Phorest & Trees August 2021

 

 

 

Phorest & Trees It’s me birthday week…And of course the old ones here.  Hope you enjoy!

Physician Finance, Workplace Attire, Overlearning, & lotsa Jobs out there

I’m married to a guju JD/MBA daughter of an accountant, so lazy me didn’t bother until now. You need to understand personal finance better than I did. I found this site to be useful and I’ve vetted it for you. Here’s the most recent evidence on how attire affects whether patients believe you know what you’re doing. I think this is required reading for the residents. Many trainees want to do “just enough” to get it right. But there may be some benefit to overlearning My friend Dr. John Norbury has joined Texas Tech University as new PMR Division Chief under Dept of Neurology. He tells of 3 positions: One is “for junior faculty, one who will be a consult/outpatient MSK physician and one will be inpatient...neurorehab would be a plus.   Both physicians would include a part time VA appointment and would have an medical education component and the ability to tailor to clinical interests or research, if desired.  They would also include public service loan forgiveness. Also, the VA here is looking for a CMO (outpatient clinic).  Great senior leadership team and beautiful brand new facility.  Having a more seasoned PM&R doc with some administrative talents in that role would be super helpful, but I'm sure any specialty which cares for veterans in the outpatient world would work.  And taxes are way less than New Jersey.“ Seattle VA / U Wash opportunity: “recruiting for a PM&R physician with clinical, education and also ideally research expertise in Amputee care. The position will be 100% based at VA Puget Sound in Seattle with clinical care focused on Amputee care with resident and fellow teaching responsibilities. VA Puget Sound has a large rehab focused research program and a candidate with a history of research funding and scholarly publications will find ample opportunity here for independent research and collaborations with current researchers.” TBI opening in Portland Oregon VA Not sure if Minneapolis VA is still looking but they wanted an amputee physiatrist too.

AANEM & EDx

Quantitative electromyography: Normative data in paraspinal muscles : talks about the “abnormal” findings seen in asymptomatic patients. Very similar to how we approach at the VA. There was a fascinating discussion thread recently posing the question as to how much of the distal onset latency prolongation can really be attributed to axon loss in the setting of low amplitudes. (Residents should have access through the training portal. The rest of you can feel the FOMO) Attached is a case of EDB pseudohypertrophy in the setting of peripheral polyneuropathy Prognostic indicators for Lumbar decompression for foot drop…Duh The AAN supports banning choke holds. Intro and Discussion of this study on MRI findings in Statin induced myopathy are helpful for the residents. “MRI features of statin-associated anti-HMGCR myopathy can be differentiated from other types of myopathies, such as sporadic inclusion-body myositis and dermatomyositis, in terms of distribution of tissue edema and fatty infiltration. In dermatomyositis, edema is often found within the fascia and subcutaneous tissue,13 which is uncommon in anti-HMGCR myopathy. In sporadic inclusion-body myositis, fatty replacement is most prominent in the anterior thigh, with relative sparing of rectus femoris,14-16 whereas anti-HMGCR myopathy demonstrates preferential posterior compartmental fatty infiltration. On the other hand, MRI features of statin-associated anti-HMGCR myopathy may share similarities with anti–signal recognition particle (SRP) myopathy, another subclass of immune-mediated necrotizing myopathy with shared histopathological hallmarks and proposed pathogenesis.17 In anti-SRP myopathy, an anterolateral pattern of muscle edema in the anterior compartment and fatty replacement of hamstring muscle has been reported,18 but with less symmetry and more severe fatty replacement than anti-HMGCR myopathy.”

MSK & PAIN

Semantics are important and the spine pain community is taking a step in the right direction by reassessing the word “Failed Back Surgery Syndrome.” See attached for the letter from IASP. It’s still woefully oversimplifying if you ask me. (more on semantics in the TREES section of this email) Residents may appreciate the attached brief review of Genicular nerve blocks/RFA for knee OA. Bottom line is that the literature is conflicting (esp the anatomy) but it’s an option I refer for in non-op endstage or post TKA patients. I somehow still get the RIC journal club emails and two were shareworthy (hoping to discuss with Dr. Ma) This 2018 ACORN study’s Intro section is excellent for R1s. The study was excellent too. I’ve included my “GMNR” on AC joint for R1s as well. The attached 2021 Multicenter GRASP RCT from Lancet found a course of PT no better than a single PT best practice advice session + corticosteroid injection. If you want the details of the interventions like I did, they are found here. Opioid Tapering Carries Significant Risks according to this JAMA study. There could be inherent bias as these are patients likely chosen for their risks pre-taper. I guess the take-home is to offer support while tapering. Ate JAMA saying statins may not be any more likely than placebo to cause muscle aches. This was the first time I had heard of “N-of-1 clinical trials.”  See this if you are confused as well.  Predictors for TFCC outcomes: above elbow splinting better than short-arm; worse with complete foveal TFCC tear and a dorsally subluxated DRUJ. My father used to pay 1 dollar for each pound his obese patients lost each visit and it worked (they had to pay him a dollar for each pound they gained). Financial incentives work but should CMS pay for them? Despite the possibility of responder bias, rheumatologic flare has not really been associated with COVID vaccine. I only read the abstract but this may open up options for RA patients that previously had cancer.

Trees

A great description of restrictive covenants (non-compete clauses) ZDOGGMD breaks down the complexity of the Delta variant and offers the possibility of hope. (Here’s a complete zdoggmd non sequitur sent to me by a fellow attending but do NOT click this link if you are easily offended by poop jokes.) More and more of my outpatients ask me about COVID Vaccine. This is a helpful description of base rate bias, an issue that contributes to confusing them. Previously infected may only need one dose of vaccine and unvaccinated are twice as likely to be reinfected than vaccinated. Scientific ways to motivate change Nanotech for potentially treating cancer. Where does the joy and meaning in medicine dwell? I tried this Harvard implicit bias test. Is it wrong for me to say that the test is biased? What the rest of us can learn from gay pride… A great narrative about our field’s role in advocacy and the AMA’s new policy opposing “excited delirium.” “If you want people in your practice to contribute toward its greater success, try making them feel valued and involved as a group. That may seem like common sense, but a new study in Health Affairs finds that when medical practices have collaborative management styles that incorporate better communication, burnout is lower and that's ultimately good for everyone." A quick video on gender bias in medicine and what we can do about it some of this was surprising. As a diabetic, I can’t wait to get one of these new monitors that were discovered by accident! Semantic clarification from this paper.

 

 

Phorest & Trees July 2021

 

Phorest & Trees Every month I share stuff I’ve been reading. This month I’ve added the new R1s and a number of alumni to the list. Those of you receiving this for the first time can access the old ones here.  Hope you enjoy!
A Bit of (Personal) Good News
	Thanks to all of you for your kind words about my recent promotion to Clinical Professor. Copious gratitude to Drs. Kirshblum and Foye for their persistent tenacity, encouragement, and filling out the copious paperwork, without whom this wouldn’t have happened.  Thanks to Chae for supporting me formally and behind closed doors in ways I probably don’t even know about. Some have asked why I bothered with this considering there are no accompanying financial benefits whatsoever attached to a non-tenure clinical promotion. I am happy to share my motivation. I did this for my dad. He was so proud of me when i got the "assistant professor" designation 15 years ago. When he passed in 2016, I decided to work toward this in his honor. So hopefully he's smiling with pride somewhere in the universe...
AANEM and EDx
Holy Shish-kabob and Shut the front door!!! A review found There is scientific evidence of the benefit of BTX-A treatment for post-paretic synkinesis, but there is lack of standardized treatment protocols. The origin of allowing >50% drop on tibials.
On ReachMD, DOXIMITY & MedPage
NSAIDs over Codeine for Post-op adult pain meta analysis. Interesting that pairing with APAP was always better. Vagus Nerve Stimulation Improves Arm Function After Stroke - Clinical Pain Advisor Do We Really Need a Fourth Year of Med School?  I concur A few real-life warnings echoing my advice to residents: physicians and other healthcare workers don’t stop being seen as an upstanding member of society when they leave work.  Your affiliation is a two way street. Multimodal approach to arthroplasty pain is standard of care How much of science is fraud? Who needs doctors when you can hire APPs? Kessler residents may have it tough but at least they’re not getting stabbed in the face!
Pain, Sports, MSK & Rheum
Fascinating study on how trunk flexion angle may contribute to running injuries. Attached for sports biomechanics geeks. Multi-society and Multispecialty Advisory warns that even small doses of gadolinium-based contrast can cause encephalopathy and fibrosis warning in its use for interventional pain procedures as an alterintive to iodinated contrast media. I would be interested to know what my interventional colleagues’ experience with DRG implants of this type have been. After reading this study on PRP for adhesive capsulitis, I realized that many of us will interpret the findings differently.,  Perhaps this is true for arthroscopic infection rates after injection, but at the VA we usually advise 6 months prior to THA. Doesn’t seem to be an increased risk for nonvertebral fracture in RA on DMARDs Back Pain Treatment: Is Spinal Fusion Surgery Being Overused? (practicalpainmanagement.com) ….duh Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis ….is anyone still prescribing these?! BMAC for knee OA review…let me know when it costs less and does better than other treatments. MRI may be warranted to detect subclinical inflammation in juvenile rheum Obvious benefits with an accelerometer after THA don’t show long term benefit
Ableism – an inherently physiatric topic to consider
Being physiatrists, we pride ourselves on being knowledgeable advocates for patients with disabilities.  This editorial tells one pediatric neurologist’s perspective and is full of clickable references to support her assertions. After diving into small but growing literature into it (only 312 references since 2006), I have some developing and conflicting thoughts on the topic which we can discuss in person. Some stuff worth sharing:   “ “[i]mmediately, and from early life and thereafter, people perceive individuals with disability as ‘vulnerable’ and of low competence, and, accordingly, treat members of this group differently.”1 Consequently, people with disabilities often continue to experience social devaluation on account of their disabilities (i.e., ableism), despite the fact that the last few decades have seen an increased awareness and a decreased social acceptability of discrimination based on other characteristics such as race (i.e., racism) and gender (i.e., sexism). People with disabilities thus remain subjected to ableist attitudes in many sectors, including — often especially — the health care system.”    Another says “Disability scholar Fiona Kumari Campbell defines ableism as “a network of beliefs, processes and practices that produces a particular kind of self and body (the corporeal standard) that is projected as the perfect, species-typical and therefore essential and fully human. Disability then, is cast as a diminished state of being human.”3 Campbell delineates an inherent link between this deficit-based construction of disability and a “biomedicalist stance,” which, since the Age of Reason, has “played a critical intervening role in the lives of people with disability and people with anomalous bodies or mentalities. Medicine has operated as the primary paradigm not only for the treatment of disabled bodies but has also shaped the way decision makers, legislators, families and society in general think about and sense disability.”   If you’ve done any research, you’ve probably looked at quality of life as an outcome measure. The very notion of QOL is scrutinized in this context “At the heart of such decisions is what disability scholar Joel Reynolds has termed the “ableist conflation” of disability, suffering and death: “wherever operative, the ableist conflation flattens communication about disability to communication about pain, suffering, hardship, disadvantage, morbidity, and mortality.”   “Medicine is, at bottom, a discipline that thinks pathologically. According to a velocity of knowledge that has exponentially increased since the 18th century via scientific experimentation and technological advance, medicine functions according to the basic idea that “healthy” is “normal” and “unhealthy” is “abnormal.” The information medicine vends as truth is predicated on this distinction. In a recent piece in CMAJ, Heidi L. Janz writes that disabled people “remain subjected to ableist attitudes in many sectors, including — often especially — the health care system.”7 The reason, as Janz correctly identifies, is based in medicine’s presumption that “not normal” is the same as “unhealthy.” I wish to include ill physicians in Janz’s formulation, for the same oppressive forces medicine wields against its subjects, it also wields against itself.”   “In science, technology, engineering, and mathematics (STEM) fields, disabled people remain a significantly underrepresented part of the workforce. Recent data suggests that about 20% of undergraduates in the United States have disabilities, but representation in STEM fields is consistently lower than in the general population. Of those earning STEM degrees, only about 10% of undergraduates, 6% of graduate students, and 2% of doctoral students identify as disabled. This suggests that STEM fields have difficulty recruiting and retaining disabled students, which ultimately hurts the field, because disabled scientists bring unique problem-solving perspectives and input.”    Even though the topic is relatively new to me to consider, there is a curriculum for medical students
Trees
A lecture on “Improving Interdisciplinary Gait Deviation Assessment and Treatment Plan Among Lower Limb Prosthetic Users” Direct TRAIN Link (Non-VA) A lecture on Lower extremity Residual limb care: Challenges and solutions We have used the iFIT socket for BKAs at the VA; they are adjustable and relatively less expensive. It was developed by Dr. Timothy Dillingham. There is now an AK version as well and I have attached the brochure. A heartwarming reminder for many of us to decenter once in a while by looking for beauty. Comics intersects PMR: The PUNISHER didn’t accurately represent TBI severity? No….

 

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.