Good morning, and thank you for joining us for the research spotlight in pain. Where do you want it in there. So I find medicine. So I'm going to introduce our a little a couple of housekeeping discussions. I just want to make sure everybody remembers that this session is being recorded to mute your microphones, that there will be a written Q&A on the chat option with this platform, and that we're going to try to keep the chats or the questions until the end, given the limited amount of time. And most importantly, we're here to support you and that we, on behalf of the Evidence of Research Committee at the AAPMNR, we're very happy that you're involved. We encourage your ongoing interest in research and advancing the science of AAPMNR. So I want to introduce our first presenter. Evan Berlin is a PGY-4 resident at Vanderbilt. He is also presenting three other posters this year. Kudos to him. He has interest in spine and sports medicine, but he's open to other fields. So please join us in hearing his presentation. Yes, thank you for that introduction. So my name is Evan Berlin. I'm a fourth year resident of physical medicine and rehabilitation at Vanderbilt University Medical Center. And today I will be presenting our research on the development of a cadaver lab curriculum for interventional spine procedures for AAPMNR residents. So there's a growing trend for AAPMNR residents to pursue fellowships. In 2020, 74% of graduating AAPMNR residents were accepted into fellowship. And of those, 80% matched into either pain, interventional spine, or sports medicine fellowship. In a recent survey of the pain, spine, and sports medicine fellowship directors, half of the directors rated incoming AAPMNR trained fellows as being below average in the knowledge of and ability to perform interventional spine procedures at the start of their fellowship. Current ACGME guidelines require AAPMNR residents to observe or perform at least 10 interventional spine procedures during residency. However, presently there is no standardized recommended curriculum. The most common mediums for procedural training outside of direct clinical interactions have been reported to be lectures and workshops, with only 24% of residency programs offering hands-on cadaver-based training. To our knowledge, the role of a cadaver lab in teaching residents needle skills for interventional spine procedures has not yet been well established. So the objective of this protocol was to evaluate the utility of a cadaver-based interventional spine curriculum to enhance AAPMNR residents' confidence in their ability to maneuver the C-arm, identify spine anatomy under fluoroscopy, and also their ability to drive the needle. So this course required access to a single cadaver. We recommended a fresh, frozen cadaver, as it most accurately mimics live human tissue, and also required a mobile C-arm, spinal needles, lead jackets, thyroid shields, and glasses for each participant. The course was completed in groups of two to three, while under the direct supervision and instruction of a fellowship-trained attending or an experienced fellow. In this protocol, we focused on the lumbar spine, as this is a spine segment that is most often intervened on. However, this could easily be applied to any other spinal segment. The participants were provided figures A1 through C that you can see on the poster to help identify the critical spinal elements for interventional procedures. To get accustomed to the C-arm, the participants first familiarized themselves with the terminology of its movements, which was provided to the participants in a form of a table, which included cephalad-caudal tilt, oblique, lateral, piston, translation, up and down, and my personal favorite, the wigwag. The participants were demonstrated how these traditional movements can be combined to optimize the image. They were also provided the Interventional Spine Procedures Checklist as a guide while in the cadaver lab, and on the e-poster you can see an example of this checklist for the lumbar medial branch blocks. They were then instructed to follow the SIS guidelines for procedures, and visual aid books such as the Atlas of Image-Guided Spinal Procedures by Dr. Michael Furman were recommended for the trainees. After the cadaver lab sessions, the participants were asked to take a short evaluation regarding their confidence and their ability to maneuver the C-arm, identify spine anatomy under fluoroscopy, and their ability to drive the needle before and after participating in this protocol. Confidence were assessed using a 10-point Likert scale ranging from 0 to 10, with higher schoolers representing more confidence. Similarly, perception of the benefit of the course was assessed using the same 10-point Likert scale. Pre- and post-course confidence scores were compared with Wilcoxon Ranked Sign Test. So a total of 12 residents participated in our protocol, four from each post-grad year. All 12 residents completed the post-course survey, and the pre- and post-course confidence levels using the 10-point Likert scale are presented in Table 2 on the e-poster. Confidence in maneuvering the C-arm increased an average of 5.4 points, and confidence in the ability to identify spine anatomy under fluoroscopy increased an average of 3.8 points, and confidence in the ability to drive the needle increased an average of 4.3 points. All were found to be statistically significant with a p-value of less than 0.005. And lastly, when asked how beneficial the cadaver lab was for education and training, residents rated the experience at a mean of 9.1 out of 10. So educational tools for providing instruction regarding interventional spine procedures can vary widely, including textbooks, educational videos, lectures, observations, live clinical participation, spine models, cadaver-based training, and each of these training methods have various benefits and drawbacks, with the most lacking the kinesthetic learning provided by hands-on experience. Moreover, it's important to highlight the potential risk involved with training participation and interventional spine procedures on quote-unquote actual patients, and potential risks associated with interventional spine procedures include bleeding, spinal cord or nerve damage, infection, intravascular uptake, pain exacerbation, and injection site soreness. We believe that the cadaver lab is a safe and underutilized environment, which allows for mistakes to be made and thus opportunities to learn. And while not meant to be all-encompassing nor a replacement for required ACGME training, residency programs could consider using our model to allow trainees a regimented experience upon which to develop the fundamentals of these procedures prior to clinical participation. I want to give a special thanks to my co-authors, Dr. Samer Khan and Christian Romer, both PGY3s at Vandy, Dr. Sherwood, a prior NASS ISMM fellow at Vandy, and then of course Dr. Yang, whose desire and passion to train the next generation of physiatrists made this all possible. Thank you guys for your time and consideration. Thank you, Dr. Berlin. Very important for our PM&R trainees, especially those going into interventional subspecialties. So now we're going to move on to Dr., actually student Dr. Arman Jahangiri. I apologize if I messed up the name. He's a medical student at Western University Health Sciences College of Osteopathic Medicine in the Pacific. He hopes to specialize in PM&R, perhaps dermatology, emphasis on sports medicine. He has interest in PM&R, dermatology, exercise science, pain, diversity in medicine and LGBTQ health. So student Dr. Jahangiri, please, please go ahead. Thank you so much for that warm introduction. I'm delighted on behalf of my fellow co-authors, as well as Western University College of Osteopathic Medicine of the Pacific Northwest, as well as Providence Brain and Spine Institute to be presenting our research today. Again, the title of our study is the efficacy of low-dose naltrexone as a therapeutic alternative for fibromyalgia, chronic pain syndrome and multiple sclerosis. And this was a retrospective chart review. So to kind of introduce our research with the ongoing opiate epidemic, there is a crucial need for a safer pharmaceutical alternative for the treatment of chronic inflammatory pain. One such alternative is known as naltrexone, which historically has been used for opioid antagonism as well as alcohol dependence. However, when prescribed in one to five milligrams, it is known as low-dose naltrexone, which has been used as an off-label form of treatment for chronic inflammatory pain. It is postulated that it does this by reducing glial inflammatory cell responses and works paradoxically as a weak agonist on opioid cell receptors, ultimately creating a sense of analgesia for patients. Although prior studies have demonstrated that low-dose naltrexone is safe and well-tolerated amongst these conditions listed above, the quality of evidence is still very insufficient to conclude in a clinical setting that it's efficacious for analgesia or to improve patient quality of life symptoms. Further, in a clinical setting, there's still insufficient evidence to determine the appropriate duration or dose response relationships for low-dose naltrexone with these patients as well. Therefore, the first aim of our study was to identify if low-dose naltrexone, if the dosage and duration was different between fibromyalgia, chronic pain syndrome and multiple sclerosis patients, and two, to determine between these patients if there was a reported improvement in quality of life and or patient reported pain alleviation. Moving on to my methodology, patients with a low-dose naltrexone prescription between January 2010 and April 2020 were randomly selected to be retrospectively abstracted using electronic health records. Our inclusion criteria included if they were 18 years or older, prescribed naltrexone hydrochloride powder capsules between one to five milligrams, and had a primary diagnosis of either fibromyalgia, chronic pain syndrome, or multiple sclerosis, and a concurrent diagnosis of chronic pain. Our exclusion criteria is listed below if you'd like more information. Regarding primary outcomes captured, we looked at duration in months and dose in milligrams per day across these primary disease diagnoses, and these were compared using median tests. Data from the date of first and final encounter while on LDN prescription were used to assess dose and duration. For secondary outcomes captured, we looked at patient quality of life changes for energy, sleep, bowel movement, balance, and mood. We also looked at patient reported pain perception subjectively looking at either better or no improvement, meaning worsening or no change. Furthermore, we also looked at if there was a concurrent opioid prescription documented at either the first or last encounter while on LDN therapy. Moving over to my results, among the 100 medical records with a documented low-dose naltrexone prescription and a primary diagnosis of fibromyalgia, chronic pain syndrome, or multiple sclerosis were reviewed, 45 patients met our inclusion criteria with 15 patients in each disease state. In Table 1 below, you can see some of the patient characteristics we found through our analyses. Regarding dosage and duration, median start doses were significantly different across groups, with multiple sclerosis and fibromyalgia patients having the overall highest start dose captured of 4.5 milligrams compared to chronic pain syndrome, which was 3 milligrams. No significant differences were found among the last documented low-dose naltrexone dose. Furthermore, differences in median duration were found with multiple sclerosis patients having the longest duration on doses less than 4.5 milligrams. Multiple sclerosis patients were also on the overall highest dose captured, 4.5 milligrams again, the longest. And this is illustrated to the top right in Figure 1, with yellow representing duration for doses less than 4.5 milligrams and blue representing duration for doses equal or greater than 4.5 milligrams. 20 of the 45 patients were started on LDM to improve pain while concurrently taking opioids. However, at the final encounter, 9 of the 20 patients in all groups were still taking a concurrent opioid for pain. This is illustrated below in Figure 2, with blue representing concurrent opioid usage at the start of LDM therapy and orange representing concurrent opioid usage at the final encounter. Regarding pain, patient reported pain, a majority of fibromyalgia patients reported pain was better at the final encounter, while more multiple sclerosis patients and chronic pain syndrome patients reported no improvement in pain. And this is illustrated below in Figure 3, with orange representing no improvement in pain and light green representing improvements in pain. Regarding quality of life, we ultimately captured 13 patients for these values. Six patients reported energy improvement, three reported sleep improvement, and four reported mood improvement. To wrap up my study and to conclude my results, multiple sclerosis patients were prescribed higher start doses compared to other groups and were also on LDM therapy the longest when comparing duration between groups. Regarding pain alleviation, although 16 of the 37 reported pain alleviation by the final encounter, more fibromyalgia patients reported improvements in pain than most of any group. Interestingly, each group had patients that ceased opioid therapy by the last encounter. Finally, looking to the future, larger separate clinical trial setting dosage and duration for each disease state are needed to really determine what the appropriate recommendations are for each group. Clinical studies should also compare different routes of administration for low-dose naltrexone to avoid first-pass metabolism mechanisms. Hopefully, future studies can also utilize more objective or standardized ways of measuring quality of life or pain-level changes when comparing low-dose naltrexone between groups when looking retrospectively. Lastly, I would like to add, in a world where not many FDA-approved options exist for chronic pain, and current recommendations may be too costly or dangerous for patients over time, low-dose naltrexone may eventually prove to be an effective alternative for chronic inflammatory pain. Thank you so much for listening to my presentation. I look forward to questions at the end of the seminar. Armand, thank you. I think what you just said about having limited options for a cohort of these pain patients is really essential. I look forward to having questions. Okay, moving on. Alyssa Mixon and her collaborator, Michael Carter, are going to present. Alyssa is an assistant professor of PM&R at the UVA Health System. She has a clinical practice on lymphedema, general PM&R, and has research interests in cancer, racial disparities, radiation-induced lumbosacral plexopathy. And she will be presenting with Michael Carter, who is a second-year medical student at Drexel. So, welcome. Good afternoon, everybody, and thank you, AAPM&R, for having us. Today, we will be presenting on racial differences in the surgical care of Medicare beneficiaries among women diagnosed with spinal metastatic breast cancer. So, breast cancer was the most common cancer diagnosed in 2020. Current estimates predict that approximately one in eight women will be diagnosed with breast cancer at some point in their lives, 6% of whom will have metastatic disease. Mortality rates for breast cancer are largely determined by the stage of cancer at the time of diagnosis. Racial disparities associated with the proper diagnosis and treatment of breast cancer have been well-documented in prior studies. Black women have significantly higher mortality rates from breast cancer when compared with non-Hispanic white women. This is because Black women tend to be diagnosed at a later cancer stage with higher-grade tumors. However, even when differences in tumor grade and stage of diagnosis are controlled for, mortality rates are still higher among Black women than among white women. This is particularly true among women diagnosed with cancer that has metastasized to the spine. Though recent studies have found increasingly favorable prognosis for patients undergoing surgery for metastatic breast cancer to the spine, Black women undergo surgical intervention at a significantly lower rate than non-Hispanic white women with the same cancer diagnosis and stage. This specific study sought to compare outcomes for Black women and non-Hispanic white women undergoing surgery specifically for spinal metastatic breast cancer. To do this, we utilized a retrospective cross-sectional analysis with data from the Surveillance Epidemiology and End Results, or SEER, for medical patients. Inclusion criteria involved female patients aged 18 years and above with breast cancer metastatic to the spine registered from 2007 to 2016. Only patients who identified as either Black or non-Hispanic white were used so that we could focus on the relationship between these two races. Outcomes of interest included time from diagnosis until the surgical intervention, complications associated with the surgery, and long-term outcomes, including hospital length of stay, hospital readmission rates, and mortality. Frailty scores were assessed based on function-related indicators such as mobility, pneumonia, respiratory failure, and oxygen use, which were all coded as binary variables. The Cox proportional hazards regression model was used to evaluate the impact of race on mortality. Generalized linear models with a binomial distribution were used to evaluate the impact of race in the process of care and complications. All models were adjusted for age at diagnosis, tumor grade, and patient frailty. Our final sample included 1,072 patients with a mean age of 63.6 years. 158 of these patients identified as Black and 914 were non-Hispanic white. When compared with non-Hispanic white patients, Black patients had a longer length of stay at the hospital, increased hospital readmission rates within 30 days, increased emergency department visits within 90 days, increased infections, increased respiratory, cardiac, neurological, renal, and vascular complications, and higher frailty scores. And now I will be turning it over to Dr. Mixon to further discuss the findings of this study. Thank you, Michael. There were no significant differences in surgical intervention rate for spinal metastases within the first year of diagnosis or in cancer-specific and all-cause mortality. So a majority of our findings are consistent with prior research that compared patients of different races undergoing spine surgeries. This and other studies suggest Black female patients are at higher risk for increased hospital length of stay and that they have more post-operative complications. The 30-day readmission rates are also significantly higher in the Black female patient population. Although Black female patients had worse post-operative outcomes compared to their non-Hispanic white counterparts, Black patients benefited from surgical intervention. Further research is necessary to determine the underlying etiology of these results, which are likely related to social determinants of health as described in the literature. The pre-operative risk stratification process for Black patients should not be any different than those who are non-Hispanic white. This is the largest study to our knowledge that evaluates racial disparities between Black and non-Hispanic white women with breast cancer and spinal metastases undergoing spine surgery. In conclusion, Black women undergoing spine surgery for metastatic breast cancer have a higher risk of post-operative complications, longer length of stay, higher readmission rates, and more post-operative emergency department visits. Continued efforts to address and overcome these disparities are necessary. Future studies should consist of identifying and addressing confounding factors to overcome these disparities. I'd like to thank my colleagues, Michael Carter, as well as William Hoffman, my mentor, Dr. Jasmine Zhang, who has been wonderful in helping mentor me for my role as a cancer rehabilitation physician, and our leader, Dr. Kamran Saifi. Thank you, Dr. Mixon. Thank you, Michael. It's an important preventive and public health issue that you brought up, and I'd love to discuss more. So, moving along. Our last presenter is Alexandra Fogarty. She's a fourth-year PGY chief resident PM&R at Washington University. She has interests in pursuing pain medicine and non-surgical sports and spine. She has a research interest in MSK and spinal disorders, cannabinoids, and chronic pain. And she will give us a wonderful presentation, and welcome. Thank you so much for that introduction. As you said, my name is Alex. I'm a PGY4 resident at Washington University. If we could go to the first slide, that would be great. I'm going to be talking today about a systematic review that I did under the mentorship of Dr. McCormick and Dr. Conger at the University of Utah. And really, the purpose of our systematic review was to look at the published literature on the effectiveness of genicular nerve radiofrequency ablation for the treatment of chronic knee pain for people with osteoarthritis. And we were interested in looking at both pain and functional outcomes at assessments greater than six months. At the time, published data only showed us outcomes to the point of three months. So we thought it was important to help both providers and patients be aware of options that might exist in the pain medicine field to provide more longstanding pain relief. So in terms of our methods, we looked at studies that looked at patients who are older than 18 years of age and who had knee pain in the setting of osteoarthritis as quantified on a validated scale, such as the Kellgren-Lawrence scale. And we were looking at really any type of radiofrequency technology, whether that was cooled RF, whether that was conventional, but we did exclude studies of pulsed RF treatment. In terms of image guidance, studies that were included had to be fluoroscopic guided. Unfortunately, we did exclude ultrasound-guided procedures because at the time there was not as much data published on the effectiveness of that imaging modality for a genicular RF. In terms of comparators, we included pretty much anything. So sham, placebo, active treatment, or none. And because we had included no comparators as a possibility, that meant that we also allowed for observational studies to be included in our analysis, but we did make the decision to exclude any retrospective studies. In terms of our primary outcome, we looked at pain reduction at six months using validated self-reporting rating scales. So for us, that really meant the numeric rating scale or the visual analog scale. And in terms of secondary outcomes, two of note would be the disability and functional assessment as per the WOMAC as well as the Oxford NEIS score. Next slide, please. Thanks. So in terms of our results, as you can see on the left here with our PRISMA flow diagram, I apologize, I know it's a little bit small. We looked at approximately 250 articles as a result of our Medline database search. And after applying our inclusion-exclusion criteria and doing full-text searches of the articles that were relevant, we were left with only nine studies. Of those nine studies, five were randomized control trials, three were observational studies, and one was a case series. On the figure on the right, you can see an example of our evidence table, which sort of goes through the authors, the study designs, as well as the populations, block paradigms, and target nerves, as well as further details about the interventions that were utilized. I will defer to you to look at the full paper for the results of the nine studies, but this just gives you an example as to what some of the data were that we extracted. In terms of the technologies for RF that were included in some of these studies, we saw papers highlighting cooled RFA technology, conventional, monopolar, and bipolar. And in terms of the comparators, was pretty heterogeneous. We had some studies looking at intraarticular steroid injections compared to RFA, hyaluronic acid compared to RFA, as well as medical management compared to RFA. However, most studies did utilize the Kellgren-Lawrence scale, and patients were deemed to have clinically apparent osteoarthritis if they had disease graded as two to four. And for the most part, all studies also targeted the same genicular nerves that we typically use in clinical practice, which are listed there, the superior medial, inferior medial, and superior lateral genicular nerves. So in terms of our results, so the six month success rates for greater than 50% pain relief after RFA ranged from 49 to 74%. And when compared to intraarticular steroid injections, the probability of success was four and a half times higher for RFA compared to intraarticular steroid injection. And when RF was compared to hyaluronic acid injections, the probability of treatment success was 1.8 times higher. In terms of the OKS and the WOMAC, the scores also improved in participants who were receiving genicular RFA as compared to both intraarticular steroid injections and hyaluronic acid injections. Next slide, please. In terms of the limitations to this analysis, I just wanted to spend a minute talking about this. Certainly, I think all systematic reviews are plagued by heterogeneity, but particular to our study, we did see quite a few differences in RFA methodology, which could really limit the interpretation of the findings. So for one, the volume of injectate that was used for the diagnostic blocks was really variable across the individual studies. And studies using cadavers have shown us that if you inject a higher volume than your probability of anesthetizing, a wider range of nerves increases and the specificity decreases. So that's one consideration. And we also did include different types of RFA technology. There was different electrode sizes and different lesioning time. And this will ultimately affect the diameter of the lesion size, which is also decreasing the probability that each individual study is actually looking at the exact same sensory nerves. And in terms of the selection of the sensory nerves themselves, certainly a lot of authors have done investigational studies in cadaver models and suggesting really that there is alternative nerves that should be targeted in the future or maybe even five nerves that should be targeted. So further research is definitely needed to make sure that we're achieving really the maximal therapeutic benefit by targeting the most appropriate sensory nerves. So in conclusion, using the GRADE analysis, our study was able to tell us that there is moderate quality evidence to support consistent improvement in pain and function in patients with chronic knee pain secondary to osteoarthritis who were treated with genicular nerve RFA. However, in the future, certainly further investigations are warranted both in the cadaver lab setting, in addition to higher quality randomized control studies are needed really to help move this field forward. Thank you very much. Alexander, thank you. That was excellent. And thank you all to the presenters for being so timely. That gives us an extra opportunity for questions. And for anybody in the audience who might be listening and watching, please remember that there is a chat option. So if you have any questions that you'd like for me to relay to the presenters, please let me know. I have some questions and we're gonna go out of order and just to make sure that it's all equal and opportunity. So Arman, excellent presentation on use of naltrexone for a chronic pain population, fibromyalgia, chronic pain syndrome, MS. Is there any generalizability of those results to other chronic pain conditions? Yeah, so we essentially selected, I guess these three inflammatory diseases just because that's what most of the literature has looked at. This is actually what most of our database where we pulled most of this data was from. Like a majority of the patients were either chronic pain, fibromyalgia or multiple sclerosis. A lot of the research has also looked at Crohn's disease as well as inflammatory bowel syndrome as other treatments for, or I guess treatment with low-dose naltrexone for therapy. It seems like most of the research have been pushed towards fibromyalgia and it seems to provide the most pain relief with fibromyalgia compared to the other disease states. It's currently being looked at for, I guess, immunomodulation for multiple sclerosis in particular. But again, in terms of the general generalizability, it's really focusing on fibromyalgia out of all those other mentioned disease states from what I've seen in the literature and what we've also just studied. Any thoughts on use in nociceptive versus neuropathic pain or mixed patterns? That I'm not quite sure. I would say it's mostly looking at just because of how it works as a paradoxical weak agonist for opioid receptors, where it's not quite postulated for what it could look like for nociceptive receptors or again, other types of nerve fibers as well. Good point. My final question is, did you look at any patient satisfaction with use of naltrexone? And if not, can you extrapolate on how the use of this medication, this cohort would have been experienced by these patients? Yeah, so essentially, the biggest issue with our study is again, and actually prior studies with naltrexone is that most of these clinical trials have very low sample sizes, as well as our study didn't have a huge sample size. And we're looking at quality of life, that's kind of what we used as our measure of how patients were satisfied with not just pain, but if it was improving their quality of life in general, with either mood, energy improvement, sleep, et cetera, that's kind of what we used as our measure. In the future, I would say, if there is gonna be a retrospective study to really find a more standardized way of measuring these values, as that was kind of the biggest issue when looking retrospectively as providers weren't always being consistent when documenting, were patients satisfied with the treatment from the beginning towards the end? So it was kind of difficult to really create a statement that says these patients were satisfied with LDN from our study itself. So that's something to kind of look about in the future. Again, hopefully using a larger sample size as well. Excellent, and I thank you for bringing up the multidimensional issues with pain and chronic pain. So I think that's important for the audience to remember. Okay, so Michael and Dr. Mixon, terrific presentation. I'm wondering if you have any specific thoughts on preventive health strategies, which may include education, to really reduce higher risks in this population of black women undergoing surgery. So I think that's a great question. And it's also something that we're looking at at UVA in terms of helping even with preventative health from complications related to other cancer interventions, such as axillary lymph node dissections causing lymphedema. So certainly educating the patients beforehand, but also I think it even starts just from the primary care physician's perspective and even a general physiatrist, if possible, when they see patients, if they can recognize if they're at risk or haven't had their appropriate screening, like mammography screening, to emphasize the importance of that, especially in the black population. Good point. Can you draw any corollary with some of the hesitancy with this specific population in getting the COVID vaccination? I mean, I think overall, so I don't know if I have the actual evidence to support what I've seen, but I think like objectively, but I think subjectively, a lot of it could be access to healthcare and coverage. I know there, even where I am at University of Virginia, there's a lot of financial barriers for, especially for this population. And I think that plays into a lot of their healthcare limitations and what we're seeing in terms of these racial disparities. Great point. Michael, do you have anything else to add that might? Yeah, I think to go off of Dr. Mixon's answer, I think that in many black communities, there is an overall distrust in the medical community at large, doctors, physicians, healthcare, just based on prior history of mistreatment of black women, men, children. And so I think it's a matter of overcoming those barriers, reestablishing trust between providers and also between members of those communities. And I think that in many ways, this COVID vaccine is just a manifestation of that in the modern day that I think that people may be okay potentially with getting this vaccine, but not for the fact that this is coming from healthcare setting that has largely mistreated this population in the past. Thank you. One other question for either of you, are there any other specific cancer diagnoses where you think access in particular plays a role in determinants of function or recovery? Yes, so I mean, I think several, several cancer diagnoses for sure, but certainly what I've seen here at University of Virginia and previously at the University of Pennsylvania would be the head and neck cancer population. And one of the areas that I focus on is lymphedema. And so, especially with the pandemic, patients were unable to have access to seeing a lymphedema therapist. And so the preventative measures that we normally take in terms of manual lymphatic drainage and compression garments, it was very limited for them. And so I think now we're kind of seeing the aftermath of that. I would agree. Okay, thank you to both of you. Excellent presentation. Nice discussion. So we're moving on to Dr. Berlin. I have some questions for you. So somebody in the chat brought up the fact that there's certainly a concern that there would be any discrepancy or any difference in procedural training for pain, spine, et cetera, but also in MSK. Would you be able to comment on that? So, yeah, the question was, I guess they were concerned about the 50% of fellowship directors saying that incoming PM&R residents were below average in their procedural skills. I think it was particularly for interventional spine. So I think this is something that we have to train on. And like I said in our presentation, only 10 procedures are required to graduate from PM&R residency in the spine. And then you can theoretically go out in the real world and practice interventional spine procedures even after just those 10 procedures. So trying to develop a curriculum that is more regimented and to help with training for these procedures, and that's safe and not just practicing on actual patients that gives real risk. And it's something that spine models have been around for a while. Spine models are extremely expensive and cadavers are expensive also. But I think fortunately, and we quoted this in our paper, I don't know the exact number, the vast majority of PM&R residencies are combined with, or are a part of a medical school. And the vast majority of medical schools have access to cadavers. So it also could be possible. And this could also be used, and we started using it with ultrasounds. We go to the cadaver lab with some ultrasound machines and practice all the peripheral joint injections. So it really can help with a bunch of different MSK injections. Excellent. Now, when do you think this particular training should occur in PM&R residency and it should it be an elective opportunity or a mandatory through the ACGME? Yeah, I think it depends on how your personal residency is set up. So for ours, it's during our spine rotation. We start spine rotation one month, our PGY-2 year, one month our PGY-3 year, and one month our PGY-4 year. And we do it early on in that rotation so that you get to practice early on and then you can practice on real patients as the month goes by. And then it's also always open to residents who are on electives and have some free time. They just wanna go to the cadaver lab with the fellowship trained attending or with the fellow himself. Very good. You mentioned physiatrists going out and having the minimum requirement of 10 procedures to go out and practice. What are your thoughts on the role of either spine specific or pain management fellowships in accreditation by insurance companies or otherwise for interventionalists in this region? Yeah, I mean, I think I'm personally doing a spine fellowship next year at Stanford. So I think there's a huge role in doing fellowships to learn more about the practice and the procedures themselves and it's best for patient care. That doesn't mean that you can't get good training during residency also. So I think it's just another way to sharpen your skill and your tools to help patients going forward. Great, great. And one final question, what were the reasons why you decided in the study to have the participants follow the SIS guidelines and a specific book by Michael Furman, both very well respected, but as you know, there are a number of different societies out there and different approaches in terms of guidance. So is there any particular reason you chose those? Probably a little bit of bias, to be honest. We do have the president of SIS currently at our program, Dr. Kennedy. So I think it's just, that's what we were used to and that's what a lot of the attendings practice by the SIS guidelines. So that's what we chose. Fair enough. Thank you. Any other comments you'd like to share with the audience? No, thank you guys for your time and consideration and for all the medical students out there, good luck with residency applications this year. And you guys chose a great field to go into. Thank you. Okay, moving on to Alexandra, if she could join us. So excellent presentation, thank you. I'm wondering about the generalizability of your results or your impressions on other chronic pain areas such as hip pathology where radiofrequency is also used. Yeah, I think it's challenging to generalize the results of this study beyond the specific joint. I think as we've seen from a lot of the cadaveric data that's emerging specific to the knee, there's a lot of controversy with regards to what the actual sensory nerve targets are for the knee itself. And I think that's the case for every other joint with which we're trying to apply RFA technology to whether that's the hip or whether that's the shoulder. Certainly different groups and different authors will argue about the various merits of doing one particular nerve paradigm or the other. And I think further cadaveric studies are really needed to characterize what it is that we're actually trying to lesion. Absolutely, where is the pain generator? What are we treating is always the key. With respect to the anatomy of the genicular nerve as opposed to the nerves that are supplying the sensory pain to the hip, do you think any of the anatomical considerations, the differences in approaching a hip versus a knee would come into play with some of the results that you've seen? Yeah, I mean, certainly the anatomical considerations I think are number one. And as we approach using RFA and when we approach studying it, I think in a systematic review sensor, even if designing a randomized controlled trial, I mean, obviously the results are going to be limited by our underlying methodology. And I think that's the big challenge. Likely one of our comments, at least in writing this manuscript, was likely the effect here is much greater than what we can actually report and what our studies are sensitive to picking up in part because it's difficult to argue conclusively that every single investigator is really localizing the same nerves. And I think that's very applicable to every other joint that you're likely lesioning. I think the studies have shown that targeting the medial branches is a lot more predictable, but when it comes to peripheral joints, certainly a lot more work needs to be done. I hope that answers your question. Agreed. There've been a couple of questions in the chat, one of which was inquiring whether the gauge of the active tip was part of your thought in analyzing this dataset. Yeah, so certainly one of the limitations that we could talk about for a while is just thinking about the different types of technologies that were utilized across the breadth of these studies. And interestingly, we only had nine studies to include in our systematic review, but everybody had very, very different ways of approaching the same problem. And when it comes to anything like the diagnostic paradigms, diagnostic blocks that they're using, the volume of local anesthetic, the nerves fortunately that they're targeting were the same, but even the way the localization of the probes, the cannula size, all of that was highly heterogeneous. And again, it kind of calls into question a little bit, what it is that we're actually treating, but in and of itself, RFA, we think, and we know is effective. It's just, can we standardize our methods so that that way we are actually in fact targeting the same things? And I think that we can dissect that down all the way to the cannula level, all the way up to the nerves themselves. Excellent comment. So we're coming to the end of the time, and I really wanna thank everyone for their time and attention today, and also a specific thank you to the presenters who've done a terrific job in helping to advance the science of PM&R. Have a good lecture. Have a good day.

cadaver lab curriculum

low-dose naltrexone

racial disparities

surgical care

chronic knee pain

osteoarthritis

interventional spine procedures

C-arm maneuvering