Future of MSK US?

[Redmen27]

---

Members do not see this ad.

I was just wondering what everyone thinks of the applications, both present and future, of msk US? To me, I think it has pretty sound utility for peripheral nerve injections, large joint injections, and tendonits. However, I think that it would take a large amount of training for these therapeutic purposes, with the difficulty being that most residencies probably aren't getting much experience in this (especially considering most residencies aren't getting great quality msk/interventional experience in general). Sounds like UMich, Mayo, and maybe a couple of other programs get quality training. Are other programs getting quality US exposure? At my institution, we get some experience with using US for botox injections, but little else. If this is going to be a large part of physiatry's future, it seems like residencies should be incorporating this trainging asap.

I also wanted to get people's thoughts on US for diagnostic purposes. Seems as if only a handful of physiatrists in the country are doing this, and would probably take hundreds of evaluations and a lot of time to get relatively competent in this. Thoughts?

 

[lobelsteve]

I was just wondering what everyone thinks of the applications, both present and future, of msk US? To me, I think it has pretty sound utility for peripheral nerve injections, large joint injections, and tendonits. However, I think that it would take a large amount of training for these therapeutic purposes, with the difficulty being that most residencies probably aren't getting much experience in this (especially considering most residencies aren't getting great quality msk/interventional experience in general). Sounds like UMich, Mayo, and maybe a couple of other programs get quality training. Are other programs getting quality US exposure? At my institution, we get some experience with using US for botox injections, but little else. If this is going to be a large part of physiatry's future, it seems like residencies should be incorporating this trainging asap.

I also wanted to get people's thoughts on US for diagnostic purposes. Seems as if only a handful of physiatrists in the country are doing this, and would probably take hundreds of evaluations and a lot of time to get relatively competent in this. Thoughts?

It is the darling of the moment, but the timing is poor for application of new technology. Outcome data will show marginal improvement for peripheral injections and safety data for spine will never pan out as the details cannot match that of contrast fluoroscopy. Diagnostic MSK US can be thought of as a part of the PE, but the cost is too great to be useful.

Reimbursement will fall off precipitously in the next 2 years as the modality is noted to be used 1000% more than current. It will also be labeled experimental/investigational by some insurers and then it will all but disappear. Go to the courses while you can.....

 

[DistantMets]

It is the darling of the moment, but the timing is poor for application of new technology. Outcome data will show marginal improvement for peripheral injections and safety data for spine will never pan out as the details cannot match that of contrast fluoroscopy. Diagnostic MSK US can be thought of as a part of the PE, but the cost is too great to be useful.

Reimbursement will fall off precipitously in the next 2 years as the modality is noted to be used 1000% more than current. It will also be labeled experimental/investigational by some insurers and then it will all but disappear. Go to the courses while you can.....

I agree that from an interventional spine standpoint, US will be limited in it's usefulness, fluoro will rule there. We know that blind peripheral injections are inaccurate a good percentage of the time so either US or fluoro is appropriate to confirm placement. I agree that the results will likely be marginal for blind vs US guided, but it is probably because steroids only work in acute/subacute inflammation and probably don't work in chronic tendonsis. (A distiniction you can make with US).

I disagree in that I think diagnostic US (performed by qualified individuals, ie AIUM certified or equivalent) is high yield and less expensive than the alternative, MRI. We're pretty spoiled with MRI, especially compared to Europe, if Obama-care starts limiting MRIs then the diagnostic US contingent might see an increased demand. MSK US is much more commonplace in Europe and we're just now catching up. In general, reinbursement will probably go down for everything, so we'll do what we can I guess. What usually happens when something new becomes popular, is you have to sort out the unqualified that dabble and the qualified...we're getting to the point with MSK US and the ACR and AIUM have come out with guidelines for qualification. A certifying exam is probably around the corner.

There is definitely a learning curve with US and physiatrists have the background to help lead the way.

 

[olafa]

sounds like steve has the crystal ball 😀
only if you could predict where this new medical plan will put us in 5 yrs you would be golden!

 

[drusso]

Ultrasound makes sense for physiatrists who do not do, or can't, do fluoro-guided injections. It's a nice extension of the physical examination and can complement other diagnostic information like EDX. It has a historical connection to the field (early physiatrsts being pioneers in therapeutic ultrasound) and has applications that span outpatient and inpatient physiatric practice.

However, I have some concerns. Consider this: EDX is a mature diagnostic modality and some PM&R programs *still* have problems making sure their residents emerge with basic competency in EDX despite having a specific program requirements (observed and performed) to do so.


http://www.acgme.org/acWebsite/RRC_340/2009_PD_Manual_PMR_AA_04162009.pdf


Image-guidance with fluoroscopy is now a mature technology. Physiatrists have been doing diagnostic and therapeutic procedures with fluoroscopy for almost 25 years. What percentage of PM&R residency programs offer their residents a sufficient breadth of experience to be competent in this modality after they leave residency?

Now, comes along ultrasound. It makes perfect sense for physiatrists. It's dynamic (ie functional), complements the physical exam, and can be used to guide intervention and therapy. A small number of programs are dedicated to putting forth the necessary curricular resources to ensure residents have sufficient number of cases at the end of their residency in order to feel competent. Ultrasound has a steep learning curve (even steeper than EDX in my experience). You need a lot of opportunity to practice scanning and a lot of opportunity to see plenty of examples of normal/abnormal pathology *under direct supervision.* The physics of image capture with ultrasound are such that you can make a tendon look abnormal. When you do a diagnostic study you're accepting the same liability as a diagnostic ultrasonographer.

So....

Will the field get it right? Will academic physiatry departments see the value of US and dedicate resources to training residents--ie remove them from low yield consult services and redundant inpatient experiences for time-intensive US training? Will the AAP lobby the RRC to put teeth in residency program requirements for ultrasound as did for EDX? A few years ago, the RRC determined that competency in therapeutic injections with fluoroscopic guidance is not in the purview of a 3-year PM&R residency, adopted a much more general requirement (opportunity for physiatric injections largely unspecified), and kicked the can down the road to fellowships to deal with competency. Now, the field is dealing with an "identity crisis" of sorts because most residents realize that fellowship training is required to be competitive for MSK/Pain/Spine career opportunities. How will the field deal with ultrasound?

Place your bets.

 

[DistantMets]

That is indeed the question...I think one of the biggest factors will be getting good MSK/spine physiatrists into good academic gigs, and that takes a salary comparable to what you can pull down in private practice. Right now the gap is pretty large. If they're in academics, they'll teach and maybe be more involved at the Academy/RRC level. More diagnostic teaching and procedure time trickles down to the residents as their are fewer 'fellows' or they are less procedure starved.

Maybe I'm wrong, but there aren't really any high-pay, private inpatient jobs. Physiatrists that like inpatient accept the fact that they will probably take lower pay either way (private or academic) so academics is more appealing.

My residency has been great, but beyond the learning experience of taking care of an SCI or BI, I definitely see the IP residents role a lot of times is doing the dirty work so the IP attending can be in clinic (or research)...interesting...OP trumps IP even for IP speciality attendings? Oh, wait...botox, pump refills, EMGs, joint injections and short follow-ups make money. Fielding pages, chasing down labs, doing discharge summaries and H&Ps only make money if a resident or mid-level is doing it.

I agree too that shifting the balance from IP to OP is hard...I think we have a private rehab hospital funding one of our residency spots and it gets used for a redundant general rehab rotation. At least our Peds is 90% outpatient and we only do 2 months of consults.

I'm starting a pain fellowship in July, but I think too that unless a few more interventional guys get into academics and prove some of this works it will take an act of God to get paid for an epidural soon and all the pain guys will be grabbing ultrasound machines too 😳

Ultrasound makes sense for physiatrists who do not do, or can't, do fluoro-guided injections. It's a nice extension of the physical examination and can complement other diagnostic information like EDX. It has a historical connection to the field (early physiatrsts being pioneers in therapeutic ultrasound) and has applications that span outpatient and inpatient physiatric practice.

However, I have some concerns. Consider this: EDX is a mature diagnostic modality and some PM&R programs *still* have problems making sure their residents emerge with basic competency in EDX despite having a specific program requirements (observed and performed) to do so.


http://www.acgme.org/acWebsite/RRC_340/2009_PD_Manual_PMR_AA_04162009.pdf


Image-guidance with fluoroscopy is now a mature technology. Physiatrists have been doing diagnostic and therapeutic procedures with fluoroscopy for almost 25 years. What percentage of PM&R residency programs offer their residents a sufficient breadth of experience to be competent in this modality after they leave residency?

Now, comes along ultrasound. It makes perfect sense for physiatrists. It's dynamic (ie functional), complements the physical exam, and can be used to guide intervention and therapy. A small number of programs are dedicated to putting forth the necessary curricular resources to ensure residents have sufficient number of cases at the end of their residency in order to feel competent. Ultrasound has a steep learning curve (even steeper than EDX in my experience). You need a lot of opportunity to practice scanning and a lot of opportunity to see plenty of examples of normal/abnormal pathology *under direct supervision.* The physics of image capture with ultrasound are such that you can make a tendon look abnormal. When you do a diagnostic study you're accepting the same liability as a diagnostic ultrasonographer.

So....

Will the field get it right? Will academic physiatry departments see the value of US and dedicate resources to training residents--ie remove them from low yield consult services and redundant inpatient experiences for time-intensive US training? Will the AAP lobby the RRC to put teeth in residency program requirements for ultrasound as did for EDX? A few years ago, the RRC determined that competency in therapeutic injections with fluoroscopic guidance is not in the purview of a 3-year PM&R residency, adopted a much more general requirement (opportunity for physiatric injections largely unspecified), and kicked the can down the road to fellowships to deal with competency. Now, the field is dealing with an "identity crisis" of sorts because most residents realize that fellowship training is required to be competitive for MSK/Pain/Spine career opportunities. How will the field deal with ultrasound?

Place your bets.

 

[RUOkie]

I think too that unless a few more interventional guys get into academics and prove some of this works it will take an act of God to get paid for an epidural soon and all the pain guys will be grabbing ultrasound machines too 😳

Very well said! That is why I emphasize being well rounded. The people who can roll with the times will survive. If you are a nitch (sp?) practitioiner and your nitch stops being reimbursed, you are screwed.

 

[PMR 4 MSK]

So....

Will the field get it right? Will academic physiatry departments see the value of US and dedicate resources to training residents--ie remove them from low yield consult services and redundant inpatient experiences for time-intensive US training? Will the AAP lobby the RRC to put teeth in residency program requirements for ultrasound as did for EDX? A few years ago, the RRC determined that competency in therapeutic injections with fluoroscopic guidance is not in the purview of a 3-year PM&R residency, adopted a much more general requirement (opportunity for physiatric injections largely unspecified), and kicked the can down the road to fellowships to deal with competency. Now, the field is dealing with an "identity crisis" of sorts because most residents realize that fellowship training is required to be competitive for MSK/Pain/Spine career opportunities. How will the field deal with ultrasound?

Place your bets.

Historically correlating and extrapolating, they will sit on the sidelines while the rest of the medical community decides for us what is best for us. They will fail to produce meaningful research. They will fail to fight government and insurance companies.

US will revert back to use by radiologists and obstetricians.

 

[drusso]

Unprecedented AIUM training guidelines speak to future of musculoskeletal ultrasound

A number of societies have endorsed this unique guideline, demonstrating a multi-specialty outlook for the technology

Laurel, MD – March 16, 2010 – The AIUM is pleased to announce that 4 professional societies have collaborated with AIUM to endorse the recent AIUM Training Guidelines for the Performance of Musculoskeletal Ultrasound Examinations. The guidelines allow for a several practitioners, including physicians, osteopathic physicians, podiatrists, and sonographers, to perform musculoskeletal ultrasound examinations, marking significant promise for the future of this growing field.

The American Academy of Physical Medicine and Rehabilitation, American Medical Society for Sports Medicine, American Podiatric Medical Association, and Musculoskeletal Ultrasound Society have provided official support/endorsement for the guidelines to date.

"When multiple societies can come together to develop and agree on training guidelines, it lays a solid framework for the area to grow and initiates high-quality patient care," said AIUM President Harvey L. Nisenbaum, MD.

With numerous specialists performing musculoskeletal ultrasound exams, the development of a comprehensive training guideline has always presented a challenge in the field.

"A guideline like this ensures a balance that allows all qualified practitioners to adopt the technology," said Levon Nazarian, MD, who began collaborating on the issue across societies on behalf of the AIUM in 2008.

Marking further progress for the future of musculoskeletal ultrasound, the Board of Directors of the American Registry for Diagnostic Medical Sonography (ARDMS) has announced to the AIUM that it has approved the development of a credentialing examination in musculoskeletal ultrasound.

"The development process is underway for a musculoskeletal sonography credentialing examination that will test in a broad range of practice areas," said Patty Prince, RDMS, RVT, Chair of the ARDMS Board of Directors. "International experts will be appointed to the examination-development task force and, as the process proceeds, ARDMS will be sharing more specifics with the sonography community."

It is anticipated that more societies will endorse the AIUM guideline as the field of musculoskeletal ultrasound continues to expand.

 

[DistantMets]

View attachment MSK US AIUM Guidelines.pdf

View attachment MSK US Training Guidelines.pdf

 

[Nico47]

I think US will take off because its usefulness has already been shown with RA patients and there's a lot of overlap.

(Example: Rheumatoid Arthritis: Ultrasound Assessment of
Synovitis and Erosions
Ultrasound Clinics - Volume 2, Issue 4 (October 2007)
Lopez-Ben, Robert M.D. Department of Radiology, University of Alabama at Birmingham School ofMedicine, JT N360, 619 19th Street South, Birmingham, Alabama 35249)

The tough part is getting adequate training in residency. My program is fortunate enough to have an US machine dedicated to MSK (thank you Veterans Affairs!), but that doesn't mean there are a lot of attendings who feel comfortable using it.

What I've done is practice on myself, co-residents, and consenting patients while having this website handy: http://www.med.umich.edu/rad/muscskel/mskus/ (thanks UMich!). Next year I think I'll use my senior stipend to pay for a formal tutorial.

Hopefully that will be enough to allow me to feel comfortable using US in practice. We'll see, though.

 

[ampaphb]

I will be very curious to see how "essential" ultrasound guidance will be considered to be when the inevitable reduction in reimbursement no longer makes its use a profit center.

 

[PMR 4 MSK]

I will be very curious to see how "essential" ultrasound guidance will be considered to be when the inevitable reduction in reimbursement no longer makes its use a profit center.

I'll still use it for larger joints and some nerve and tendon injections, even if they don't pay extra. We have the machine, it works, I'll use it until I don't have it anymore.

 

[ampaphb]

I'll still use it for larger joints and some nerve and tendon injections, even if they don't pay extra. We have the machine, it works, I'll use it until I don't have it anymore.

But once you need a new machine, will you buy one if the reimbursement is reduced significantly?

 

[PMR 4 MSK]

But once you need a new machine, will you buy one if the reimbursement is reduced significantly?

Excellent question that gets to the heart of the matter. At $40K for a new machine, highly unlikely to be justifiable.