Phorest & Trees June 2021

 

Phorest & Trees Enjoy the brevity because I’ve been deep reading topics for my lectures.

AANEM and EDx

My good friend Ileana Howard was recognized on the baseball field by the Mariners for Lou Gehrig Day.  She also was awarded the Advocacy Award by the AANEM.  She’s destined for so much more greatness. I’m super proud of her!

On ReachMD, DOXIMITY & MedPage

On coffee “The public’s limited understanding regarding the current evidence associated with stem cell therapies for osteoarthritis and tendinous pathologies may contribute to unrealistic expectations and misinformed decisions.”

Jobs

Graduate of our program Nicky Lacerda, MD is now the PM&R Associate Program Director at University of New Mexico in Albuquerque where she is looking to hire physiatrists (glacerda@unmmg.org  323-240-2298 cell). “Help us to build a PM&R residency program and department at the.  Clinical opportunities include electrodiagnostics, inpatient consults, neurorehabilitation/traumatic brain injury, musculoskeletal medicine and general rehabilitation. If you are passionate about physiatry, teaching and patient care, we have a place for you.     Albuquerque is a 4-season, mountain city with outdoor and cultural activities for all. Plus traffic and mosquitoes are minimal!”

MSK & Rheum

Congratulations to my friend Brian White, DO, an interventional physiatrist in Bassett’s PMR, for being awarded the 2020 William F. Streck Fellowship in Health Policy Management. He’s been actively fighting the good fight for years now with the Medical Society for the State of New York. An interesting idea of looking at the footwear in gout. An unusual reason for axillary pain

Trees

When You Ignore My Gender, You Dehumanize Me  was a moving description from a nonbinary medical student but what is more compelling is the slew of intense comments in response. Brings up many questions. "Am I still me? My brain injury has shaken my confidence in my own personality, my own existence. " A brain injury survivor eloquently shares her experience.

 

Phorest and Trees May 2021

 

Phorest & Trees “Most people rust out due to lack of challenge. Few people rust out due to overuse” – Unknown “I got something to say, it’s better to burn out than fade away!” – Def Leppard

On ReachMD, DOXIMITY & MedPage

Large multicenter study of COVID-19 in Patients with Rheumatic Disease: Finally, a Denominator JAMA on early intervention for CP Can Kessler and other acute rehabs convince insurance companies to pay for an extra hour? It’s not just dr. google anymore.  Most YouTube Videos About Carpal Tunnel Syndrome Have the Potential to Reinforce misconceptions. This is going to tick off a bunch of my friends. Systematic review and meta analysis Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular-Syndrome Related Complaints Uncontrolled non-randomized Prospective cohort suggesting Subacromial PRP gets people 100% better in sports context. Same thing can be said about eccentric strengthening. Surprise: Your Car Insurance Plan May Not Cover High Medical Bills After A Crash : Shots - Health News : NPR Op-Ed: COVID-19 Has Unleashed Vile Antisemitism

Exercises do work for neck pain, knee OA, and safe in pregnancy

I know some of you still doubt it but a lower trap HEP (see attached) significantly improved pain, improved head/neck angle/posture, and increased ultrasound measurement of muscle thickness. No needles needed for neck pain?   A formal neuromuscular, weight management, self management training program of therapists led to improved implementation in Australia. This led to better patient adherence and quality of life in patients with knee OA. 74% of those who desired surgery no longer desired it 12 months later.   mild and moderate intensity exercise increases angiogenesis, but does not increase placental oxidative or endoplasmic reticulum stress in healthy pregnancies, bolstering support for routine exercise as a part of standard care in pregnant women.

Intramuscular steroids as good as intra-articular? And other oarsi stuff

Attached is an interesting 24 week multicenter RCT comparing IM to IA corticosteroid injection in knee OA. Thoughts? BMI correlates with DJD symptoms but weight cycling (BMI variability) may be worse. Central obesity leads to earlier symptoms of OA Hand OA prevalence in gen pop. Intra-articular saline just as good as everything else we inject into the hip? (see attached) Knee joint distraction results in MRI cartilage thickness increase up to ten years after treatment sounded like a great idea until I read the methods…they used an ex-fix!

EDx

Asymptomatic lateral elbow abnormalities on ultrasound are common in the context of CTS

Trees

Molecular geeks will appreciate this review of the roles of inflammasome in disk degeneration (maybe just me and Levy) For years we’ve been watching exoskeleton videos. In the video you can see Buddy, an extraordinary Veteran who has dedicated the last five years to regaining his ability to ambulate using this 30 pound version. A very good read about informed consent from my malpractice insurer. VA's implant tests could help paralyzed veterans to walk again | Fox News 'Light Therapy' Could Help Brain-Injured Veterans Struggling With PTSD | Health News | US News Doctors Harness the Power of Human Connections - The New York Times (nytimes.com) India's COVID-19 Variant: What We Know So Far | MedPage Today Op-Ed: Want a Public Option? Not So Fast, Say Health Insurers | MedPage Today: Very important to understand if you support a public option. Physicians want partners, not bosses (advisory.com) Fauci to Internists: A Lot of 'Oops' in Early Days of Pandemic | MedPage Today This Ohio Surgeon wrote his own obituary and it’s priceless. Acetabular labral reconstruction with medial meniscal allograft: preliminary results of a new surgical technique - PubMed (nih.gov) Imaging of trigger points…god please why

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.