Phorest & Trees April

 

Phorest & Trees Sharing the things I’ve recently been reading... and a few event announcements.

Master Educator

My very dear friend John Norbury, MD received the Brody School of Medicine Master Educator Award for Educational Innovation and Curriculum Development, the highest award for Teaching at the Medical School. I am so so proud of him and glad that he has been appreciated for the hard work and long hours dedicated to teaching. If you haven’t already, check out his Neuromuscular Ultrasound Monograph in Muscle & Nerve. I look forward to seeing him continue to dominate!  READ MORE.

New GMNR

I deep dove into the Meniscus. See attached and Be warned. Geeks only.

A possible game changer for knee OA HEP

We know activity affects knee osteoarthritis symptoms. In 2014 >6000 steps was the magic number of knee OA. This year, an RCT in JAMA showed 72% of 206 participants had clinically important improvement in pain with a free web-based exercise intervention supported by text messaging.  Some of the results were interesting in that those that didn’t adhere were also more likely to depend on injections & meds. Also, control participants tended to go more toward modalities as the study progressed. Limitations were acknowledged but this didn’t affect my feelings about it.

How sex surrogates are helping injured Israeli soldiers

Former trainee rocked my world with this provocative BBC article on intimate relationship rehabilitation after disability. She says “I'm on a 2 week pediatric rotation and didactics was on puberty issues for cerebral palsy kids, including menses and sex ed for the teens and for parents how to support those conversations and their transition into adulthood. Also how to educate them against abuse which is to common in this vulnerable population.” She sent me lots of other great resources and I’ve attached 2 for you.

EMG/AANEM stuff

It is an amazing time for Neuromuscular conditions. Numerous and perhaps seemingly untreatable, lately, treatments are springing up. Take Paramyotonia Congenita which is a channelopathy, seems to be responsive to buprenorphine. May 4, 7:00pm EDT FREE Webinar: Starting a NM Ultrasound Laboratory John Norbury, MD; Michael Cartwright, MD; David Preston, MD; Kris Karvelas, MD. Link to Register. May 13-14 $750 Wake Forest/AANEM Virtual NM Ultrasound Course. Link to Register.

On Doximity

Last time I told you about machine learning in medicine. This time I ask you to think about your role in its evolution. Intertrochanteric takes longer to rehab than femoral neck fracture. “training for clinicians does not address how to manage our internal reactions the way training does for our colleagues in psychology.” They told her it was all in her head Risk/benefit discussion about corticosteroid injections circa COVID vaccine administration. Is It Time to Eliminate Outdoor Mask Mandates? - HIV and ID Observations HIV and ID Observations (jwatch.org) Evidence-Based Medicine Training in US-based Physiatry Resid... : American Journal of Physical Medicine & Rehabilitation (lww.com) by VA physiatrist Thiru Annaswamy A fascinating read on spin in the shoulder review literature.  If you want a copy of the article let me know. A painting reminds the author “In medicine, being present is what happens when a clinician’s connection is untrammeled by a screen or other competing inputs. It’s the focus of mind, spirit, and intent around a moment in time that’s about another person and his or her most pressing problem. Presence, be it in a clinic exam room or with a friend over coffee, is a uniquely human gift..”

Trees

This discussion may challenge some of your long held beliefs, for those of you who teach technical skills (e.g. injections). How to Stop Anti-Science | MedPage Today Thanks to my friend Dr. Michael Mehnert for completely bumming me out with this old case of a doctor being sued for following guidelines. Outsourced (one of my cover bands) will be playing it’s first show since COVID, outdoors. See flyer attached.

Phorest & Trees late March 2021

 

Phorest & Trees Sharing can go both ways. I’d love to hear what you’re enjoying.

VA News

Somewhat new news: VANJ welcomes Dr. Christine Roque-Dang to the Pain service with Dr. Ben Levy. She is a graduate of our program and the “Stitik” fellowship. Super psyhed by this news. The Mission Act has allowed the VA to pay non-va community providers for services but some of us have had concerns. “According to the report released last month, hundreds of providers removed from VA for providing poor care could still be part of its community care network, thanks to loopholes in the program’s screening.” Proud to say we police our own. Proud to see we don’t just jump in the fire with a new EHR like everyone else. The VA’s work on improving LGB and transgender healthcare. ““Gender alterations is listed as an exclusion in the medical benefits package,” Shipherd explained. “It’ll take some work to remove that exclusion, but if we’re able to do that it means transgender veterans would be able to access surgical care in the future.””

Found on Doximity

2 days of step reduction to <5000 per day impairs fat metabolism more than 1 hour of mod intensity running stimulates it. Wow! A proposal on how to approach corticosteroid injections during COVID. The author uses the evidence but still errs on the side of caution. Another win for dexa. A decent study found that self-paced physical and cognitive activity during the first week after sustaining a concussion alone neither hastened nor prolonged concussion recovery in children and teens. A review of the pharm tx for agitation in TBI. After 15 years not much has changed. “Runner’s high” is actually attributed to endocannabinoids NOT endorphins. The NY Times covered it too.  Machine learning is going to be a big part of the medical literature if you haven’t already noticed it. Here they used it to look at vital signs as a marker of pain in sickle cell. “The researchers found that these vital signs indeed gave clues into the patients' reported pain levels. By taking physiological data into account, their models outperformed baseline models in estimating subjective pain levels, detecting changes in pain, and identifying atypical pain levels. Pain predictions were most accurate when they accounted for changes in patients' vital signs over time.” Practical advice on addressing sexual health in females. At the VA, I’ll admit I have no problem addressing this with the majority of my population because I have 15 years’ experience with males limited by their pain or too embarrassed to address with their primary. The advice in this interview was helpful for specifically the females who would require a different approach. Meta analysis of the various injectates. I read this whole study which was well done but I wonder about the heterogeneity of the literature assessed that makes them arrive at their conclusions. But then this one contradicts. Placebo works in the short term for low back pain Hopefully we are all more humble than this physician.

Resources

New England Journal of Medicine Reviews. I go here when a family member or friend has a medical condition that I quickly want to know more about. Thanks to dr. Jon Kirshner for introducing me to the American Bone and Joint Initiative where they have an archive of videos aimed at patient education.  All free and open access. MDPI - Publisher of Open Access Journals

“Inflammatory” Back Pain

This may interest you if you see patients with back pain (I skipped over the IL-17 inhibitor stuff.). Apparently, 25% of chronic low back pain patients are undiagnosed nonradiographic axial spondyloarthropathies and more likely to be missed in women. The symptom burden can be just as bad with nonradiographic axial spondyloarthropathies as RA. Some of the terminology was new to me including the suggested classification of spondyloarthropathies (since 2009).

Osteopathic vs. Sham manipulation in Chronic LBP

First of all, the DO’s on this list know that I have deep respect for the history and benefits of OMT. But I do not support OMT as the sole treatment in the management of anything just like I would not support only injections or only pills. OMT is a manual modality. This well-designed study published in JAMA showing no clinically meaningful benefit in chronic low back pain did not surprise me. No modality is going to show long term benefit in the chronic setting. (Do you think heat or TENS findings would be any different?). What I love about this is the medical community finally giving this important topic the attention it deserves. If you have different thoughts, let me know.

Motorized Internal Limb lengthening

May not be new to my peds friends but this is exciting new stuff to me. For kids and adults with leg length issues, after osteotomy (separating the bone into two segments), instead of external fixators, they insert an intramedullary nail through the length of the shaft. The nail is a motorized telescoping metal rod which the patient activates daily by placing a magnetic external remote controller to cause lengthening. Bone forms in the space and the device is removed. Here’s a marketing version and the process. A whole journal issue was dedicated to it if you’re a real geek.

EMG Stuff

Optimal placement for Radial motor NCS Variability in the digital sensory distributions So proud of my colleague and friend Dr. Sandra Hearn who received the AANEM Young Lectureship award and she’s chosen to tackle the elephant in the room.

Trees

Gut Microbiome knowledge reviewed for 2020 These reproductive guidelines serve as the biggest intersection between rheum and OBGYN. Our Neurology friends are catching up to us in appreciating the role of physical activity. See attached.

Phorest & Trees 3/2021

  

Phorest & Trees Just sharing the things I’m consuming (reading but not eating).  Haven’t shared since before the holidays. I hope you and your families are healthy and safe.  The Landmark Scoliosis study

At the board review course, Dr. Goldstein pointed to this study as a game changer for scoliosis.

Found on Doximity

The International society of sports nutrition position on caffeine & Exercise may surprise you. If one of you ultrasound nerds can look at this one, I’d appreciate your opinion on whether you think ultrasound vibro–elastography might replace invasive carpal tunnel pressure testing. Oh the lengths we’ll go for back pain. Biomarker correlation to Modic changes. Who knows, we may have a blood test as a screen for who should get MRI… The case for why technology won’t replace us in rehab medicine. One local doctor’s way of connecting with patients. This editorial may have been written after a few cocktails but it does present some interesting views on what we inject. If that’s not exciting enough for you, try injecting stem-cell rich prolo into the fat pad and then write about it as a retrospective case series. ESWT is making a comeback in terms of articles. A Chinese study found improvement in knee OA at 8 tendon/ligament sites over placebo ESWT. Meta-analysis finds hydrodilitation + CSI superior for frozen shoulder Yuck: One sweaty, huffing, exercising body emits 5x the chemicals and those human emissions, including amino acids from sweat or acetone from breath, chemically combine with bleach cleaners to form new airborne chemicals with unknown impacts to indoor air quality.

Advice on Long Living, Resilience, Stoicism, & kindness From a 95 year old WW2 amputee

A beautiful write up on a former patient of mine. A German doctor showed clever compassion to save his life.

Amputee/Proshetics stuff

The following are provided mostly for the concise introductory reviews on their topics that the research was based on. Prosthetic digits (finger) The first two sections talk about cutaneous neuroprosthetic concepts Pirigoff amputations are still performed (and still on the boards I think) Openly Accessible 3D Printed Prosthetic Hands for War-Wounded Children can generate 22 newtons of grasping force for $20. Not bad. Computer assisted TKA

COVID stuff

Thanks to Dr. Shenoy for sharing this excellent narrative of the mRNA aspect of the vaccine. Ingredient list for the Pfizer Vaccine. Sometimes spelling it out is calming to the anxious. 6 month follow up of consequences after COVD admission

The Placebo effect in CIDP

Dr. Shenoy gives an excellent talk on the placebo effect. This is an application of that content. Science News: Placebo Effect in Chronic Inflammatory Demyelinating Polyneuropathy: The PATH Study an | American Association of Neuromuscular & Electrodiagnostic Medicine (aanem.org)

Biden’s Healthcare priorities

Here they are

Trees

opinion, size, age, shape, color, origin, material, purpose. Thanks to Caitlin Hartsgrove for introducing me to this as a “thing.” Inclusion body myositis can affect the diaphragm Alternative to fusion Peripheral Nerve Hyperexcitability syndrome (PNHS) Humorous explanation of “Correlation does not equal causation” Tired of not knowing what they meant I looked up 2 stats terms: Delphi method and Intention to treat. Summary attached if you need help falling asleep. This Christmas I learned a valuable lesson: Do not buy CHEAP transparent tape.

Phorest & Trees 11/2020

 

Phorest & Trees Sharing the things I’m reading but not eating

COVID infection: Not recommended based on recent anecdotal evidence I meant to send this email out 2 weeks ago (around thanksgiving) but me and my family were afflicted with COVID-19. We are all fine now. Thank you for the many people who reached out with kind wishes.

Brachial Neuritis in the news Thanks to Dr. Bitterman for the link. I would recommend minimally knowing what is in this article because it is being read by your patients.

The Biphasic SNAP

For those of you I have taught some volume conduction theory concepts, I typically admit defeat about the biphasic SNAP. Theoretically it should be triphasic with an initial positive deflection. So I asked Dr. Dumitru to explain it and I finally do. This is not for the faint of heart. Actually it’s really not for anyone except true geeks. So I recommend you not click on this.

Fraud and Abuse

Are you at risk for penalty by the OIG for the talks you’re giving? AANEM advocated for Bipartisan H.R. 8780 which addresses quality in EDx medicine. The bill addresses “ongoing problems with EDX fraud and abuse, as well as poor quality EDX testing, by unqualified providers, many of whom are using substandard EDX equipment.” It was modeled after the approach taken by mammography and sleep labs who faced similar battles. See the attachment for details. Click here for AANEM advocacy.

More about Coding 2021

There was some confusion about the modifiers 25 and 26. I asked the coding expert at AANEM and this is what she shared (along with a great attachment explaining why insurance companies should pay us for same day EMG and E&M) “Modifier 26 is typically used in a hospital setting. Each code is made up of three components:  a professional component (physician work), a technical component (supplies, equipment, etc.) and liability. For physicians who work in a hospital system, the hospital needs to bill for the technical portion of the code and the physician bills for the physician work part of the code.  Modifier 26 is what the physician would use to do this and the TC modifier is what the hospital would use.        Modifier 25 is used to establish that there was an identifiably separate E/M performed on the same day as a procedure. This is done because inherent within each procedure code is time to perform a basic evaluation and management. There are many instances where it is appropriate to bill for an E/M on the same day, but modifier 25 needs to be used with the appropriate E/M code in those instances.  I have attached AANEM’s position statement Billing for Same Day Evaluation and Management and Electrodiagnostic Testing which details some common scenarios where it is OK to bill for an E/M on the same day as an EDX procedure.” Thanks to Ethan Colliver for this link. ·         One of our graduates at a large non-VA institution who frequently lectures on coding had this to offer (which I agree with): “My very simplified impression of the new coding rules is that the MDM rules are basically the same, the level of service was always really determined by MDM, now they more explicitly state the HPI and bullet points in the PE don’t matter (thank goodness).   If you do a procedure same day as the visit it gets a -25 modifier. If you are doing a test (EMG) then you can't double dip by reviewing it in an E+M visit the same day. AANEM has very strict criteria as to what denotes medical necessity for doing an E+M visit on top of the EDx visit. I rarely bill a f/u visit if i am doing EDx (or a new patient for that matter) , and if i did the medical decision making is not explaining the EDx (that gets reimbursed with the EDx codes) its ordering medication, discussing other problems, ordering PT and having a discussion about planning and other treatment options not related to the usual counselling expected from an EDx visit.  Don't be fooled by the new rules...if we don't continue to have robust H+P we will see denials go up for advanced imaging and procedures.  (Which i am already seeing and others have mentioned too). I don't expect my average LOS to change a whole lot, hopefully documentation will be quicker. My new plan is to shrink my notes significantly..especially since patients will be able to read them more easily. I fear every word I write will be scrutinized by certain patients and it's just not worth the time. I will template more things to ensure studies and procedures get covered.”

Revenge of PMR Poster Boy

This is the universe getting back at me for the last one. Ugh. I should have sent a newer picture.

Trees

To my brain injury folks. Using music to awaken the mind. If you watch, please do so to the end. Next time you’re on Netflix, look up Crip Camp: A Disability Revolution. Why we don’t use sterile water with our botox?...cuz it hoitz! When you’re at the VA, check out the Atlas of orthoses and Assistive devices. (Link likely won’t work outside the VA.) thanks dr. edmond. Also of interest is the Atlas of common pain syndromes (Attendings may like the Atlas of Uncommon Pain Syndromes) A patient of mine wanted a referral for “TMR” to address pain; I am quite familiar with its use in prosthetic control but not pain. If anyone has experience with this, please contact me. TMR consists of a nerve transfer of residual peripheral nerves to otherwise redundant target muscle motor nerves. When TMR is performed on an amputee, the residual peripheral nerve is mobilized and any neuroma is excised. The native motor nerve of the target muscle is then located through nerve stimulators and transected near the muscle. Lastly, the residual peripheral nerve is coapted to the motor nerve, close to its point of entry into the muscle. New knowledge of specific chemo induced CNS neurotoxicity: CD19-directed immunotherapies are clinically effective for treating B cell malignancies but also cause a high incidence of neurotoxicity. The result is that a subset of patients treated with chimeric antigen receptor (CAR) T cells or bispecific T cell engager (BiTE) antibodies display severe neurotoxicity, including fatal cerebral edema associated with T cell infiltration into the brain. Swimming benefits autonomic responses.

Phorest and Trees early November 2020

 

Phorest & Trees Sharing the things I’m reading (big or small) Many more trees this time. Enjoy!

CODING 2021

See attached for my long awaited summary of the upcoming coding changes. Admit it you’ve been waiting with baited breath.

Ground Round Discussion

There was some recent controversy surrounding the role of the Ground Electrode. I have attached Larry Robinson’s articles on the ground electrode as well as the forum discussion involving dr. Dumitru and Robinson. (I almost spat my lunch out on the screen while reading the last of dr. robinson’s hilarious posts.)

Who says VA aint GQ?

The NJ VA’s very own Dr. Rex Ma is the poster boy for AAP and VA/ECU attending Dr. John Norbury is the same for AANEM. Who says we VA docs can’t be GQ?

Is it ethical to test the asymptomatic limb?

I found the answer by Dr. Stalberg to this question to be all encompassing on the AANEM forum. If you find this stimulating, I encourage you to lurk on the forum and read our gods and demigods discuss practical stuff. Enjoy:   I think that there are often indications for bilateral studies, also with unilateral symptoms. As you indicated, for a side-comparison with age,height,temperature (BMI) matched values.( In our lab we have all reference values normalized for age, height, and keep control of temperature and distance, but still often make bilateral testing for neurography.) We find that absolut bilateral values may be within refernce limits, but the side difference is outside (lab ref values), It may be essential to rule out generalized EDX abnormalities, in spite of unilateral symptoms. (mononeuritis multiplex/pnp, CTS, ulnar entrapment…). Particular for neurography. If the patient has bilateral symmetrical symptoms, unilateral study may be enough to assess type of pathology. For EMG, the situation may be more tricky. Requires usually quantitation. Examples of recommended bilateral studies: MND question in a patients with one-sided symptoms, atypical radiculopathy and more…... As you see, I give different suggestions for neurography (CAMP ampl, and latency, F-latency and persistence, sensory amplitudes) and EMG. You asked if it ethical to make bilateral studies in unilateral symptoms. One can also ask if it “ethical” of professional to make just local studies and miss important subclinical information. Usually very easy to explain the strategy to the patient.

CRS Socket Design

No it doesn’t stand for “can’t remember s%$t” in this case. Attached is my summary of an atypical socket design that uses alternating pressure and release built into the casting process to allow for more efficient motion. The original article lightly touches on the physics but I thought it was very well written and easy to understand. I am in the midst of discussions with prosthetists who have actually (Thanks to Dr. Shenoy for the reference!).

Diabetes stuff

My deeper interest owing to my own diagnosis Reinforcement that speaking conversationally (I personally even go colloquially) with patients may improve outcomes.  Mismatches between oral glucose tolerance testing and A1c. False positives? Gila monster venom: Exenatide, (Byetta or Bydureon) CGM gets easier to obtain from the VA and DoD

Trees

Why we don’t use sterile water with our botox?...cuz it hoitz! Hi-tech bandage for wound care for my SCI friends When you’re at the VA, check out the Atlas of orthoses and Assistive devices. (Link likely won’t work outside the VA.) thanks dr. edmond. Also of interest is the Atlas of common pain syndromes (Attendings may like the Atlas of Uncommon Pain Syndromes) A patient of mine wanted a referral for “TMR” to address pain; I am quite familiar with its use in prosthetic control but not pain. If anyone has experience with this, please contact me. TMR consists of a nerve transfer of residual peripheral nerves to otherwise redundant target muscle motor nerves. When TMR is performed on an amputee, the residual peripheral nerve is mobilized and any neuroma is excised. The native motor nerve of the target muscle is then located through nerve stimulators and transected near the muscle. Lastly, the residual peripheral nerve is coapted to the motor nerve, close to its point of entry into the muscle. New knowledge of specific chemo induced CNS neurotoxicity: CD19-directed immunotherapies are clinically effective for treating B cell malignancies but also cause a high incidence of neurotoxicity. The result is that a subset of patients treated with chimeric antigen receptor (CAR) T cells or bispecific T cell engager (BiTE) antibodies display severe neurotoxicity, including fatal cerebral edema associated with T cell infiltration into the brain. Vocab: STRUT ACDC is back!