We should begin with every patient by validating that their pain is real. He discussed the role played by cognitive behavioral therapy (CBT). It is referenced most often because it has the best evidence, but we do not really know how to break that down for patients. He described three basic stages. It is important to recognize that CBT is not the best and only treatment. Exercise is important in a lot of musculoskeletal conditions, but it should be tailored to benefit that window between benefit and symptom aggravation. Next, is the question of what must be done with all the information he has provided in this presentation thus far. There seems to be evidence of some advantage to participating in athletics or being fit. Also, not everyone who is fit is having a good time and not everyone with a chronic condition can jump into fitness in the right way. So, we need to figure out how to meld that. Patients come to us because they are suffering. We need a team approach to close the performance gap they experience. A psychological battle must be dealt with at the same time as physical problems. He described strategies he would use. Find out what exercise they do now and for how many minutes, and their amount of sleep. Determine what they enjoyed doing in the past. It is important to focus on one of their problems and aim to achieve success in treating it. He described some available resources that are useful.

A Question & Answer period followed.

PART 1

Dr. Vasudevan began by discussing how pain is experienced by athletes and non-athletes, how to identify components of multidisciplinary care for both those groups, and incorporate some reasonable strategies that might help with exercise prescriptions and lifestyle modifications for those with chronic pain. He provided some definitions for various terms, such as pain medicine, sports medicine, and pain. The latter is in the brain, which is the summation of all inputs. As physiatrists, we look at what the pain is keeping you from doing what you want to perform. He addressed the question of whether there are gender differences in the perception of pain. The short answer is no. Strength and endurance matter more. Endurance athletes can tolerate pain better. He discussed some consequences of the overtraining syndrome. If an athlete cannot perform at a desired level, there is a higher mental risk. Insufficient sleep is a risk factor. A pertinent concern is how to improve mental health in athletes. He indicated what they do at Penn to address this matter. Non-pharmacological interventions are preferred for treating injuries, e.g., massage modalities. The use of topical medications can be effective from a systemic perspective. The discussion then switched to chronic pain. 

Holly Cohen is the program manager of assistive technology and the driving rehabilitation program at NYU Langone Health. She is an Occupational Therapist with over 25 years of experience. She also is an adjunct professor at New York University where she teaches occupational therapy and engineering students on the importance of accessibility and adaptability in everyday technology.  Additionally, she has lectured both nationally and internationally on the importance of assistive technology to improve function and quality of life for users.

The following items were discussed in Part 1: Determining the ability of patients to use various forms of assistive technology; examples of the kinds of assistive technology employed in providing care to patients; kinds of patients treated; treatment offered in the clinical setting and by telehealth; if patients ever abandon using assistive devices; whether patients influence the kinds of assistive technology used; use of a patient group-based treatment approach; emerging technology; and key lessons learned in improving patient care. 

This is an exciting year for RUSK, celebrating our 75th anniversary! As part of our celebration, we are hosting a number of events including our Research Symposium, podcasts, and interviews. Our content continues to cover a wide range of topics within PM&R, and this particular segment includes special Rusk 75th Anniversary episodes featuring Rusk leadership, faculty, and residents.

This is the third of three special episodes...

Dr. Lindsey Gurin specializes in Dementia & Alzheimer's, Neuropsychiatry and is Assistant Professor, Department of Neurology at NYU Grossman School of Medicine, an Assistant Professor, Department of Psychiatry at NYU Grossman School of Medicine ,and an Assistant Professor, Department of Rehabilitation Medicine at NYU Grossman School of Medicine She is also Director of both the  Neurology/Psychiatry Residency Program and Behavioral Neurology, NYU Langone Orthopedics Hospital.

Dr. Prin Amorapanth is an Assistant Professor, Department of Rehabilitation Medicine at NYU Grossman School of Medicine . He completed his residency at the Rehabilitation Institute of Chicago, Rehab Medicine and his fellowship at NYU Langone Medical Center, Brain Injury Medicine. 

Dr. Jessica Rivetz is currently a resident physician in Physical Medicine and Rehabiitation at NYU Grossman School of Medicine and will be applying for her fellowship in brain injury medicine. 

This is an exciting year for RUSK, celebrating our 75th anniversary! As part of our celebration, we are hosting a number of events including our Research Symposium, podcasts, and interviews. Our content continues to cover a wide range of topics within PM&R, and this particular segment includes special Rusk 75th Anniversary episodes featuring Rusk leadership, faculty, and residents.

This is the second of three special episodes...

Dr. Jonathan Whiteson is Assistant Professor, Department of Rehabilitation Medicine; Assistant Professor, Department of Medicine; Medical Director of Rusk Outreach and Growth; and Medical Director of Cardiac Rehabilitation. His research interests include: cardiac and pulmonary rehabilitation coping strategies during cardiac rehabilitation following cardiac surgery, pulmonary rehabilitation of individuals exposed to world trade center dust, and recognizing encephalopathy and delirium in the cardiopulmonary rehabilitation setting. He is also part of the Senior Leadership team of Rusk Institute and Medical Director of the Rusk Institute Outpatient program.

This is an exciting year for RUSK, celebrating our 75th anniversary! As part of our celebration, we are hosting a number of events including our Research Symposium, podcasts, and interviews. Our content continues to cover a wide range of topics within PM&R, and this particular segment includes special Rusk 75th Anniversary episodes featuring Rusk leadership, faculty, and residents.

This is the first of three special episodes...

Steven Flanagan, MD is professor and chairman of the Department of Rehabilitation Medicine, New York University School of Medicine, and the medical director of the Rusk Institute of Rehabilitation Medicine, New York University Langone Medical Center. Dr. Flanagan has served on medical advisory boards of many national and international committees and has presented at scientific meetings both nationally and internationally, most notably on topics pertaining to brain injury rehabilitation. He has authored numerous chapters and publications and has participated in both federally and industry sponsored research, funded by such organization as the National Institute on Aging.

Dr. Jonathan Whiteson is Assistant Professor, Department of Rehabilitation Medicine; Assistant Professor, Department of Medicine; Medical Director of Rusk Outreach and Growth; and Medical Director of Cardiac Rehabilitation. His research interests include: cardiac and pulmonary rehabilitation coping strategies during cardiac rehabilitation following cardiac surgery, pulmonary rehabilitation of individuals exposed to world trade center dust, and recognizing encephalopathy and delirium in the cardiopulmonary rehabilitation setting. He is also part of the Senior Leadership team of Rusk Institute and Medical Director of the Rusk Institute Outpatient program.

Dr. Weiss is Professor of Rehabilitation Medicine at the NYU Long Island School of Medicine. She previously was the Chairman and Director of Residency Training for the Department of Physical Medicine and Rehabilitation at Nassau University Medical Center. She also was the Director of Electrodiagnostic Medicine and Chair of the Ethics committee. She is Board Certified in both Physical Medicine and Rehabilitation and Electrodiagnostic Medicine and in November 2018 was among the first group of professionals to become Healthcare Ethics Consultant-Certified. Dr. Weiss has published numerous articles, book chapters, and authored 10 books. She is active in professional organizations on a national level. Her professional interests include electrodiagnostic medicine, ethics, and women in medicine.

The following items were discussed in Part 2: 

Differences between monopolar and concentric needles; possible role of contaminants leading to diagnostic misinterpretation; training or certification required to become eligible to engage in EMG testing; kinds of clinical personnel who conduct EMG tests; size of the workforce engaged in EMG testing; the role of EMG wearables by patients; future studies of EMG testing; and personal current research involvement.

Dr. Weiss is Professor of Rehabilitation Medicine at the NYU Long Island School of Medicine. She previously was the Chairman and Director of Residency Training for the Department of Physical Medicine and Rehabilitation at Nassau University Medical Center. She also was the Director of Electrodiagnostic Medicine and Chair of the Ethics committee. She is Board Certified in both Physical Medicine and Rehabilitation and Electrodiagnostic Medicine and in November 2018 was among the first group of professionals to become Healthcare Ethics Consultant-Certified. Dr. Weiss has published numerous articles, book chapters, and authored 10 books. She is active in professional organizations on a national level. Her professional interests include electrodiagnostic medicine, ethics, and women in medicine.

The following items were discussed in Part 1: 

Reason for deciding to practice in PM&R; some indications for electrodiagnostic testing; difference between nerve conduction studies and EMG; most common health problems that govern EMG testing; kinds of musculature tested; how electrodiagnostic testing differs from MRIs and x-rays; if patient age affects EMG tests; diagnostic information furnished by needle insertion and placement of electrodes over the skin surface; and patient characteristics to take into account when inserting needles.

The following items were discussed in Part 2: how ableism, including structural ableism appear in the healthcare setting; how medicine, including the field of rehabilitation, contributed to ableism in society; the importance of having health care organizations systematically collect and record patients’ disability status within the electronic health record; challenges in achieving effective documentation in the record and how to overcome them; how to determine patients’ needed disability accommodations and implementing them into routine clinical and hospital care; and any ongoing studies in which she is involved and anticipates undertaking in the near term.

Dr. Morris currently works full-time as a researcher. She is founder and director of the Disability Equity Collaborative where her work focuses on provider and health care organization-level factors that negatively impact the quality of care delivered to patients with disabilities. Her work has been funded by the NIH and other key sources of support. She has published in major medical periodicals, including the New England Journal of Medicine and the journal Health Affairs. Dr. Morris has a Masters of Science degree in Speech-Language Pathology, a Masters of Public Health degree, and a PhD in Rehabilitation Sciences from the University of Washington. She completed post-doctoral fellowships at Northwestern University and the Mayo Clinic in health services research. She has served as a faculty member at the Mayo Clinic, Harvard Medical School, and the University of Colorado Medical School.

The following items were discussed in Part 1: her definition of the term ableism; meaning of the term structural ableism and how it is manifested in society; whether there can be a tendency for ableism to occur in conjunction with another kind of ism, such as racism; and how she developed an interest in focusing on the topic of ableism.

The following items were discussed in Part 2: whether NYU offers any standardized screening to identify residents who may be struggling with mental health and burnout concerns; if NYU has a mentorship program for residents; kinds of differences that may occur in the types of pressures and challenges that may arise depending on the medical specialty; cultivating resilience to increase an ability to cope with various everyday pressures; and enhancing self-management skills in self-monitoring, recognizing, and reporting symptoms of any mental health problems.

Dr. Salvador Portugal is an Assistant Professor in the Dapartment of Rehabilitation Medicine at NYU Grossman School of Medicine. He is also Director of the Sports Fellowship program and Medical Director, Sports Medicine Rehabilitation. Dr. Portugal completed his residency at NYU Grossman and his fellowship at UMDNJ. He also received an MBA from Brandies in 2020. 

In this segment, Dr. Portugal indicated that in 2014, a systematic review was done, which found that a combination of PT and mobilization was strongly recommended, especially in patients in stages two and three. Cortisone injections were found to be most effective early, and acupuncture plus therapeutic exercises improved pain, range of motion and function. Therapeutic sonograph treatment was not recommended. PT is recommended after phase one or after the painful phase. A Cochrane study concluded that PT should be provided in combination with other treatments. Patients that were compliant with home exercises are shown to be equally effective compared to supervised stretching exercises. He also discussed cortical steroid injections compared to other interventions. Similarly, platelet-rich plasma (PRP) was described in comparison to other forms of treatment, such as physical therapy. A related area of interest is the use of shock wave therapy in comparison to oral steroids. Many patients do well with non-surgical forms of treatment, but surgery may be an option for those who do not do so well with non-surgical treatment.

Dr. Salvador Portugal is an Assistant Professor in the Dapartment of Rehabilitation Medicine at NYU Grossman School of Medicine. He is also Director of the Sports Fellowship program and Medical Director, Sports Medicine Rehabilitation. Dr. Portugal completed his residency at NYU Grossman and his fellowship at UMDNJ. He also received an MBA from Brandies in 2020. 

For this portion, he discussed several topics, such as clinical presentation, risk factors, pathophysiology, diagnostic testing, and non-surgical treatment options. He provided a review from the standpoint of what we should be doing in current practice. Shoulder injury usually is characterized as a marked decrease in range of motion. Patients often have difficulty reaching overhead or behind the back that causes a sensation of pain and stiffness. Prevalence in the general population is 2-5% and women are more affected than men. Pathophysiology is not often understood. Adhesive Capsulitis of the Shoulder after surgery potentially may be a risk. Prevalence is around 11% and women are affected more than men. He addressed the issue of which kind of imaging is important, such as X-rays and MRIs. He then moved on to additional diagnostic testing. Patients with a thyroid condition or diabetes are at increased risk of developing adhesive capsulitis. So, when should we begin considering testing or evaluating these conditions? Approximately one-third of patients with adhesive capsulitis are likely to have diabetes. Next, he focused on non-surgical forms of treatment and management.  

Dr. Moroz attended the NYU School of Medicine and remained at NYU-Rusk Rehabilitation for residency training, and subsequently, his first and only job. He rose through the faculty ranks and currently is Director of Residency Training and Vice Chair for Education. Dr. Moroz sought out additional training and became a New York State certified acupuncturist, and is directing the Integrative Sports Medicine program, which includes an 18-month track for PM&R residents leading them to becoming certified physician acupuncturists.

Dr. Brian Sunwoo is a current administrative chief resident in the Physical Medicine and Rehabilitation residency program at NYU Langone Health. He attended Rowan School of Osteopathic Medicine, where he received the Dean's Recognition Award and will begin a fellowship in Interventional Spine after completing residency. As an NYU resident, he has served on the Rusk Health Equity, GME Diversity and Inclusion, and House Staff Leadership Committees. Dr. Sunwoo currently is completing his clinical acupuncture certification through the NYU PM&R residency program with plans to incorporate its use in his future practice.  

The following items were discussed in Part 2: effectiveness of acupuncture treatment either pre- or post-operative in dealing with nausea and vomiting in the post-surgical period; use of acupuncture in treating mental health conditions; extent to which sham acupuncture is being used in research; whether expectancy data are collected beforehand to measure how strongly patients anticipate a positive acupuncture treatment outcome; health problems where research indicates a high-certainty level of evidence for acupuncture; use of artificial intelligence in acupuncture research and treatment; and current or planned research endeavors at NYU that involve acupuncture.

Dr. Moroz attended the NYU School of Medicine and remained at NYU-Rusk Rehabilitation for residency training, and subsequently, his first and only job. He rose through the faculty ranks and currently is Director of Residency Training and Vice Chair for Education. Dr. Moroz sought out additional training and became a New York State certified acupuncturist, and is directing the Integrative Sports Medicine program, which includes an 18-month track for PM&R residents leading them to becoming certified physician acupuncturists.

Dr. Brian Sunwoo is a current administrative chief resident in the Physical Medicine and Rehabilitation residency program at NYU Langone Health. He attended Rowan School of Osteopathic Medicine, where he received the Dean's Recognition Award and will begin a fellowship in Interventional Spine after completing residency. As an NYU resident, he has served on the Rusk Health Equity, GME Diversity and Inclusion, and House Staff Leadership Committees. Dr. Sunwoo currently is completing his clinical acupuncture certification through the NYU PM&R residency program with plans to incorporate its use in his future practice.  

The following items were discussed in Part 1: number of participants in the residency program at NYU using acupuncture with patients; professional qualifications deemed necessary to use acupuncture in treating patients; insurance company coverage of acupuncture treatment; role of patients’ age in achieving desired clinical outcomes involving acupuncture; different kinds of instruments used by acupuncture practitioners; acupuncture as a lone intervention and also as an adjunct to western medicine; contributions that acupuncture can make in dealing with problems, such as stroke; and possible differences among clinicians in different health professions regarding the effectiveness of acupuncture treatments?

Dr. Byron Schneider is currently an associate professor with the Department of Physical Medicine and Rehabilitation at Vanderbilt University Medical Center and serves as the Director of the Interventional Spine and Musculoskeletal Medicine Fellowship. Previously, he completed his residency and interventional spine fellowship at Stanford University. He has nearly 100 publications, with a research focus on the safety and outcomes of interventional spine procedures. He has given over 100 lectures at national and international meetings. He currently is on the Spine Intervention Society Board of Directors as the Chair of Research, and within the North American Spine Society is Chair of the Interventional Spine and Musculoskeletal Section as well as Co-Chair for the Coverage Committee.

In Part 2 of his presentation, he indicated that the study by Wolf and his group was observational and retrospective, so there are some missing data. They enrolled patients based on provocation discography, which you hope would result in better outcomes. He stated that this number, 50 percent of people saying that they are 50 percent better is very common in pain literature. He wouldn’t say it is favorable. Over and over, these are the numbers we see that turn out to be dead ends. These are non-compelling data unless we are able to show they are non-placebo. You need RCTs to do that. He is a huge proponent of observational studies. They can give you very meaningful clinical information, but unfortunately for a new technology like this, we need at least some evidence that these things are doing something beyond placebo. Next, he indicated the discussion in his presentation would shift to discussing some RCTs that have been published more recently. As of right now, however, the totality of evidence because of the negative RCTs in the research done today, stem cells do not work as a treatment for disc-related low back pain. He then described four new RCTs that came out in the last two years that will shed some new light. The first study involved a comparison with saline treatment. Unwanted side effects, such as infections and other complications have occurred as a result of the treatments in the four studies. Safety continues to be a concern in developing effective treatments using stem cell and PRP approaches.

Dr. Byron Schneider is currently an associate professor with the Department of Physical Medicine and Rehabilitation at Vanderbilt University Medical Center and serves as the Director of the Interventional Spine and Musculoskeletal Medicine Fellowship. Previously, he completed his residency and interventional spine fellowship at Stanford University. He has nearly 100 publications, with a research focus on the safety and outcomes of interventional spine procedures. He has given over 100 lectures at national and international meetings. He currently is on the Spine Intervention Society Board of Directors as the Chair of Research, and within the North American Spine Society is Chair of the Interventional Spine and Musculoskeletal Section as well as Co-Chair for the Coverage Committee.

In Part 1 of his presentation, the focus was on a systematic review that was done of how stem cells and PRP pertain to back pain. He began by going over the history and regulations. Traditionally as it pertains to all biologics, they were largely exempt from the pathway of the FDA. Because they did not go through that process, these medicines were allowed to be done, but really did not have any insurance coverage. They became a cash cow for those offering fee-for-service treatment for things that did not have a lot of evidence behind them yet. It led to much public confusion, but that gap has shrunk in recent years. The FDA began issuing more restrictive language in 2020 regarding treatments that were not approved by that agency. The primary purpose of the aforementioned review was to look at 50 or more percent relief of low back pain at a six-month outcome. Based on those criteria, the number of citations was whittled down from 3,000 citations reviewed to 37, then finally down to only 12 that actually met the criteria. Those results should be alarming given that hundreds of clinics in the U.S. were providing treatments for cash payments that were based on only 12 research papers. Only one paper was on PRPs and one on stem cell treatment. He then described a study on PRP in 2015. He also provided summaries of other investigations that entailed PRP and stem cell treatments.

Dr. Baumhauer is a tenured Professor and serves as the Senior Associate Dean of Academic Affairs for the University of Rochester School of Medicine and Dentistry. She also is the Associate Chair of Academic Affairs within the Department of Orthopaedics at the University of Rochester. In addition to providing clinical care and performing surgery, she holds the position as the Director of the Clinical Health Informatics Core for the UR Healthcare System and is a board of director of Accountable Health Partners, ACO for the Rochester Region. She received her Doctorate of Medicine from the University of Vermont College of Medicine. She completed orthopaedic residency at the Medical Center Hospital of Vermont and a Fellowship in Foot and Ankle Surgery at the Medical College of Wisconsin. She also completed a Masters in Public Health degree from the University of Rochester. Dr. Baumhauer is the past president of the American Board of Orthopaedic Surgery, American Orthopaedic Foot and Ankle Society (AOFAS), and Eastern Orthopaedic Association. She currently is the President of the Patient-Reported Outcomes Measurement Information System (PROMIS) Health Organization and has published over two hundred peer reviewed papers and book chapters.

In Part 2, Dr. Baumhauer described research showing that patients who were able to report at times that were important to the patient ended up visiting the emergency room less and were experiencing more favorable outcomes. She discussed how data are used. The first time seeing a patient, it is important to know what their baseline values are, e.g., mild depression and moderate symptoms for physical function and pain. Trends can be noted that make it possible before meeting with a patient to look at the PROMIS scores and be able to anticipate how much time to spend with this individual. It enables the physician to triage, which patients appreciate. Patients also are asked anchoring questions, such as general health status questions that make it possible to link the medical visit. An example is are you worse, better, or the same since your last visit? Another question is can you live with your symptoms? She also discussed how patients can ask questions, such as whether there will be substantial improvement as a result of surgery. If such an outcome is unlikely, surgery should not occur. Another question patients ask is which of various treatment options should be selected? It is important to know what the patient wants to measure.

Dr. Baumhauer is a tenured Professor and serves as the Senior Associate Dean of Academic Affairs for the University of Rochester School of Medicine and Dentistry. She also is the Associate Chair of Academic Affairs within the Department of Orthopaedics at the University of Rochester. In addition to providing clinical care and performing surgery, she holds the position as the Director of the Clinical Health Informatics Core for the UR Healthcare System and is a board of director of Accountable Health Partners, ACO for the Rochester Region. She received her Doctorate of Medicine from the University of Vermont College of Medicine. She completed orthopaedic residency at the Medical Center Hospital of Vermont and a Fellowship in Foot and Ankle Surgery at the Medical College of Wisconsin. She also completed a Masters in Public Health degree from the University of Rochester. Dr. Baumhauer is the past president of the American Board of Orthopaedic Surgery, American Orthopaedic Foot and Ankle Society (AOFAS), and Eastern Orthopaedic Association. She currently is the President of the Patient-Reported Outcomes Measurement Information System (PROMIS) Health Organization and has published over two hundred peer reviewed papers and book chapters.

Part 1:  Data are needed to help understand how a patient is feeling and functioning to implement preventive health strategies, maximize healthy behaviors, assess their treatment response, and understand how health care resources are being allocated. Dr. Baumhauer defined a patient reported outcome as information directly reported by the patient who experiences it and is not interpreted as when we usually obtain some health history and tell it in our terms and report it into the patient’s note. She provided examples of the disconnect between what is important to the patient and what the clinician believes is important for the patient. A validated number can be placed on how the patient is feeling and functioning. It is important that a validated instrument be used that is quick and does not hold up the clinician. At the University of Rochester, they landed on the use of PROMIS (Patient-Reported Outcomes Measurement Information System) on a custom platform called UR VOICE (Validated Outcomes in Clinical Experience). They collect the same information for each patient. They try to ask the right questions when the information is needed most. The aim is to be domain specific, such as symptom-based, using the core package of pain, physical function, and depression rather than focusing on various diseases. Depending on the medical specialty, the symptoms emphasized can be different. Compared to SF-36, PROMIS is a better measure since it is more responsive to change.