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.

Adipose Tissue Impacts Radiofrequency Ablation Lesion Size: Results of an Ex Vivo Poultry Model.

BACKGROUND: Radiofrequency ablation (RFA) is a common treatment in which radiofrequency (RF) is used to heat neural tissue and reduce pain. The impact of adipose content in tissue on the lesion size may impact efficacy, and to date, there is little, if any, data comparing its influence on RFA. OBJECTIVES: We evaluated the influence of adipose tissue on RF lesion size. STUDY DESIGN: Controlled, ex vivo study. SETTING: Academic institution in a procedural setting. METHODS: RF lesions were created using 20-G 10-mm protruding electrode (PE) needles inserted into unbrined chicken breasts and thighs at 21°C. RF current was applied for 90 seconds at 80°C. Chicken breasts were used as the control group and chicken thighs were used as the high adipose variant. Four different groups were examined: 1- Standard 20 g RFA needle, 2- 20 g RFA PE needle, 3- Standard RFA needle with lidocaine 2% injectate, and 4- Standard RFA needle with iohexol 240 mg injectate. There were 12 lesions performed in each group; length, width, and depth were measured. RESULTS: The control group had significantly deeper lesions in all 4 cohorts. Lesions' lengths were smaller in the fat-rich group. The control and PE cohorts showed a significant difference in width between the 2 fat-rich and nonfatty groups. LIMITATIONS: Radiofrequency ablation was performed at room temperature and not heated to physiological temperature. This was an ex vivo study, thus factors of human anatomy and physiology could not be evaluated. CONCLUSIONS: Adipose tissue content was inversely related to lesion size in all samples. This factor should be considered when assessing methods of enhancing lesion size in human models.

Percutaneous Ultrasound-Guided Coracohumeral Ligament Release for Refractory Adhesive Capsulitis: A Prospective, Randomized, Controlled, Crossover Trial Demonstrating One-Year Efficacy.

BACKGROUND: Adhesive capsulitis (AC) is a painful and disabling condition with restricted range of motion (ROM) that affects 2% to 3% of the population and up to 20% of patients with diabetes. AC can be idiopathic, iatrogenic, or secondary to shoulder injuries. Some associated conditions include diabetes mellitus, thyroid disorders, dyslipidemia, stroke, prolonged immobilization, and autoimmune conditions. Management ranges from analgesics to physical therapy, local injections, hydrodilatation, and advanced surgical interventions. This study examines percutaneous coracohumeral ligament (PCHL) sectioning with the hypothesis that interruption would improve pain and ROM in patients with AC refractory to conservative management. OBJECTIVES: To use sonographically guided percutaneous interruption of the CHL for the treatment of refractory AC. STUDY DESIGN: A prospective, randomized, controlled, cross-over trial. SETTING: Academic medical center. METHODS: Patients were identified based on inclusion and exclusion criteria under the supervision of the Principal Investigator. After primary screening, research staff explained the study, risks, and benefits to the patients, and consent was obtained. Patients' pain score and shoulder ROM were assessed before and after the procedure, at one month, and one year. The Oxford Shoulder Scoring (OSS) questionnaire was also completed before the procedure and in the one-year follow-up visit.Forty patients were enrolled with refractory AC. Forty-six shoulders were treated; 6 patients underwent a bilateral procedure. Block 2:1 randomization was performed for the 2 groups (PCHL release [PCHLR] and local anesthetic CHL [LACHL]). The LACHL group received a lidocaine injection at CHL, and the PCHLR group received the CHL using a Tenex® (Tenex Health, Lake Forest, CA) needle. ROM, Numeric Rating Scale (NRS-11), and OSS were evaluated at baseline, immediate postprocedure, and long term. RESULTS: Among 46 shoulders included in the study, 7 were excluded due to lost to follow-up, total shoulder replacement, and shoulder manipulation. Twenty-six were randomized to the PCHLR group and 13 to LACHL group. ROM (external rotation and abduction), pain, NRS-11 score, and OSS score were measured at baseline and long term, confirmed by a nonbiased health care personnel. There was no statistically significant difference in ROM, NRS-11, and OSS between the 2 cohorts at the baseline visit. Nine patients in LACHL group crossed over to the PCHLR arm at one month. Data analysis in the long term revealed durability of the PCHLR group with a statistically significant difference in ROM, NRS-11, and OSS. External rotation improved by double, and abduction improved by almost 30% (P value < .001). NRS-11 decreased from 8 (IQR 8, 9) at baseline to 3 (IQR 2, 7) at long term among those who received PCHLR. The baseline mean OSS in the PCHLR group increased from 7.44 to 31.86 at one-year follow-up and was statistically significant (P value < .001). LIMITATIONS: This study represents a small population of patients with a CHL-related ROM deficit. Patients were not excluded for osteoarthritis or other motion-disabling shoulder conditions. We submit that the strength of the study could have been improved if the physician performing the procedure was blinded and if the patient was blinded as well to minimize operator and patient bias. CONCLUSIONS: We demonstrate that our technique for PCHLR is a safe, effective, and durable procedure that improved ROM, pain, and shoulder function in our patient population when compared to the control. KEY WORDS: Tenex, frozen shoulder, pain, range of motion, function, shoulder, minimally invasive, durable.

Percutaneous Ultrasound-Guided Tenotomy of the Iliotibial Band for Trochanteric Pain Syndrome: A Longitudinal Observational Study With One-Year Durability Results.

BACKGROUND: Upper lateral hip pain is a common complaint in adults and is referred to as greater trochanteric pain syndrome (GTPS) and is more prevalent among older women. This is a debilitating condition that could result in lower physical activity and quality of life, and higher unemployment rate. GTPS is a clinical diagnosis, and many cases improve with conservative medical management (CMM). However, there is still a gap between patients not responding to CMM and those who are not good surgical candidates. Thus, percutaneous ultrasound tenotomy (PUT) may be a valuable treatment option to limit this gap. OBJECTIVES: Demonstration of the one-year pain and functional outcomes, including sit to stand. SETTING: Academic tertiary care medical center. METHODS: Forty-eight consecutive patients with refractory trochanteric pain due to iliotibial band (ITB) tendinopathy. Fifty-six hips were treated; 8 patients underwent bilateral procedures. Electronic medical record review of consecutive patients who underwent ITB TENEX® was performed at Montefiore Medical Center from December 2019 to December 2021. Institutional guidelines recommended TENEX® for greater trochanteric pain refractory to conservative treatment and ultrasound (US) confirmed ITB tendinopathy (hypoechogenicity or thickened tendon > 6 mm). Pain level, as well as sit-to-stand, side-lying, and walking tolerance levels were evaluated at baseline preprocedure visit and one-year visit. Follow-up was performed by independent practitioners and corroborated by chart review. RESULTS: Numeric Rating Scale (NRS-11) improved by 4 points across all patients. Seventy percent of patients endorsed pain relief at one-year visit. Median preprocedure NRS-11 was 9. The reported median NRS-11at one year was 5 (Wilcoxon signed rank NRS-11 demonstrated a Z score of -6.042 with P < 0.001). One-year analysis among all patients revealed 57%, 78%, and 66% improvement in side-lying, sit-to-stand, and walking tolerance levels, respectively. LIMITATIONS: We believe that our results must be confirmed with a randomized control trial with a control arm and more patients included. CONCLUSIONS: PUT of the ITB using the TENEX® tissue remodeling device could be a safe and effective treatment for ITB tendinopathy-associated GTPS.

A Smart Service System for Spatial Intelligence and Onboard Navigation for Individuals with Visual Impairment (VIS4ION Thailand): study protocol of a randomized controlled trial of visually impaired students at the Ratchasuda College, Thailand.

BACKGROUND: Blind/low vision (BLV) severely limits information about our three-dimensional world, leading to poor spatial cognition and impaired navigation. BLV engenders mobility losses, debility, illness, and premature mortality. These mobility losses have been associated with unemployment and severe compromises in quality of life. VI not only eviscerates mobility and safety but also, creates barriers to inclusive higher education. Although true in almost every high-income country, these startling facts are even more severe in low- and middle-income countries, such as Thailand. We aim to use VIS4ION (Visually Impaired Smart Service System for Spatial Intelligence and Onboard Navigation), an advanced wearable technology, to enable real-time access to microservices, providing a potential solution to close this gap and deliver consistent and reliable access to critical spatial information needed for mobility and orientation during navigation. METHODS: We are leveraging 3D reconstruction and semantic segmentation techniques to create a digital twin of the campus that houses Mahidol University's disability college. We will do cross-over randomization, and two groups of randomized VI students will deploy this augmented platform in two phases: a passive phase, during which the wearable will only record location, and an active phase, in which end users receive orientation cueing during location recording. A group will perform the active phase first, then the passive, and the other group will experiment reciprocally. We will assess for acceptability, appropriateness, and feasibility, focusing on experiences with VIS4ION. In addition, we will test another cohort of students for navigational, health, and well-being improvements, comparing weeks 1 to 4. We will also conduct a process evaluation according to the Saunders Framework. Finally, we will extend our computer vision and digital twinning technique to a 12-block spatial grid in Bangkok, providing aid in a more complex environment. DISCUSSION: Although electronic navigation aids seem like an attractive solution, there are several barriers to their use; chief among them is their dependence on either environmental (sensor-based) infrastructure or WiFi/cell "connectivity" infrastructure or both. These barriers limit their widespread adoption, particularly in low-and-middle-income countries. Here we propose a navigation solution that operates independently of both environmental and Wi-Fi/cell infrastructure. We predict the proposed platform supports spatial cognition in BLV populations, augmenting personal freedom and agency, and promoting health and well-being. TRIAL REGISTRATION: ClinicalTrials.gov under the identifier: NCT03174314, Registered 2017.06.02.

Methodological Issues Relevant to Blinding in Physical Medicine and Rehabilitation Research.

ABSTRACT: Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding.

Real-Time Loosely Coupled 3DMA GNSS/Doppler Measurements Integration Using a Graph Optimization and Its Performance Assessments in Urban Canyons of New York.

Smart health applications have received significant attention in recent years. Novel applications hold significant promise to overcome many of the inconveniences faced by persons with disabilities throughout daily living. For people with blindness and low vision (BLV), environmental perception is compromised, creating myriad difficulties. Precise localization is still a gap in the field and is critical to safe navigation. Conventional GNSS positioning cannot provide satisfactory performance in urban canyons. 3D mapping-aided (3DMA) GNSS may serve as an urban GNSS solution, since the availability of 3D city models has widely increased. As a result, this study developed a real-time 3DMA GNSS-positioning system based on state-of-the-art 3DMA GNSS algorithms. Shadow matching was integrated with likelihood-based ranging 3DMA GNSS, generating positioning hypothesis candidates. To increase robustness, the 3DMA GNSS solution was then optimized with Doppler measurements using factor graph optimization (FGO) in a loosely-coupled fashion. This study also evaluated positioning performance using an advanced wearable system's recorded data in New York City. The real-time forward-processed FGO can provide a root-mean-square error (RMSE) of about 21 m. The RMSE drops to 16 m when the data is post-processed with FGO in a combined direction. Overall results show that the proposed loosely-coupled 3DMA FGO algorithm can provide a better and more robust positioning performance for the multi-sensor integration approach used by this wearable for persons with BLV.

The complexity of eye-hand coordination: a perspective on cortico-cerebellar cooperation.

BACKGROUND: Eye-hand coordination (EHC) is a sophisticated act that requires interconnected processes governing synchronization of ocular and manual motor systems. Precise, timely and skillful movements such as reaching for and grasping small objects depend on the acquisition of high-quality visual information about the environment and simultaneous eye and hand control. Multiple areas in the brainstem and cerebellum, as well as some frontal and parietal structures, have critical roles in the control of eye movements and their coordination with the head. Although both cortex and cerebellum contribute critical elements to normal eye-hand function, differences in these contributions suggest that there may be separable deficits following injury. METHOD: As a preliminary assessment for this perspective, we compared eye and hand-movement control in a patient with cortical stroke relative to a patient with cerebellar stroke. RESULT: We found the onset of eye and hand movements to be temporally decoupled, with significant decoupling variance in the patient with cerebellar stroke. In contrast, the patient with cortical stroke displayed increased hand spatial errors and less significant temporal decoupling variance. Increased decoupling variance in the patient with cerebellar stroke was primarily due to unstable timing of rapid eye movements, saccades. CONCLUSION: These findings highlight a perspective in which facets of eye-hand dyscoordination are dependent on lesion location and may or may not cooperate to varying degrees. Broadly speaking, the results corroborate the general notion that the cerebellum is instrumental to the process of temporal prediction for eye and hand movements, while the cortex is instrumental to the process of spatial prediction, both of which are critical aspects of functional movement control.