The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Current Waveforms in Spinal Cord Stimulation and Their Impact on the Future of Neuromodulation: A Scoping Review.

BACKGROUND: Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care. OBJECTIVE: This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS. STUDY DESIGN: The study is a scoping review of the literature about newer generation SCS waveforms. MATERIALS AND METHODS: A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy. RESULTS: A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added. CONCLUSIONS: Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies.

Early Neuropathic Treatment May Prevent the Chronic Stage of Complex Regional Pain Syndrome Type II (CRPS II​).

Complex regional pain syndrome (CRPS) is a debilitating condition characterized by autonomic and inflammatory features, often caused by fractures, surgeries, or other injuries. Multimodal treatment is utilized, which often includes neuropathic medications and physical therapy. We had a case of a 24-year-old man who was diagnosed with CRPS II following an open reduction and internal fixation of a trimalleolar fracture. Significant improvement of edema, pain, and function was achieved with early initiation of gabapentin, nortriptyline, and physical therapy. In this case report, we discuss the therapeutic challenges regarding his recovery and review the literature on the utility of medications and interventional methods in treating CRPS II. We note that early treatment response may be an important prognostic indicator for the progression of CRPS II and additional studies targeting interventions for the specific type and clinical stage of CRPS are needed.

Comparing the Effectiveness of Hands-on vs. Observational Training of Residents in Interlaminar Epidural Steroid Injections (ILESI) Using a High-Fidelity Spine Simulator.

Introduction The Accreditation Council for Graduate Medical Education (ACGME) requires that residents in the Physical Medicine and Rehabilitation (PM&R) residency observe or perform certain interventional procedures, one of which is an interlaminar epidural steroid injection (ILESI). While the traditional learning model relying heavily on observation is commonplace, it leaves the practice phase of learning to happen on real patients. High-fidelity simulation may be a worthwhile alternative as a training approach to increase physician comfort with the procedure and improve patient safety. Methods Current PM&R residents from two programs between their second and fourth year, inclusively, who lacked prior training experience in ILESI attended one hour of either: (1) an experimental arm of supervised hands-on training on a simulation device or (2) a control arm observing the procedures performed by an attending on the same device. Assignments were made based on resident schedule availability. Pre-training knowledge, training, and post-training knowledge were assessed at the Multidisciplinary Pain Clinic at Montefiore Medical Center. Participants were assessed on their procedural competence using an adapted version of a previously published grading checklist before the session. Participants also evaluated their confidence in performing the procedure prior to and after training. Data was analyzed using the Wilcoxon signed-rank test and the Wilcoxon rank-sum test. SAS Version 9.4 was used for analysis. Results Fifteen residents initially participated, but three residents dropped out at the 15-week follow-up. There was a significant increase in test scores in both arms immediately after the intervention (p=0.008 in control, p=0.016 in the experiment), with greater improvement shown in the hands-on training group (p=0.063). At the 15-week follow-up, there was no significant change in test scores in the control arm (p=0.969) while there was a decrease in the experiment arm (p<0.001). Conclusion Hands-on learning with high-fidelity simulation demonstrated more improvement for short-term motor-skill acquisition, while observational learning with repetition showed more benefits for long-term retention. Optimal procedural training should employ both educational modalities for best short- and long-term results.

Inciting Events Associated With Cervical Radiculopathy.

BACKGROUND: Cervical radiculopathy (CR) is a clinical diagnosis defined as a combination of neck, shoulder, and arm pain, often accompanied by sensory and motor symptoms. CR is often caused by degenerative spine pathology associated with impingement of a cervical nerve root, and this pathology can be visualized using magnetic resonance imaging (MRI) or computed tomography (CT). [Correction added September 4, 2019, after online publication: 'computer tomography' corrected to 'computed tomography'] Factors that are associated with the onset of CR have not been explored. OBJECTIVE: To investigate the types and frequencies of patient-reported inciting events associated with CR in patients with imaged-confirmed pathologies that correlate with symptoms. DESIGN: Prospective observational case series. SETTING: Two spine physiatry and three orthopedic spine surgery practices. PATIENTS: One hundred twenty-two patients with symptoms suggestive of CR were recruited. Of these, 107 patients had MRI or CT evidence of cervical disk herniation or foraminal stenosis that correlated with symptoms and matched our inclusion criteria. METHODS: We categorized patient-reported inciting events associated with onset of CR into six categories reflecting increasing severity of inciting event, and recorded the clinical characteristics, physical examination findings, pain intensity, and disability. We analyzed the characteristics of patients based on subgroups of inciting events. RESULTS: Two-thirds of patients reported that they either awoke with symptoms or symptoms began without a memorable event, and one-third of patients reported inciting physical activity or trauma associated with the onset of CR. Clinical characteristics of CR were not influenced by categories of inciting events. CONCLUSION: Most CR with correlating spine pathology was found to have onset without a specific inciting events. Furthermore, physical inciting events did not influence the severity of clinical manifestation of CR. LEVEL OF EVIDENCE: IV.

Gabapentin Does Not Appear to Improve Postoperative Pain and Sleep Patterns in Patients Who Concomitantly Receive Regional Anesthesia for Lower Extremity Orthopedic Surgery: A Randomized Control Trial.

In recent years, gabapentin has gained popularity as an adjuvant therapy for the treatment of postoperative pain. Numerous studies have shown a decrease in pain score, even with immediate postoperative activity, which is significant for early post-op ambulation and regaining functionality sooner. However, studies have been in conclusive in patients undergoing lower extremity orthopedic surgery. For this reason, we hoped to study the effect of gabapentin on postoperative pain in patients undergoing total knee arthroplasty, total hip arthroplasty, or a hip fracture repair. This was done in the setting of ensuring adequate postoperative analgesia with regional blocks and opioid PCA, as is protocol at our institution. Given the sedative effects of gabapentin and the potential for improving postoperative sleep patterns, we also studied the drug's effect on this aspect of our patient's postoperative course. We utilized the Pittsburg Sleep Quality Index and Visual Analog Scale for pain to obtain a more objective standardized score amongst our study population. Our results indicate that gabapentin does not offer any additional relief in pain or improve sleep habits in patients who have received either a femoral or lumbar plexus block for lower extremity orthopedic surgery. This trial is registered with NCT01546857.