Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans.

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Botulinum toxin type A for nonsurgical lateral release in patellofemoral pain syndrome: a case study.

SETTING: Outpatient rehabilitation clinic. PATIENT: A 37-year-old physically active male. CASE DESCRIPTION: The patient presented with anterior left knee pain, exacerbated when climbing stairs, sitting, and running. Exam showed lateral tracking patellae and palpable crepitus. One hundred fifty units of botulinum toxin A was injected into his left vastus lateralis. He underwent a 12-week home exercise program targeting the vastus medialis (VM). ASSESSMENT/RESULTS: Visual analog scale decreased from 70 to 0 on a 150-mm scale, from initial until 8 weeks postinjection. Functional Index Questionnaire increased from 5 to 16 over the same period. Knee torque and surface electromyography findings showed increased activity of the VM during knee extension. CONCLUSION: Botulinum injection into the vastus lateralis in conjunction with VM strengthening may provide more effective treatment of patellofemoral pain syndrome. Further study is needed to explore this novel treatment of patellofemoral pain syndrome.

Whole Medical Systems the Rehabilitation Setting (Traditional Chinese Medicine, Ayurvedic Medicine, Homeopathy, Naturopathy).

Elements of whole medical systems (WMSs) are re-emerging in a modern, patient-centered care model that leverages the benefits of evidence-based conventional medical practice with WMSs modalities. Many of these re-emerging modalities had their origins in traditional Chinese medicine, ayurvedic medicine, homeopathy, or naturopathy. To date, research has been conducted predominantly on multimodality treatment of experimental groups, drawing conclusions without a comparative control group or using modalities that are not actually WMSs.

Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives.

Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.

Integrative Medicine in Traumatic Brain Injury.

Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine. Integrative medicine combines treatment with conventional medical practices and elements of CAM in which there is strong evidence in efficacy and safety. Although there is growing interest in the integrative medical approach in treating the patient population with traumatic brain injury, there is a paucity in high-quality clinical trials supporting its use. This article reviews the background and current clinical data concerning some of the more common CAM interventions.

Pain in Parkinson's disease: pathology to treatment, medication to deep brain stimulation.

This article reviews the current literature on pain in Parkinson's disease to include the anatomy, pathology, and both basic and clinical science research. It explores treatment methods to include medication management as well as deep brain stimulation.

How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? a case report.

Chest pain in a patient with acquired immune deficiency syndrome (AIDS) has a broad differential diagnosis including, but not limited to, coronary artery disease, gastroesophageal reflux, fungal esophagitis, and musculoskeletal pain. However, spontaneous pneumothorax must also be added to the list of possibilities. Spontaneous pneumothorax occurs 450 times more frequently in patients with AIDS versus the general population and is now the leading cause of nontraumatic pneumothorax in the urban population, to include both those with and without AIDS. Because many patients with human immunodeficiency virus (HIV) are young and typically devoid of comorbidity, the presentation of this pulmonary complication may be subtle. HIV-positive patients are receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for spontaneous pneumothorax to be an etiology of chest pain. We present a case exemplifying the need for rehabilitation professionals to maintain a broad-based approach when caring for patients with HIV and AIDS.

Sports and performing arts medicine. 1. General considerations for sports and performing arts medicine.

UNLABELLED: This self-directed learning module highlights general considerations in sports and performing arts medicine. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVE: To discuss similarities and differences of injuries sustained in sports and performing arts using case vignettes.

Sports and performing arts medicine. 2. Shoulder and elbow overuse injuries in sports.

UNLABELLED: This self-directed learning module discusses classic topics and highlights new advances in this area. This article discusses upper-limb sports injuries as part of a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on shoulder and elbow pain in the athlete. OVERALL ARTICLE OBJECTIVE: To discuss shoulder and elbow overuse injuries in sports.

Sports and performing arts medicine. 3. Lower-limb injuries in endurance sports.

UNLABELLED: This self-directed learning module highlights new advances in this topic area. It is part of the study guide on sports medicine and performing arts in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on (1) ankle pain in a runner, (2) heel pain in an adolescent, (3) anterior knee pain in a runner, (4) lateral knee pain in a cyclist, (5) shin splints in a runner, (6) buttock pain in a hiker, and (7) collapse of a marathoner from hyponatremia. OVERALL ARTICLE OBJECTIVE: To summarize lower-limb injuries commonly seen in endurance sports.

Sports and performing arts medicine. 4. Traumatic injuries in sports.

UNLABELLED: This self-directed learning module focuses on injuries often seen in contact sports. It includes information on trauma to the cervical spine, wrist, shoulder, knee, ankle, foot, and chest and also discusses concussion in sport. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the etiology, differential diagnoses, treatment, and return-to-play criteria for traumatic sports injuries. OVERALL ARTICLE OBJECTIVE: To summarize the approach to common traumatic sports injuries.

Sports and performing arts medicine. 6. Issues relating to dancers.

UNLABELLED: This self-directed study module highlights biomechanics unique to dance that predispose to common injuries of the lower extremity and discusses preventative strategies. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVE: To summarize lower-limb and back injuries commonly seen in dancers.

Sports and performing arts medicine. 5. Issues relating to musicians.

UNLABELLED: This self-directed learning module discusses classic topics and highlights new advances in this topic area. This article, which discusses upper-limb injuries in musicians, is a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes to elaborate on issues relating to musicians. OVERALL ARTICLE OBJECTIVE: To summarize overuse injury, nerve entrapment, and focal dystonia in instrumental musicians.