Musculoskeletal ultrasound

[PMR2008]

On the interview trail I was told by a few programs that they have recently started incorporating musculoskeletal ultrasound training in the program. Some programs sent PM&R faculty to MSK U/S seminars and others have recently bought machines. Are there any programs out there that are actively teachingresidents MSK U/S and can any seniors comment on the advantages or disadvantages of using MSK U/S.

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[PMR2008]

I found this in the archives of PM&R

PEER-REVIEWED POSTER: PR_119
Interest in Musculoskeletal Ultrasound Among Physiatrists and Neurologists. Jeffrey Ward, MD (Mercy Hospital, Pittsburgh, PA); Jay Smith, MD; Gary Goldberg, MD. Email:
[email protected]
Disclosure: None.
Objectives: To survey physiatrists and neurologists about their desire to integrate diagnostic musculoskeletal ultrasound (US) into their clinical practices; (2) to assess formal training obtained by clinicians currently utilizing musculoskeletal US; and (3) to determine the level of interest in
developing training and a certification process for musculoskeletal US. Design: Survey.
Setting:
The Surveymonkey.com website and the 2005 national assemblies of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) and the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Participants: 565 practicing physician members of the
AAPM&R, AANEM, and the Pennsylvania Academy of Physical Medicine and Rehabilitation.

Interventions: Not applicable.

Main Outcome Measures: Percentage of respondents who currently
use musculoskeletal US; the level of formal training obtained by clinicians currently using musculoskeletal US; and the percentage of respondents interested in a certification process for musculoskeletal US. Results: Of 565 respondents, 232 (43%) stated they were “very interested in
diagnostic musculoskeletal US,” while 22% were “moderately interested.” 50% were interested in participating in a formal certification process, while an additional 40% responded that they would be interested in “hearing more about it.” Among the 96 (18%) respondents who stated they currently
utilize musculoskeletal US, 35 (36%) respondents stated they have not received any formal training (coursework or hands-on training), 29% stated they received more than 30 hours, while 26% received between 5 and 30 hours of formal training.

Conclusions: Based on our survey results, there
appears to be substantial interest among physiatrists and neurologists in participating in formal training and certification in musculoskeletal US in order to successfully integrate this imaging technology into clinical practice.

 

[dc2md]

I know University of Michigan is HUGE with MSK U/S. LSU doesn't have any...and no plans to start.

 

[normalforce]

I know University of Michigan is HUGE with MSK U/S. LSU doesn't have any...and no plans to start.

We have it (Dr. Paul Lento) at RIC. We get a chance to learn it. Also, we do some botox with ultrasound like (like parotid and sublingual an salivary gland)

NF

 

[dc2md]

does anyone have details as to the cost of a typical U/S unit that we'd use for MSK U/S? also, is there any reimbursement advantage to using U/S or is it just a tool to aid at better performing certain injections and helping with diagnosis?

-chris

 

[DOctorJay]

Jefferson is actively teaching their residents (they have their own machine to practice with as well) and is having a course coming up in May in Atlatnic City.

 

[lobelsteve]

Jefferson is actively teaching their residents (they have their own machine to practice with as well) and is having a course coming up in May in Atlatnic City.

Just got my flyer in the mail! Looks like a good way to spend my CME money.

12.5 Credits.

My office has a new, expensive US machine and no one is using it.....

 

[ShrikeMD]

We have been using our rehab hospital's ultrasound machine for guidance in spasticity injections for about 8 yrs. We recently purchased a new machine with much better resolution.

I generally find some utility for the machine in 3 situations:
1. individuals with morbid obesity where I am injecting pectorals and subscapularis or other trunk muscles (and I am trying to avoid a pneumothorax);
2. "recurrent" spasticity cases after muscle lengthening/tendon transfers where the muscles are no longer likely to be found where they normally are;
3. injection "failures", where I feel I injected sufficient dose into the proper spastic muscles with emg + stimulation guidance.


For us, it is not an "easy" procedure. The ultrasound probe + machine adds an encumbrance factor that usually outweighs the added diagnostic certainty for localization provided by emg/e-stim guidance.

 

[caedmon]

MSK ultrasound is pretty hot at Mayo right now. One of our well regarded sports guys is doing a ton- pioneering new procedures and techniques. We're having a second MSK ultrasound (CME) course in the near future featuring several radiologists and cadaver experience.

Several of our attendings are actively pursuing training in ultrasound. We have several machines (for dc2md, they range in price from 30K for a good portable to 100K for diagnostic quality), several which are utilized by residents for practice.

Recently, MSK ultrasound has been incorporated into our didactics with a guided injection course using fresh frozen cadavers. We can be certified to use ultrasound after completing testing and performing certain numbers of injections under supervision. In our MSK clinic, there are now half days for ultrasound guided injections by our physiatrists. Residents get to do a lot of these.

As far as billing goes, there is good reimbursement for use of ultrasound.

 

[njdevil]

As far as billing goes, there is good reimbursement for use of ultrasound.

for a radiologist only.

 

[caedmon]

actually you can bill for ultrasound guidance for injections

 

[mdmagc]

Albert Einstein, Montefiore Medical Center has been using it for a few years and just bought a new US machine last year. It is taught to residents during the US guided injection clinic and the foot clinic.

 

[drusso]

I played around with ultrasound a little in residency and fellowship. It has its applications. It's got a very, very steep learning curve. It's cumbersome to do some injections with US guidance---goopy and poor ergonomics.

The reimbursement for office-based US-guided injection is pretty good, but you have to look at the opportunity costs of the time you spend dinking around with machine verus doing "other things."

 

[MN1]

I played around with ultrasound a little in residency and fellowship. It has its applications. It's got a very, very steep learning curve. It's cumbersome to do some injections with US guidance---goopy and poor ergonomics.

The reimbursement for office-based US-guided injection is pretty good, but you have to look at the opportunity costs of the time you spend dinking around with machine verus doing "other things."

drusso- you're just still mad that Patterson and I learned it in residency while you didn't get to.


MSK ultrasound CAN be very helpful from a financial standpoint, but you must own the machine. The technical fee is much higher than the professional fee.

drusso is right.....the learning curve is very steep. I learned MSK U/S in my fellowship.....I did procedures 3 half-days a week. It wasn't until about 4-6 months in until I started feeling comfortable with even the basic injections. Although once you are good at it, its really not that "cumbersome" at all. Even with all the set-up, its easy to get a hip or shoulder done in 15-20 minutes. Plus, you can do everything in the office.

 

[SSdoc33]

20 minutes for a shoulder injection? GOO!!!!!!

i'd like to believe that the outcomes are better (and not solely the reimbursement) with ultrasound guided injections than blind inejctions. i do believe that you'd be more accurate, but if it doesnt make a difference in the long run, then you have to question its usefulness.

also, can anyone tell me how in the world people are doing facets under MSK U/S? really? facets?

 

[drusso]

drusso is right.....

Well, after 26 posts it's about time you finally say something sensible!

20 minutes for a shoulder exam is a huge opportunity cost in our practice. But, I imagine in "better hands" than my own it could work out well. Having in-office fluoro I can bang out hips, knees, and shoulders before the betadine dries...

The best applications I saw for US in fellowship was for diagnostic peripheral nerve blocks: Lateral femoral cutaneous, ilioinguinal, genitofemoral, occipital nerve blocks, etc.

 

[MN1]

Well, after 26 posts it's about time you finally say something sensible!

20 minutes for a shoulder exam is a huge opportunity cost in our practice. But, I imagine in "better hands" than my own it could work out well. Having in-office fluoro I can bang out hips, knees, and shoulders before the betadine dries...

The best applications I saw for US in fellowship was for diagnostic peripheral nerve blocks: Lateral femoral cutaneous, ilioinguinal, genitofemoral, occipital nerve blocks, etc.

The 15-20 minutes was complete time.....talking with the patient, explaining the procedure, prep, injection, and checking on them post injection. The procedure itself is obviously very quick. I didn't think scheduling 15-20 minute appointments for an injection was that long.

If 20 minutes for a shoulder injection is a "huge opportunity cost" in your practice, I should practice with you. The reimbursement for the injection is quite good for 20 minutes of work.



I think any injection that you can ensure accuracy is a good use of guidance, whether fluoro or US. I don't quite get the people that insist you must use fluoro for spine injections, and say that those who don't are crazy, yet then they criticize you for using guidance for peripheral injections. Either you think being accurate is important, or you don't.

 

[MN1]

20 minutes for a shoulder injection? GOO!!!!!!

i'd like to believe that the outcomes are better (and not solely the reimbursement) with ultrasound guided injections than blind inejctions. i do believe that you'd be more accurate, but if it doesnt make a difference in the long run, then you have to question its usefulness.

also, can anyone tell me how in the world people are doing facets under MSK U/S? really? facets?

Anyone who uses ultrasound for facets or caudal epidurals, in my opinion, is crazy. Just because you "CAN" use it, doesn't mean you should.

 

[Diamox]

FYI - Can't bill for U/S guided procedures in Canada unless you're a Rads. Bunch on MSK physiatrists would love to hop in the bandwagon but limited by lack of fee codes.