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Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists’ surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the “baseline” upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.

Objective The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources. Methods The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements. Results Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed “a lot” or “some” interest in learning more, but only 19% reported “a lot” of knowledge. Respondents reported “a lot” of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). “None” or “some” knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%). Conclusion Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training. Impact Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

To summarize the recommendations on the interventional management of subacute and chronic non-radicular low back pain (LBP) from the 21 quality-appraised CPGs identified in the previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review". By disseminating this information, we aim to facilitate the implementation of these recommendations into clinical practice.Electronic bibliographic databases, guideline databases and grey literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria.21 CPGs were quality-appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections (ESIs), radiofrequency procedures (RF), facet injections, sacroiliac injections (SI), and prolotherapy. Within each treatment category, the recommendations were organized based on 2 factors: quality of CPG and strength of recommendation.Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly-for. The second, third and fourth most common strength of recommendations were inconclusive, weakly-against and strongly-against respectively and the least common was strongly-for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation-weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive.Most of the interventional management recommendations for management of non-radicular LBP in the 21 CPGs appraised in this review were either weakly-for, weakly-against or inconclusive, with several recommendations within each treatment category contradicting each other. AGREE II quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.

Our objectives were to explore the association between phosphodiesterase 5 inhibitor use and lumbar decompression surgery by evaluating the prevalence of lumbar decompression surgery in a treatment group of patients with lumbar spinal stenosis compared with a control group.We performed database review and extracted data including lumbar decompression surgery prevalence, phosphodiesterase 5 inhibitor dosage, and fill dates. Treatment group was defined as those with phosphodiesterase 5 inhibitor fill dates of less than 30 days before surgery, and control group was defined as those with phosphodiesterase 5 inhibitor fill dates at any other time. Lumbar decompression surgery prevalence rates for both groups were calculated.Our study found 599 lumbar spinal stenosis patients who were prescribed phosphodiesterase 5 inhibitor. Three hundred thirty-eight underwent lumbar decompression surgery. Of these, 71 (21%) filled their prescription of less than 30 days before surgery, whereas 267 (79%) filled their prescription during a different period. The majority (94.6%) of surgical patients received decompression at two or more spinal levels.Prevalence of lumbar decompression surgery for lumbar spinal stenosis was significantly lower in patients in the treatment group on phosphodiesterase 5 inhibitor therapy compared with the control group. Among many potential explanations, the vasodilatory effect of phosphodiesterase 5 inhibitor may have contributed to a lower surgical rate. This is the first study to explore this novel association. Future prospective studies are necessary to better define the utility of phosphodiesterase 5 inhibitor in lumbar spinal stenosis.

This article discusses the use of physical and biometric sensors in telerehabilitation. It also discusses synchronous tele-physical assessment using haptics and augmented reality and asynchronous physical assessment using remote pose estimation. The article additionally focuses on computational models that have the potential to monitor and evaluate changes in kinematic and kinetic properties during telerehabilitation using biometric sensors such as electromyography and other wearable and noncontact sensors based on force and speed. And finally, the article discusses how virtual reality environments can be facilitated in telerehabilitation.

PURPOSE We performed this study to evaluate the effect of back bracing to treat patients with chronic low back pain. METHODS This was a prospective, unblinded, randomized controlled trial of 61 adults with uncomplicated chronic low back pain (>12 wks) and imaging findings of degenerative spondylosis, to assess the effectiveness of a semirigid back brace. All study participants received back school instruction. The treatment group also received a lumbar orthosis and was instructed to wear it as needed for symptom relief. At baseline, 6 wks, 12 wks, and 6 mos after intervention, we collected: Numerical Rating Scale to measure pain intensity, Pain Disability Questionnaire, Patient-Reported Outcome Measurement Information System, and EuroQol 5-Dimension (EQ-5D) to measure patient-reported function and quality of life. RESULTS An interim analysis at the halfway point in enrollment (61 of 120 planned participants) revealed the Pain Disability Questionnaire, Patient-Reported Outcome Measurement Information System, and EQ-5D scores in the treatment group to be worse than in the control group, but no significant group differences in Numerical Rating Scale scores. Outcome differences between groups analyzed over time revealed (effect [P]): Pain Disability Questionnaire = 0.84 (0.04); Patient-Reported Outcome Measurement Information System = 0.78 (0.005); EQ-5D = 0.06 (0.01); and Numerical Rating Scale = 0.02 (0.6). We halted the study because continuation was unlikely to produce significant changes to the results. CONCLUSIONS In patients with uncomplicated chronic low back pain, a back brace when combined with education and exercise instruction did not provide any pain relief compared with education and exercise instruction alone. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES Upon completion of this article, the reader should be able to: (1) Describe the effect of lumbar back bracing on pain intensity in patients with chronic low back pain; (2) Discuss the effects of lumbar back bracing on pain-related disability, function, and quality of life in patients with chronic low back pain; and (3) Understand the role of lumbar back bracing in the treatment of patients with chronic low back pain. LEVEL Advanced. ACCREDITATION The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

OBJECTIVE Motor unit number index is a quantitative electrophysiological measure that provides an index of the number of motor neurons supplying a muscle. The aim of this exploratory study was to assess the utility of motor unit number index in the evaluation of patients with lumbar spinal stenosis. DESIGN Participants were assigned to three groups: clinical and radiological lumbar stenosis (lumbar spinal stenosis with neurogenic intermittent claudication), group A; radiological lumbar spinal stenosis without neurogenic intermittent claudication, group B; and a control group, group C. Patients self-rated their pain and functional disability using the numerical rating scale and a series of functional questionnaires. An electromyographer performed nerve conduction tests, electromyography, and motor unit number index testing. RESULTS Seventeen patients completed the study. There were 9, 5, and 3 patients in groups A, B, and C, respectively. There were no discernable differences in motor unit number index values of any individual muscle or combined motor unit number index score between the three groups. Motor unit number index values did not correlate to pain/functional measures. CONCLUSIONS In this exploratory study, motor unit number index did not demonstrate discriminatory ability between patients with lumbar spinal stenosis and was not correlated with pain and functional measures. Further study is needed to explore motor unit number index's role in longitudinal evaluation of patients with the clinical syndrome of lumbar spinal stenosis.

OBJECTIVE The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines. DESIGN Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations. RESULTS All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53). CONCLUSIONS Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.

Objectives While obstructive sleep apnea (OSA) is associated with several chronic health conditions such as hypertension, obesity, and chronic hypoxia, there is limited information on its association with neuromuscular and spinal pathologies that may be of interest to a musculoskeletal (MSK) medicine or pain management clinician. The objective of this study was to perform a systematic literature review to examine the association between OSA and cervical spine pathologies, postural changes, and pain. Design We systematically reviewed PubMed and Embase databases up to 4/15/2019. We included studies that explored associations between OSA and a) pain, b) postural characteristics or changes, or c) cervical spine morphology. Systematic reviews, meta-analysis, randomized control trials, cohort studies, and case–control studies were included. Case reports, narrative reviews or expert opinion papers were excluded. From the articles that met selection criteria, information regarding type, direction and magnitude of such associations was extracted. The OSA-pain association studies were further divided into 3 subgroups: neuropathic, temporomandibular, and chronic pain. Results 21 articles that met our study criteria were selected for this review. Two studies were on cervical spine pathologies, eight on postural changes, and eleven on pain associated with OSA. Exploring the association between OSA and cervical spine pathologies, postural changes, and pain in this systematic review we found: (1) Cervical spine lesions, fusions, and abnormalities that reduce retropharyngeal space are associated with OSA, likely by way of worsening posture and decreasing range of motion. (2) Head extension and anteriorization are associated with OSA likely as a compensatory mechanism. Extension may improve airway function, while anteriorization helps to maintain visual sense. (3) Head-of-bed-elevation may improve OSA symptoms and can possibly supplement other conservative treatment measures. (4) Neuropathic pain is associated with OSA, likely by way of inflammatory pathways. (5) Oral appliance use (eg mandibular advancement/protruding device) in OSA likely contributes to transient temporomandibular pain. (6) There is little association between OSA and chronic pain prevalence. (7) Increased pain intensity and decreased pain tolerance are somewhat associated with OSA, likely by way of hypoxemia and sleep fragmentation. Conclusions Clinicians in MSK and pain medicine need to consider these associations and consider obtaining imaging studies and/or making referrals for management of their OSA to better provide appropriate care to these patients.

Background Chronic low back pain (cLBP) results in significant physical, psycho-social and socioeconomic burden. Identifying efficient and reliable patient reported outcome measures is critical for research and clinical purposes. The NIH’s Patient Reported Outcomes Measurement Information System (PROMIS) instruments have not been compared to validated “legacy” instruments in older adults with cLBP. This study evaluates construct (convergent and discriminant) validity and time to complete (TTC) PROMIS as compared to legacy instruments. Methods We enrolled older Veterans (age 60+) with cLBP with/without leg pain scheduled for lumbar epidural steroid injections. Subjects completed PROMIS computer adaptive test item banks and corresponding legacy instruments in the following domains: pain intensity, interference, and behavior; functional status; depression and anxiety; fatigue; sleep and social functioning. Convergent and discriminant validity between PROMIS and legacy instruments was evaluated using Spearman rank order correlations; Mann-Whitney U tests compared TTC. Results Of the 71 Veterans recruited, the median (IQR) age was 67 (63–71) years old, 94% were men, 76% were White, 17% Black, and 96% were Non-Hispanic. Spearman correlations between PROMIS and legacy instruments showed moderate to very strong convergent validity in all domains (r = 0.4–1.0), except for social functioning and pain behavior (PROMIS Pain Behavior with Fear Avoidance Belief Questionnaire). The total median TTC for all PROMIS items was significantly shorter than legacy items, 8 min 50 s vs 29 min 14 s respectively, p Conclusions Given time efficiency of using PROMIS, along with strong construct validity, PROMIS instruments are a practical choice for measuring multidimensional PROs in older Veterans with cLBP for both research and clinical purposes.

Objective To evaluate the quality of rehabilitation Clinical Practice Guidelines (CPG), specifically with respect to their applicability. Data Sources The Medline, Embase, Web of Science, CINAHL, PsycINFO, and Cochrane Library databases were searched for papers published between 2017 and 2019 that applied the Appraisal of Guidelines for Research & Evaluation II (AGREE II) CPG quality assessment tool to rehabilitation CPGs. Study Selection Deduplicated abstracts (N=449) were independently screened by 2 authors, resulting in 47 articles. Independent screening of 47 full texts by 2 authors resulted in a final selection of 40 papers appraising 544 CPGs. Data Extraction Data were extracted by 1 author using a pretested Excel form and were checked by a second author. Key data on the review papers included: purpose, methods used for finding and appraising CPGs, and observations and conclusions on CPG quality, specifically applicability. Key data on each CPG included the 6 AGREE II domain scores or 23 item scores, as well as 2 global evaluations. Data Synthesis The mean AGREE II domain scores for the 544 CPGs (all on a 0-100 scale) were: scope and purpose (72), stakeholder involvement (53), rigor of development (56), clarity of presentation (71), applicability (34), and editorial independence (50). Only 36% of CPGs were recommended without modification. The 40 review authors generally stated that all or most of the CPGs they appraised were poor or mediocre, especially with respect to applicability. They only infrequently pointed out what information, going beyond that specified in AGREE II, would enhance applicability. Conclusions CPGs in principle are an ideal means to move knowledge obtained from clinical research into practice. Our review of reviews of rehabilitation CPGs shows that they commonly have deficits, especially in terms of applicability. Much work needs to be done by guideline developers to make it easier for the average rehabilitation organization and clinician to implement CPGs in daily practice.

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed.

Background context The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. Study design This is a guideline summary review. Methods This guideline is the product of the Low Back Pain Work Group of NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. Results Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. Conclusions The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – also known as COVID-19 – is primarily known for respiratory illness. While it is clear that patients with moderate to severe cases of COVID-19 will require pulmonary rehabilitation, physiatrists will need to consider effective management plans for COVID-19 survivors with extra-pulmonary involvement. This report will summarize key non-pulmonary considerations to guide rehabilitation clinicians who may be involved in the care of COVID-19 survivors with the best available early evidence.

To appraise the quality of low back pain (LBP) clinical practice guidelines (CPG) that include interventional management recommendations and to associate their quality with characteristics including publication year and creating organization. TYPE: Systematic Review.LBP (subacute or chronic) CPGs in English (symptom based, governmental or professional society created, January 1990-May 2020) were found using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, ECRI, Guidelines International Network, NICE, and SIGN.In this third order systematic review, search results were deduplicated, title and abstract screened by two independent reviewers, and full texts reviewed by four reviewers. Discrepancies were resolved by a third reviewer. Resulted CPGs were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool by four appraisers each. Association of their quality with creating organization, geographical region, and year of creation was calculated.Seven hundred fourteen screened documents resulted in 21 final CPGs. On appraisal, average overall CPG quality was 5.2 (range 2.5-6.75). Domain 5 (applicability) had the lowest average (44%) and domain 4 (clarity of presentation) had the highest average score (82%). For overall recommendation, 16 received "yes" or "yes with modifications," six received unanimous "yes" and two unanimous "no" votes. The interrater agreement of domain scoring was excellent (0.8-1.0; p .001). There was no association found between quality of CPG and (1) year of publication (RThe majority of the 21 CPGs identified in this systematic review were of high quality, but overall quality and recommendation ratings were variable. The quality of appraised CPGs showed no association with their characteristics. Some domains such as "applicability" scored uniformly lower, revealing opportunity for improvement in future CPG development. LBP CPGs should be scrutinized before adopting their recommendations.

Background Epidural steroid injections (ESIs) may be beneficial for lumbar spinal stenosis (LSS) symptoms. Past studies found interferon-gamma, fibronectin-aggrecan complex, and electromyography (EMG) to predict patients' response to ESIs for other spinal pathologies, but no similar studies have been done for LSS. Objective To explore the ability of biomarkers and EMG to help predict outcome after ESI in LSS. Design Prospective observational cohort. Setting The physical medicine & rehabilitation spine clinic at a tertiary care center. Participants Eleven patients with LSS were recruited from the spine clinic at a Veterans Affairs Medical Center. Interventions Participants underwent one interlaminar ESI. Before ESI, the following data were collected: pain intensity on visual analog scale (VAS), disability via the Pain Disability Questionnaire (PDQ) and LSS symptoms via the Swiss Spinal Stenosis Questionnaire (SSSQ), serum high-sensitivity C-reactive protein level, standard diagnostic EMG, assay of epidural lavasate (epidural saline lavage performed immediately prior to ESI) and serum cytokine biomarkers indicative of inflammation. Outcome measures Leg pain intensity (VAS), disability (PDQ), LSS symptoms (SSSQ) and satisfaction (SSSQ satisfaction subscale) were assessed at 1 and 2 months following ESI. Pearson correlational coefficients were calculated between independent variables and outcome measures. Results Serum monocyte chemoattractant protein-1 (MCP-1) level positively correlated with improvement on 2-month satisfaction. Abnormal EMG finding of radiculopathy positively correlated with improvement in PDQ score at 1 month. Epidural cytokine levels were not detectable in most samples, except for scattered marginally elevated levels in a few cytokines such as MCP-1, RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted) and interleukin-1b. Conclusions This exploratory pilot study revealed that some biomarkers and EMG findings indicative of inflammation and nerve root injury may be predictive of improvement following ESI in patients with LSS. The results of this study will be used to inform a fully powered study to further evaluate these relationships in LSS patients.

This study describes the features and utility of a novel augmented reality based telemedicine system with haptics that allows the sense of touch and direct physical examination during a synchronous immersive telemedicine consultation and physical examination. The system employs novel engineering features: (a) a new force enhancement algorithm to improve force rendering and overcoming the “just-noticeable-difference” limitation; (b) an improved force compensation method to reduce the delay in force rendering; (c) use of the “haptic interface point” to reduce disparity between the visual and haptic data; and (d) implementation of efficient algorithms to process, compress, decompress, transmit and render 3-D tele-immersion data. A qualitative pilot study (n=20) evaluated the usability of the system. Users rated the system on a 26-question survey using a seven-point Likert scale, with percent agreement calculated from the total users who agreed with a given statement. Survey questions fell into three main categories: (1) ease and simplicity of use, (2) quality of experience, and (3) comparison to in-person evaluation. Average percent agreements between the telemedicine and in-person evaluation were highest for ease and simplicity of use (86%) and quality of experience (85%), followed by comparison to in-person evaluation (58%). Eighty-nine percent (89%) of respondents expressed satisfaction with the overall quality of experience. Results suggest that the system was effective at conveying audio-visual and touch data in real-time across 20.3 miles, and warrants further development.

OBJECTIVE The aim of the study was to describe the current physiatrist workforce in the United States. DESIGN An online, cross-sectional survey of board-certified physiatrists in 2019 (N = 616 completed, 30.1% response) collected information about demographic and practice characteristics, including age, sex, practice area, practice setting, hours worked, patient characteristics, staffing, and work responsibilities. Physiatrists were stratified by substantive practice patterns using a cluster analysis approach. Survey responses were arrayed across the practice patterns and differences noted. RESULTS The practice patterns identified included musculoskeletal/pain medicine, general/neurological rehabilitation, academic practice, pediatric rehabilitation, orthopedic/complex conditions rehabilitation, and disability/occupational rehabilitation. Many differences were observed across these practice patterns. Notably, primary practice setting and the extent and ways in which other healthcare staff are used in physiatry practices differed across practice patterns. Physiatrists working in musculoskeletal/pain medicine and disability/occupational rehabilitation were least likely to work with nurse practitioners and physician assistants. Physiatrists working in academic practice, general/neurological rehabilitation, and pediatric rehabilitation were most likely to have primary practice settings in hospitals. CONCLUSIONS Physiatry is an evolving medical specialty affected by many of the same trends as other medical specialties. The results of this survey can inform policy discussions and further research on the effects of these trends on physiatrists and physiatry practice in the future.

The use of physical agent modalities dates back to the early days in the development of the field of physical and rehabilitation medicine. The term physiatrist is derived from the Greek words physis, pertaining to physical phenomena, and iatreia, referring to healer or physician. Thus a physiatrist is a physician who uses physical agents to relieve a patient's discomfort. Modalities are physical agents used to produce desired therapeutic effect. They include cold, heat, sound, electromagnetic waves, electricity, and mechanical forces. In this chapter, their physiologic effects, indications, techniques, and precautions are reviewed and discussed. Acupuncture and moxibustion, which use needling and heat to produce therapeutic effect, are also included. Physical agent modalities, although generally considered adjunctive rather than curative treatments, are widely used and important in the daily practices of most physiatrists.

Optimal healthcare quality can be defined as the provision of safe and effective care that improves outcomes, optimizes health, results in higher patient satisfaction, and furthers quality of life. The focus of healthcare worldwide has shifted from the fee-for-services model in which healthcare services rendered were rewarded in terms of volume to an emphasis on the best possible quality, safety, and outcomes as the top priorities. Thus the evaluation, measurement, and reporting of quality and outcomes have become the business of not only every healthcare institution and hospital but also of every individual healthcare provider. Physical medicine and rehabilitation practitioners have become increasingly aware of the importance of measuring healthcare quality and outcomes. This comes from increased scrutiny of healthcare quality, the cost of care, and quality reporting requirements from third-party payers, insurance companies, and reimbursing agencies. However, practicing physiatrists and professional member societies have also been realizing the importance of data on healthcare quality and outcomes. This has driven advancements in and availability of data repositories such as clinical registries. This chapter discusses healthcare quality, evidence-based medicine, clinical practice guidelines, outcome measures, performance measures, practice improvement, patient safety, and accreditation as it applies to healthcare in general and the practice of physical medicine and rehabilitation in particular.

OBJECTIVE The aim of this study was to assess the current and future adequacy of physiatrist supply in the United States. DESIGN A 2019 online survey of board-certified physiatrists (n = 616 completed, 30.1% response) collected information about demographics, practice characteristics, hours worked, and retirement intentions. Microsimulation models projected future physiatrist supply and demand using data from the American Board of Physical Medicine and Rehabilitation, national and state population projections, American Community Survey, Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and other sources. RESULTS Approximately 37% of 8853 active physiatrists indicate that their workload exceeds capacity, 59% indicate that workload is at capacity, and 4% indicate under capacity. These findings suggest a national shortfall of 940 (10.6%) physiatrists in 2017, with substantial geographic variation in supply adequacy. Projected growth in physiatrist supply from 2017 to 2030 approximately equals demand growth (2250 vs. 2390), suggesting that without changes in care delivery, the shortfall of physiatrists will persist, with a 1080 (9.7%) physiatrist shortfall in 2030. CONCLUSION Without an increase in physiatry residency positions, the current national shortfall of physiatrists is projected to persist. Although a projected increase in physiatrists' use of advanced practice providers may help preserve access to comprehensive physiatry care, it is not expected to eliminate the shortfall.

Lumbar spinal stenosis is one of the most commonly diagnosed spinal disorders worldwide and remains a major cause for surgery in older adults. Lumbar spinal stenosis is clinically defined as a progressive degenerative disorder with low back pain and associated neurogenic intermittent claudication. Conservative and surgical management of lumbar spinal stenosis has been shown to be minimally effective on its symptoms. A treatment option that has not been investigated in the United States is the utilization of prostaglandin E1 analogs, which have been used primarily in Japan for the treatment of lumbar spinal stenosis since the 1980s. The vasodilatory and antiplatelet aggregation effects of prostaglandin E1 presumably improve symptoms of lumbar spinal stenosis by increasing blood flow to the spinal nerve roots. This brief report examines the potential vascular pathology of lumbar spinal stenosis, reviews evidence on the use of prostaglandin E1 analog limaprost in Japan for lumbar spinal stenosis, and briefly discusses misoprostol as a possible alternative in the United States. The studies summarized in this report suggest that prostaglandin E1 analogs may provide benefit as a conservative treatment option for patients with lumbar spinal stenosis. However, higher-quality studies conducted in the United States and comparison with other currently used conservative treatments are required before it can be recommended for routine clinical use.

The COVID-19 pandemic has forced a rapid adoption of telemedicine over traditional in-person visits due to social restrictions. While telemedicine improves access and reduces barriers to healthcare access for many, several barriers and challenges remain for persons with disabilities, and novel challenges have been exposed, many of which may persist long-term. The challenges and barriers that need to be systematically addressed include: Infrastructure and access barriers, operational challenges, regulatory barriers, communication barriers and legislative barriers. Persons with disabilities are a vulnerable population and little attention has been placed on their healthcare access during the pandemic. Access and communication during a healthcare encounter are important mediators of outcomes for persons with disabilities. Significant, long-term changes in technological, regulatory, and legislative infrastructure and custom solutions to unique patient and health system needs are required to address these barriers going forward in order to improve healthcare access and outcomes for persons with disabilities.

ObjectiveThis report describes the details of Mr. MAPP, a virtual mirror therapy system and the results of a clinical feasibility and evaluation study of a pilot sample of patients with history of lower limb amputation and phantom limb pain.Materials and MethodsMr. MAPP system uses a Kinect V2 RGB-D camera to capture the patient, generates a live interactive 3D model, and incorporates it into a virtual exergame. Mr. MAPP mirrors their preserved limb and allows participants to visualize their amputated limb virtually and perform their prescribed exercise program. Mr. MAPP creates a digital diary of their therapy sessions by recording game performance and errors. Ten consecutive patients with history of limb loss and phantom pain were targeted for this pilot study. They received a Mr. MAPP system and a laptop for home use for 1-month. Outcome measures including pain intensity and pain interference measured on Numerical Rating Scale (NRS) and McGill Pain Questionnaire (MPQ) as well as functional outcomes measured on Patient Specific Functional Scale (PSFS) were obtained at baseline, and after 1-month.ResultsSeven participants were enrolled, out of which four completed the study. The study was temporarily suspended due to restrictions imposed during the COVID-19 public health emergency. In-game performance data showed a trend towards improvement in most participants. Compared to baseline, NRS and MPQ scores at 1-month showed no clear trends. PSFS scores improved for 1 participant and remained unchanged for others.ConclusionGamified home exercises performed via a novel, mixed-reality system—Mr. MAPP— using which virtual mirror therapy was delivered, is feasible and has potential to improve pain and pain related function in patients with lower limb amputations and phantom limb pain.

The purpose of the ongoing trial is to improve care of older Veterans with chronic low back pain (CLBP, i.e., low back pain for ≥6 months on ≥ half the days). Current CLBP care is limited by being either overly spine-focused or non-specifically prescribed and both approaches frequently lead to suboptimal reduction in pain and improvement in function. Through prior studies we have laid the foundation for a patient-centered approach to care for older Veterans with CLBP in which the spine is a source of vulnerability but not the sole treatment target. The approach considers CLBP a geriatric syndrome, a final common pathway for the expression of multiple contributors rather than a disease of the spine. We describe here the rationale and design of a randomized controlled trial to test the efficacy of an older Veteran-centered approach to CLBP care in “Aging Back Clinics (ABCs)” compared with Usual Care (UC). Three hundred thirty Veterans age 65–89 with CLBP will be randomized to ABCs or UC and followed for 12 months after randomization. We will assess the impact of ABCs on our primary outcome of pain-associated disability with the Oswestry Disability Index at 6 and 12 months, and secondary outcomes of pain intensity, health-related quality of life, balance confidence, mobility and healthcare utilization. If shown efficacious, the approach tested in ABCs has the potential to transform the care of older adults with CLBP by improving the quality of life for millions, reducing morbidity and saving substantial healthcare costs.

OBJECTIVE The aim of the study was to compare hyaluronate with triamcinolone injections in treating chronic low back pain suggestive of lumbar zygopophyseal joint arthropathy. DESIGN This was a prospective, double-blind, randomized controlled trial. Thirty subjects were randomly assigned to receive bilateral L3-S1 lumbar zygopophyseal joint injections with triamcinolone (KA) or Synvisc-One (HA). Pain (visual analog scale) and Pain Disability Questionnaire scores at 1, 3, and 6 mos were evaluated. RESULTS No significant intergroup differences (P > 0.05) in outcomes were noted in the 30 recruited subjects. For KA/HA (baseline; 1 mo; 3 mos; 6 mos), visual analog scale scores were the following: 70 (15)/74 (10); 58 (29)/45 (25); 58 (29)/56 (25); and 59 (28)/63 (24), respectively. Pain Disability Questionnaire scores were the following: 100 (23)/102 (28); 77 (30)/74 (34); 87 (26)/74 (36); and 96 (25)/79 (25). Overall percent improvement at 6 mos for KA was 51 (35) and for HA was 42 (33) (P = 0.51). Synvisc-One group visual analog scale scores improved significantly (70 [20]-45 [25] at 1 mo, P = 0.008). Pain Disability Questionnaire scores improved at 1 mo (100 [23]-77 [30], P = 0.009) in the KA group and at all time points in the HA group (102 [28]-74 [34] at 1 mo, P = 0.002; 74 [36] at 3 mos, P = 0.037; 79 at 6 mos [median = 52-99.5], P < 0.001). Medians and quartiles were used in statistical analysis when data did not pass normality. CONCLUSIONS Patients with chronic low back pain suggestive of lumbar lumbar zygopophyseal joint arthropathy responded similarly to triamcinolone or hyaluronate injections. Synvisc-One group showed significant short- and long-term functional improvement and short-term pain improvement; KA group showed only significant short-term functional benefit and no significant short- or long-term pain improvement.

The purpose of this study is to summarize published literature on health-care quality, and value-based principles in musculoskeletal (MSK) medicine as it relates to physical medicine & rehabilitation (PM&R) practitioners. This review specifically focuses on spine care as a case example. Related policy and practice issues and future research needs will also be discussed. Results of a recent study on the effects of required PM&R consultation prior to surgical evaluation for low back pain management contradicted the conclusions of a previous landmark study on a similar topic. Physiatrists involved in musculoskeletal care need to be aware of the shift in focus from volume of care to value-based care. Clinical registries and practice guidelines are increasingly available, practical to use, and should be utilized to improve quality of care provided to patients with MSK disorders. Continuous improvements in quality of care provided and cost savings will drive upward the value of MSK care delivered. Future research in MSK care outcomes needs to evaluate not only effectiveness and efficacy but also cost and value.

Hylan G-F 20 (Synvisc-One) is a hyaluronic acid derivative used for viscosupplementation of synovial fluid in osteoarthritic joints. Injection of hylan G-F 20 is Federal Drug Administration approved for use in knee osteoarthritis and is generally well tolerated with few reported adverse effects, the most common being local pain or swelling. We present the case of a 72-year-old man with bilateral, diffuse, joint pain and swelling with elevated inflammatory markers suggestive of a systemic inflammatory polyarthropathy that developed acutely 2 days after lumbar zygapophyseal joint injection with hylan G-F 20. Systemic effects after hylan G-F 20 injection have not been well documented, and this is the first reported case of systemic inflammatory polyarthritis after injection, to our knowledge. Further research is needed to better establish the safety and efficacy of lumbar zygapophyseal joint injections with hylan G-F 20.

Phantom pain is a chronic pain that is experienced as a vivid sensation stemming from the missing limb. From traditional mirror box to virtual reality-based approaches, a wide spectrum of treatments using mimic feedback of the amputated limb have been developed for alleviating phantom limb pain. In our previous work, Mixed reality-based framework for MAnaging Phantom Pain (Mr.MAPP) was presented and used to generate a virtual phantom upper limb, in real time, to manage the phantom pain. However, amputation of the lower limb is more common than that of the upper limb. Hence, in this paper, on top of demonstrating the reproducibility of the Mr.MAPP framework for upper limb, we extend it to manage lower limb phantom pain as well. Unlike an upper limb amputee, a patient with lower limb amputated is constrained to perform the training procedure in a sitting posture. Accordingly, virtual training games are designed for lower limb exercises with sitting posture such as knee flexion and extension, ankle dorsiflexion and tandem coordinated movement. Finally, the technical details of the system setup for playing the training games are introduced.

Background Minimal longitudinal data exist regarding the role of lumbar musculature in predicting back pain and function. In cross-sectional study designs, there is often atrophy of the segmental multifidus muscle in subjects with low back pain compared with matched controls. However, the cross-sectional design of these studies prevents drawing conclusions regarding whether lumbar muscle characteristics predict or modify future back pain or function. Objective The primary objective of this study is to determine whether the cross-sectional area (CSA) of lumbar muscles predict functional status or back pain at 6- or 12-month follow-up in older adults with spinal degeneration. The secondary objective is to evaluate whether these muscle characteristics improve outcome prediction above and beyond the prognostic information conferred by demographic and psychosocial variables. Design Secondary analysis of a randomized controlled trial. Participants A total of 209 adults aged 50 years and older with clinical and radiographic spinal stenosis from the Lumbar Epidural steroid injection for Spinal Stenosis (LESS) trial. Methods Using baseline magnetic resonance images, we calculated CSAs of the lumbar multifidus, psoas, and quadratus lumborum muscles using a standardized protocol by manually tracing the borders of each of the muscles. The relationship between lumbar muscle CSAs and baseline measures was assessed with Pearson or Spearman correlation coefficients. The relationship between lumbar muscle characteristics and 6- and 12-month Roland Morris Disability Questionnaire (RDQ) and back pain Numeric Rating Scale (NRS) responses was further evaluated with multivariate linear regression. A hierarchical approach to the regression was performed: a basic model with factors of conceptual importance including age, gender, BMI, and baseline RDQ score formed the first step. The second and third steps evaluated whether psychosocial variables or muscle measures conferred additional prognostic information to the basic model. Main Outcome Measures Function as measured by the RDQ and back pain as measured by the NRS at 6- and 12-month follow-up. Results Lumbar muscle CSA was not a significant predictor of 6- or 12-month RDQ or pain score in multivariate analyses. Conclusions Cross-sectional areas of lumbar muscles do not predict function or pain at medium- and long-term follow-up in adults with lumbar spinal stenosis. Level of Evidence III

A 62-year-old female nursing supervisor with a history of diabetes mellitus (hemoglobin A1C score: 7.8) presents to your office with a 5þ-year history of right knee pain. She does not report any traumatic events or injuries and states that her right knee is progressively getting more painful with walking and especially when descending stairs. She has participated in both land-based and aquatic therapy in the past with limited improvement. She also reports that she received an ultrasound-guided intra-articular corticosteroid injection 8 weeks ago with tremendous improvement in her pain and function, but now the pain has returned. Examination reveals that she is obese, with a body mass index (BMI) of 34.5, and that she has moderate tenderness over the medial and lateral right knee joint lines. Her range of motion is normal with minimal swelling around the knee joint. Her right knee radiograph reveals Kellgren-Lawrence grade 3 osteoarthritis (OA). She has recently read the guidelines for treating knee OA put forth by the American Academy of Orthopaedic Surgeons (AAOS), in which viscosupplementation is no longer recommended. However, she has many family members and friends who received “Synvisc” in the past and experienced significant improvement in pain and function, and she would like to try this treatment option. Drs Thiru Annaswamy and Erika Gosai will argue that, despite the new AAOS guidelines, viscosupplementation should be offered to the patient to treat the symptoms caused by knee degenerative joint disease. Dr David Jevsevar will argue that there is very little evidence that viscosupplementation is effective for knee OA and that either alternative conservative treatments or surgery should be recommended.

Study Design. Secondary analysis of data from a double-blind randomized controlled trial. Objective. To identify mediators of the effect of lumbar epidural injections of corticosteroid plus lidocaine on patient satisfaction at 6 weeks postinjection in patients with lumbar spinal stenosis. We hypothesized that short-term (≤3 wk) change in leg pain would be a significant mediator of satisfaction. Summary of Background Data. No prior studies have identified mediators of effects of epidural injections on patient satisfaction with treatment of lumbar spinal stenosis. Methods. We used mediation analysis methods to examine selected intermediate variables (adverse events and change in leg pain, back pain, disability, depression, and fatigue at 3 wk) as potential mediators of the effect of lumbar epidural injections of corticosteroid plus lidocaine on patient satisfaction with treatment. We used the overall satisfaction item from the Swiss Spinal Stenosis Questionnaire as our primary outcome to measure patient satisfaction with the injection procedure at 6 weeks. Results. Among 400 patients randomized to receive epidural injections with corticosteroid plus lidocaine or with lidocaine alone, 369 had complete data for the satisfaction outcome and potential mediators and served as the analysis sample. Contrary to our expectations, 3-week change in leg pain intensity did not have significant mediation effects on patient satisfaction. Three-week change in disability as measured by the Roland-Morris Disability Questionnaire was a significant mediator of the effects of lumbar epidural corticosteroid injections on patient satisfaction at 6 weeks, explaining 48% to 60% of the treatment effect on satisfaction. Changes in pain intensity in the leg and back together explained very little of the treatment effect on satisfaction beyond the information contributed by disability change alone. We did not find other intermediate variables to be mediators of patient satisfaction. Conclusion. These findings support the current approach of examining disability as a primary patient-reported outcome in comparative effectiveness studies of lumbar spinal stenosis. Conclusion. Level of Evidence: 2