgeons have the training to safely perform paddle lead (versus cylindrical lead) implantation. This is typically performed with an incision and a laminotomy to implant the device, including the trial. Paddle and cylindrical leads have different energy delivery, which has not been shown to affect outcomes.

Q: What is the difference in training between SCS trials vs. SCS permanent placements?

Dr. Sayed: As mentioned, placement may be performed by pain physicians or surgeons. There are surgical skills required for percutaneous placements, therefore it is imperative to have proper training to manage pre-op and post-op care. It is my opinion that anyone doing SCS should have trained at an ACGME accredited Pain Fellowship at a minimum.

Dr. Manzi: Training depends on the trainee. One can be very hands on and learn all of the techniques, from trial through implant. Others may not feel comfortable performing and managing surgical complications that may occur. Only physicians confident in being able to manage their own complications should be performing these procedures. It will take a trainee to seek out higher level training to become proficient at these skills. A neurosurgeon or orthopedic surgeon should be utilized if that is the setup in the community, if there is a level of discomfort in doing these procedures, or if the patient has altered anatomy and may be high risk. PM&R physicians and anesthesiologists with the appropriate training can perform trials and surgical implants confidently.

Dr. Hagedorn: I would hope that during a chronic pain fellowship training, one would get adequate training in both trials and permanents. This involves training at your fellowship program, but also industry sponsored training events and conference opportunities. A percutaneous trial is performed through the skin, but in addition to placing the lead in the epidural space and steering it to the appropriate level, you must securely fasten the lead to the skin to reduce migration and cover the device with a sterile dressing to avoid infection. The work is not done when you get loss of resistance in the epidural space. An implant involves making two incisions in the skin and really is a surgical procedure. Thus, appropriate surgical training is necessary. This involves the whole surgical experience, including pre-operative, intra-operative, and post-operative preparations, in addition to a responsibility to handle complications when they arise. All chronic pain fellowship trained physicians should be able to handle both SCS trials and implants. If anatomy or prior surgery precludes safe placement of a cylindrical lead, a surgical referral should be placed for paddle lead placement under direct visualization.

Dr. Kohan: Training for both is similar in regards to identification of appropriate radiographic interlaminar entry points and “driving” of the leads. Fellowship trained pain management physicians (regardless of primary specialty) are generally well suited to perform both percutaneous trials and implants, assuming they received sufficient training in both methods during their training. Sometimes it may be necessary to refer a patient to a spine surgeon to perform an implant. Because percutaneous leads emit energy circumferentially, more energy is “wasted” since it is not directed towards the spinal cord. Depending on the needs of the patient and his/her pain pattern, a paddle lead may be more appropriate at times to “capture” the painful area, hence a surgeon involvement. Yet, technology has advanced, and percutaneous leads are now better able to “capture” the back, therefore it seems less likely that a patient would need to be referred for a “paddle lead”.

Q: What are the advantages of performing trials only vs. trials and permanent SCS procedures?

Dr. Sayed: The biggest advantage for me is the continuity of care with patients by performing the trials and permanents. Most patients like the idea to have a physician that participates in all phases of care, that helps to develop the trust factor and a comfort level that is important in chronic pain care.

Dr. Manzi: Trials can take only a few minutes to perform, where as a permanent implant can take usually at least a half an hour. Trials are like doing an epidural injection, and usually very straightforward. Permanent implants are a surgical procedure and may take some time to become proficient. If in a practice that utilizes a specific team of surgeons for implants, then the pain physician should wisely perform the trials.

Dr. Hagedorn: I strongly believe that all chronic pain physicians should perform both SCS trials and implants, if they are comfortable and have sufficient training. As a former surgeon, this is the aspect of chronic pain management that I enjoy the most. Advanced interventional therapies to improve quality of life and provide pain relief.

Dr. Kohan: In the community setting, there may be advantages to only performing SCS trials. Many physicians decide to only perform SCS trials and to routinely refer patients to a surgeon for a laminectomy implant. There are various reasons behind this decision, including maintaining a referral base and not have access to a surgical suite. Studies have shown a higher risk of lead movement and infection with cylindrical leads, which may lead a private practice physician to prefer referring to a spine surgeon for implantation. In the academic setting, advantages of performing both the trial and the implantation includes ensuring fellows are appropriate trained in both techniques.

Dr. Kendall: For the patient it is nice to get everything done with one physician and in a timely manner. Not waiting for trial approval, then getting trial, then having explanted, then seeing surgeon, then scheduled for OR, then having it done.

Dr. Schneider: Doing permanent SCS implants requires the infrastructure to take care of these patients on an emergent basis, necessitating a call pool that can physically assess and treat patients if needed and be available to the ED if needed. While surgical practices often have this in place already, many outpatient pain or PM&R spine practices do not necessarily have this in place.

Dr. Carayannopoulos: Advantages of performing both trials and implants include clinical continuity of care with the patient, as the same physician will be performing both procedures. Additionally, there is more assurance that if the same physician is performing both the trial and implant, the placement of electrodes will be most consistent. Advantages of performing trials only include clinical practice efficiency and reduction of surgical risk.

Q: How do you foresee the future of SCS?

Dr. Sayed: We are very lucky. There is a renaissance in the field. When I was doing my fellowship, the innovation was fairly flat. What we have seen in the last five years are actual innovations that improve outcomes and new targets, such as dorsal root ganglion (DRG), high frequency stimulation, microglial stimulation, closed loop stimulation, etc. This is really a fascinating time to be in the field. There is no shortage of patients and chronic pain has been improperly managed, so the timing is great that we have this explosive advance in technology to match with a great need, given the opioid epidemic.

Dr. Manzi: The opportunities are endless. I believe that the field of neuromodulation has only begun. Although it has been around for 40 years, this field will likely have widespread applications for years to come.

Dr. Hagedorn: I think the momentum will continue and the future is very bright. I believe we will see smaller devices, better technology and energy delivery, and improved safety. All of these improvements will allow us to provide better pain care to our patients.

Dr. Kohan: The future of neuromodulation is bright. New modalities with increasing efficacy are emerging at an astounding rate. Different frequencies and types of waveforms are allowing for better efficacy of the therapy. These new techniques have allowed for paresthesia free stimulation, which many patients prefer. Closed-loop technology is also being utilized. This technology allows the SCS device to communicate with the spinal cord and adjust the degree of stimulation accordingly. It is likely that the future will continue to see evolving technology allowing patients to see increased efficacy from their devices, thereby allowing for improved pain control and better function.

Dr. Kendall: Neuromodulation has come a long way since I trained. I think there is hope that there will be continued success for some of the chronic pain and neurogenic pain (central and peripheral). However there is still a lot of difficulty with longevity of relief, due to loss of efficacy of stimulators (scar tissue, lead migration, central adaptation). There is still difficulty with more than 2 year outcome data, which is problematic if it is a permanent implant that limits MRI for future.

Dr. Schneider: There is certainly momentum with neuromodulation, and almost certainly a role for this in the future. SCS is still riding an upward slope towards a peak of inflated expectations. There is very little literature on SCS that is not influenced by industry, and collectively many of the studies are in conflict with each other.

Dr. Carayannopoulos: The future of neuromodulation will grow exponentially as electrical paradigms evolve, indications expand, and as the technology improves. The introduction of closed-loop technology, which offers a more individualized treatment approach may revolutionize the future.

Q: What recommendations and words of wisdom do you have to share with residents/fellows looking to practice this intervention in their careers?

Dr. Sayed: It is a competitive climate now, the quality of people continues to rise and it is so competitive. My biggest advice is to get involved and work to advance the field of pain management. Get involved in academic endeavors, research, abstracts, associations. We are really looking for people with a dedication to the field, more than board scores and good grades in training exams. Show a genuine interest and motivation to stand out.

Dr. Manzi: Be a sponge and learn what you can while you have the opportunity in residency and fellowship. This time is going to prepare you for the rest of your life. Utilize it wisely. Do not hesitate to ask questions and be involved as much as possible. What you learn in residency and fellowship may not be exactly what you are doing in the future; however, it will prepare you to be well versed and know what to do and when to refer out.

Dr. Hagedorn: Always remember the patient. The sole reason we should be discussing this technology is to decrease the suffering and increase the quality of life of a patient in pain. If this remains your focus, you will do great things.

Dr. Kohan: While technical skills are of course important in SCS training, I would encourage all trainees to pay attention to pre-operative planning, as well as post-operative care. These are essential to the proper management of patients with neuromodulation devices. It is not simply the act of placing the stimulator. Patient selection, the ability to clearly communicate the procedure and obtain proper consent, as well as the ability to recognize and manage post-operative and long term complications is essential.

Dr. Kendall: My opinion is all providers entering the field at this time should be aware of the mechanisms of action, appropriate indications for use, contraindications for use, and methods of placement. Even if not performing them they should be able to explain to a patient if they may benefit, and also understand the risks of placement before referral. If residents/fellows intend to practice this procedure they should probably do (not watch) about 10 trials and 10 implants to expect to receive credentials upon starting a job after training.

Dr. Schneider: Learn the proper indications, and limitations of the technology. Learn it as one tool to be leveraged in the management of these conditions, but realize there is still plenty to be determined about how it will ultimately be utilized long term.

Dr. Carayannopoulos: My recommendations for trainees are to find an appropriate mentor to provide guidance along their journey. Additionally, it is helpful to volunteer your time to help with committees and other educational opportunities, such as academic writing and contributing to research, Furthermore, and most importantly, it’s imperative to study and learn not only the anatomy and pathophysiology, which compose the biomedical side of pain, but also to learn and understand the biopsychosocial aspects, which need to be addressed and treated in order for a patient in pain to improve in the long term.

Full-text available at: https://bit.ly/2YUGlUJ

Vinny Francio is a PGY1 TY Resident at SSM Health St. Anthony Hospital in Oklahoma City, OK, and incoming Resident in the Department of Physical Medicine and Rehabilitation at The University Of Kansas Medical Center (KUMC). Follow him on Twitter @VinnyFrancioMD.

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