Toward a Consensus for Musculoskeletal Ultrasonography Education in Physical Medicine and Rehabilitation: A National Poll of Residency Directors

Variability in procedure volume of physical medicine and rehabilitation residents graduating from 2014 to 2021

BACKGROUND

Adequate exposure to commonly performed procedures during physical medicine and rehabilitation (PM&R) residency is an important issue.

OBJECTIVE

To assess temporal trends and variabilities in reported procedural volumes, including the number of residents achieving procedure minimum requirements as established by the Accredited Council for Graduate Medical Education (ACGME) PM&R Residency Review Committee.

DESIGN

This was a retrospective cohort study of PM&R residents graduating from 2013-2014 to 2020-2021. Descriptive statistics were calculated for tracked procedures and compared over time with analysis of variance (ANOVA) tests. Variability was calculated as the procedure volume difference between the 90th and 10th percentile groups.

SETTING

ACGME-accredited PM&R residency training programs.

PARTICIPANTS

A total of 3231 PM&R residents graduating from 2014 to 2021.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Reported procedure volume and number of residents achieving minimum requirements.

RESULTS

Total procedure volume increased over the study period (436 ± 225 to 523 ± 238, p = .013). The percentage of all procedures that were performed versus observed was stable over the study period (81%-77%, p = .234). Variability in total reported procedure volume remained stable over the study period. The percentage of PM&R residents not achieving minimum requirements ranged from 2% for peripheral joint injections to 22% for ultrasound in the contemporary training period.

CONCLUSIONS

The volume of reported procedures has increased along with the number of PM&R residency programs and residents. Variabilities in total reported procedure volume were stable over time, but PM&R residents struggle to obtain minimum requirements for ultrasound procedures.

The Current Situation of Musculoskeletal Ultrasound Education: A Systematic Literature Review

As a radiation-free and dynamic imaging tool, musculoskeletal ultrasound improves diagnostic and therapeutic safety. With its growing application, the demand for training opportunities rises rapidly. Therefore, this work was aimed at mapping the current state of musculoskeletal ultrasonography education. A systematic literature search was conducted in January 2022 in the medical databases Embase, PubMed and Google Scholar. By use of specifically selected keywords, matching publications were filtered; then abstracts were screened independently by two authors and the inclusion of each publication was checked against pre-defined criteria according to the PICO (Population, Intervention, Comparator, Outcomes) scheme. Full-text versions of included publications were reviewed, and relevant information was extracted. Finally, 67 publications were included. Our results revealed a wide variety of course concepts and programs that have been implemented in different disciplines. Musculoskeletal ultrasonography training especially addresses residents in rheumatology, radiology and physical medicine and rehabilitation. International institutions, such as the European League Against Rheumatism and the Pan-American League of Associations for Rheumatology, have suggested guidelines and curricula to promote standardized ultrasound training. The development of alternative teaching methods incorporating e-learning, peer teaching and distance learning on mobile ultrasound devices and the determination of international guidelines could facilitate overcoming the remaining obstacles still to be passed. In conclusion, it can be stated that there is a broad consensus that standardized musculoskeletal ultrasound curricula would improve training and facilitate the implementation of new training programs.

Longitudinal Ultrasound-Guided Injection Curriculum for Physical Medicine and Rehabilitation Residents

ABSTRACT

Physiatrists are increasingly using musculoskeletal ultrasound for both diagnostic and therapeutic purposes. However, a standardized longitudinal curriculum for instructing physical medicine and rehabilitation residents in performing ultrasound-guided interventional procedures has yet to be established. The purpose of this study is to develop and assess the effectiveness of a longitudinal curriculum in training residents to perform common ultrasound-guided musculoskeletal injections using fresh-frozen cadaveric specimens. The course included six weekly hands-on educational sessions, divided by anatomical region, integrated into an established anatomy and physical examination curriculum. After completion of the curriculum, residents reported improved comfort and confidence and displayed improved competence in performing these injections. Other physiatry residency programs should consider implementing longitudinal, hands-on cadaveric training courses to better prepare trainees to perform ultrasound-guided injections as part of their future clinical practice.

Longitudinal Cadaver-Based Training Curriculum for Musculoskeletal Ultrasound-Guided Procedures Among Physical Medicine and Rehabilitation Residents

ABSTRACT

Musculoskeletal ultrasound has become a fundamental diagnostic and treatment tool in the field of physical medicine and rehabilitation. However, there is no standardized curriculum for teaching and practicing musculoskeletal ultrasound during physical medicine and rehabilitation residency. The objective of this study was to describe a longitudinal curriculum using unembalmed fresh frozen cadavers to teach physical medicine and rehabilitation residents ultrasound-guided procedures. This protocol can help guide residents to begin learning how to independently identify important musculoskeletal structures and perform some of the most common musculoskeletal procedures relevant to clinical practice. Residents performed a procedure on average 6.99 times per block, and residents' self-reported confidence in various aspects of ultrasound practice significantly improved after this curriculum ( P < 0.005). Hence, a cadaver-based training curriculum may be a worthwhile tool for preparing physical medicine and rehabilitation residents to perform musculoskeletal ultrasound-guided procedures in the clinical setting.

A Hybrid Musculoskeletal Ultrasound Curriculum for Physical Medicine and Rehabilitation Residents-a Multi-center Pilot Program

Purpose of Review

The increased use of musculoskeletal ultrasound (MSKUS) in clinical practice warrants achieving competency earlier in physiatrists' careers. Physical Medicine and Rehabilitation (PM&R) residency programs have started incorporating formal MSKUS training in their curricula; however, significant heterogeneity remains in MSKUS education.

Recent Findings

Numerous barriers contribute to the lack of consensus for MSKUS training during residency, but the COVID-19 pandemic severely disrupted in-person learning. As an adjunct or alternative to in-person learning, teleguided technology is being utilized.

Summary

This curriculum demonstrates the role of a hybrid MSKUS training with interinstitutional collaboration. Twenty PM&R learners, from two institutions, were divided into a fundamental or advanced track. Virtual didactic sessions alternated weekly with hands-on ultrasonographic scanning sessions. Following a 12-month longitudinal curriculum, an end-of-year practical examination was used for competency assessment, in addition to a survey assessing resident perceptions and feedback. To our knowledge, this is the first collaborative and hybrid MSKUS curriculum for PM&R learners that can be easily reproduced at most training institutions and circumvent some of the barriers amplified by the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40141-023-00380-z.

Residents' Perspective on Need for Point-of-Care Ultrasound Education During Pediatric Residency

OBJECTIVES

Many medical disciplines incorporate point-of-care ultrasound (POCUS) into their practice. Despite well-defined applications, POCUS has not been widely adopted in pediatrics and is not commonly taught during residency. Our objective was to profile the current state of POCUS education in pediatric residency training from the resident perspective.

METHODS

We surveyed pediatric trainees about their POCUS education, general opinions about POCUS, and perceived barriers to POCUS training in residency. We distributed the survey to a random sample of Ohio pediatric residents, stratified by program size and training level. Descriptive statistics were used to characterize responses.

RESULTS

We sampled 66.4% of the population (371 of 559) of Ohio pediatric residents and achieved a response rate of 59.3%. Only 15% of respondents received POCUS training during residency, with 85% having never performed a POCUS scan. Most (86%) desired POCUS education and 67% believed it should be required during residency. Residents felt that POCUS would be useful for procedural guidance (95%), clinical diagnosis (94%), and patient safety (74%). Most residents (61%) believed POCUS education would benefit their careers, particularly those planning on subspecialization. Barriers to POCUS education included lack of an established curriculum (75%), competing educational priorities (58%), and a shortage of qualified instructors (52%).

CONCLUSIONS

Although Ohio pediatric residents do not receive formal POCUS education in residency, they desire such training and believe it would benefit their future practice. Consensus on scope of practice, development of a standardized curriculum, and increased faculty training in POCUS may help address this educational gap.

Introductory Resident-Led Physical Medicine and Rehabilitation Case-Based Ultrasound Workshop for Medical Students

ABSTRACT

The core clinical ultrasound milestones for medical students in the United States do not cover the majority of clinical topics pertinent to the specialty of physical medicine and rehabilitation. In addition, one of the major barriers to teaching physical medicine and rehabilitation residents ultrasound is a lack of instructors with sufficient experience. A solution to both of these problems is the establishment of a resident-led case-based ultrasound workshop for medical students that introduces them to the field of physical medicine and rehabilitation. This novel workshop involved 30 medical students and 9 resident instructors. The students participated in five hands-on interactive physical medicine and rehabilitation clinical cases where each student had 5 mins per case to scan. A program evaluation survey showed that the workshop achieved the objectives of increasing medical student confidence in describing the role of a physical medicine and rehabilitation physician and physical medicine and rehabilitation patient populations as well as confidence using ultrasound for evaluating the peripheral nervous system and musculoskeletal system. Resident instructors endorsed that the workshop was beneficial for improving their physical medicine and rehabilitation ultrasound teaching skills and also increased their interest for contributing to future workshops. The intention of this project is to reproduce similar initiatives in physical medicine and rehabilitation residency training programs across the United States.

Musculoskeletal Ultrasound as a Motivator for Selecting a Physical Medicine and Rehabilitation Residency Program in the United States: A Multicenter Survey Study

ABSTRACT

This study aimed to determine the influence of musculoskeletal ultrasound (MSKUS) curriculum on applicants during the residency-selection process. A survey of 666 applicants for the Johns Hopkins University, Mayo Clinic, and Harvard/Spaulding Rehabilitation Physical Medicine and Rehabilitation programs was conducted in June 2020. A total of 180 respondents scored the influence of a MSKUS curriculum on their decision making for residency selection. In addition, applicants were asked to rank specific areas of physical medicine and rehabilitation that influenced their decision making. Participants most commonly included MSKUS in their top three areas of interest when constructing their rank order list. When asked whether MSKUS presence within a program had an effect during the interview-selection process, 71% responded with "very important" or "absolutely essential" (P < 0.001). For 74% of applicants, exposure to MSKUS in residency was an important factor when creating their rank order list (P < 0.001). More than 92% of applicants stated that they are "likely" or "very likely" to use MSKUS in their future practice and 83% would recommend a program with MSKUS to future candidates (P < 0.001). Based on these results, a large percentage of physical medicine and rehabilitation applicants intend on using MSKUS in their future practice. Therefore, MSKUS may be an important factor for residency selection.

Convergent Validity and Test-Retest Reliability of Multimodal Ultrasonography and Related Clinical Measures in People With Chronic Stroke

OBJECTIVE

To assess the test-retest reliability of diagnostic ultrasonography measurements of the bilateral biceps brachii (BB), brachial artery, medial gastrocnemius (MG), and popliteal artery in survivors of stroke and their convergent validity with related clinical comparators.

DESIGN

Cross-sectional study.

SETTING

All procedures were conducted in a university laboratory.

PARTICIPANTS

Sixty-five community dwelling adults (N=65; 26 women, 39 men) with an average age of 60.9±7.7 years and stroke duration of 5.7±3.9 years participated in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measures of muscle structure (ie, thickness, cross-sectional area, fascicle length, pennation angle), stiffness, and intramuscular blood perfusion were conducted using B-mode, elastography and color flow Doppler ultrasonography modes, respectively. Convergent validity was assessed by examining correlations between ultrasonography measures and assessments of related constructs (ie, dynamic stiffness, isometric peak torque, spasticity, and systemic vascular function using myotonometry, dynamometry, the Composite Spasticity Scale, and the Ankle-Brachial Index, respectively). A 2-way random-effects intraclass correlation coefficient (ICC) model (ICC_2,3) was used to determine agreement between intersession measures among a smaller cohort of participants with stroke (n=20).

RESULTS

ICC estimates ranged from moderate to excellent for muscle stiffness (paretic: ICC=0.74-0.89; nonparetic: ICC=0.66-0.88), structure (paretic: ICC=0.87-0.99; nonparetic: ICC=0.81-0.98), and blood perfusion measures (paretic: ICC=0.74-0.84; nonparetic: ICC=0.73-0.88). Weak to moderate associations were found between myotonometry and elastography measures of the bilateral BB (r=0.29-0.52, P≤.05) and MG muscles (r=0.31-0.69, P≤.05). The correlations between elastography measures and spasticity scores for the paretic upper (r=0.35-0.63, P≤.05) and lower limbs (r=0.25-0.37, P≤.05) were also weak to moderate.

CONCLUSIONS

Elastography demonstrated mostly weak to moderate correlation with measures of stiffness using myotonometry as well as scores of paretic upper and lower limb spasticity. The results also indicate acceptable intersession reliability for muscle and vascular measures using several ultrasonography modalities among individuals with chronic stroke.

Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Physical Medicine and Rehabilitation Residency Training

ABSTRACT

A sports medicine physician manages musculoskeletal (MSK) injuries and sport-related medical and MSK conditions of patients of all ages and abilities. Physical medicine and rehabilitation physicians (physiatrists) must be adequately trained to provide this care for all patients including, but not limited to, athletes participating in organized sports, the weekend warrior as well as athletes with disabilities. Accreditation Council of Graduate Medical Education core requirements and basic guidelines help physiatry residency training programs develop and implement residency curriculums. The goal of this article is to provide suggested curricular guidelines to optimize physiatrist training in MSK and sports medicine.

Reliability and Validity of Ultrasound Elastography for Evaluating Muscle Stiffness in Neurological Populations: A Systematic Review and Meta-Analysis

OBJECTIVE

Ultrasound elastography is an emerging diagnostic technology used to investigate the biomechanical properties of the musculoskeletal system. The purpose of this study was to systematically review the psychometric properties of ultrasound elastography techniques for evaluating muscle stiffness in people with neurological conditions.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using software, reviewers independently screened citations for inclusion. Peer-reviewed studies that evaluated in vivo muscle stiffness in people with neurological conditions and reported relevant psychometric properties were considered for inclusion. Twenty-one articles were included for final review. Data relevant to measurement technique, site, and neurological condition were extracted. The Consensus-Based Standards for the Selection of Health Measurement Instruments checklist was used to rate the methodological quality of included studies. The level of evidence for specific measurement outcomes was determined using a best-evidence synthesis approach.

RESULTS

Reliability varied across populations, ultrasound systems, and assessment conditions (ie, joint/body positions, active/passive muscle conditions, probe orientation), with most studies indicating moderate to good reliability (ICC = 0.5-0.9, n = 13). Meta-analysis results showed a good overall correlation across studies (r = 0.78, 95% confidence interval = 0.64-0.86), with no between-group difference based on population (Q1 = 0.00). Convergent validity was demonstrated by strong correlations between stiffness values and measures of spasticity (n = 5), functional motor recovery or impairment (n = 5), and grayscale or color histogram pixel intensities (n = 3). Discriminant or known-groups validity was also established for multiple studies and indicated either significant between-group differences in stiffness values (n = 12) or within-group differences between more and less affected limbs (n = 6). Responsiveness was observed in all intervention studies reporting posttreatment stiffness changes (n = 6).

CONCLUSIONS

Overall, ultrasound elastography techniques showed moderate reliability in evaluating in vivo muscle stiffness, good convergent validity with relevant clinical assessments, and good divergent validity in discriminating tissue changes within and between groups.

IMPACT

Ultrasound elastography has clinical utility in assessing muscle stiffness, monitoring its temporal changes, and measuring the response to intervention in people with neurological conditions.

Education in the Time of COVID: At-a-Distance Training in Neuromusculoskeletal Ultrasonography

Point of care ultrasound is important to the specialty of physical medicine and rehabilitation (PM&R) to aid in the diagnosis and treatment of a variety of neuromusculoskeletal conditions commonly seen in practice. However, across Canada, resident education of sonoanatomy skills is variable. There remain no standards in terms of how ultrasound is taught as part of the residency curriculum as set by the Royal College of Physicians and Surgeons of Canada. As such, residents are often required to find their own educational opportunities. This report describes an alternative approach to learning these skills that was inspired by disruption due to coronavirus disease 2019 in first year residency. This report explores how a PM&R resident was able to develop valuable ultrasound skills from home using not only textbooks and videos, but also new and novel teleguidance technology, namely an ultrasound probe that connects to a clinician’s own smart devices to display images.

An Evaluation of Musculoskeletal Interventional Ultrasound Training in Canadian Physical Medicine and Rehabilitation Residency Programs

BACKGROUND

Ultrasound is a rapidly evolving field of medicine with strong utility in musculoskeletal practices. In Canadian physical medicine and rehabilitation (PM&R) residency programs there are no national standards for objectives of training in this area. This possible disconnection between demand and availability could lead to gaps in education.

OBJECTIVE

(1) To determine the current state of interventional musculoskeletal ultrasound (MSUS) training in Canadian PM&R residency programs, as perceived by both residents and program directors; (2) to evaluate the perspectives of experts in the field on current and future MSUS curriculum inclusion.

DESIGN

This study was a cross-sectional cohort study using an explanatory sequential mixed methods design.

SETTING

This project included anonymous online surveys and targeted telephone/in-person semistructured interviews.

PARTICIPANTS

Participants were Canadian PM&R residents or clinicians. Survey responses included 71 residents and nine program directors. Interviews were conducted with nine MSUS experts.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures included residents' level of interest, amount of exposure, and barriers to training. Themes regarding resident exposure and future directions for MSUS training were obtained based on expert interviews.

RESULTS

The vast majority (97%) of current PM&R residents are interested in using ultrasound clinically, with 73% reporting having had "none" to "limited exposure" in MSUS. Expert interviews revealed four major themes: (1) appropriate training is dependent on access, (2) MSUS represents an emerging standard of care, (3) a minimal baseline level of competence should be expected, and (4) various strategies may be used to integrate basic MSUS into existing residency curriculums.

CONCLUSIONS

The use of ultrasound as a clinical tool is rapidly increasing. Current PM&R residents have a desire to incorporate this skill into their future practices. Although barriers exist to implementing this training on a national level, the future looks promising with multiple strategies outlined to assist the process.

Design and Implementation of a Musculoskeletal Ultrasound Curriculum for Physical Medicine and Rehabilitation Residents: Pilot Data on Improvement of Palpation Accuracy in Physical Examination

Studies have shown that physical medicine and rehabilitation residents have poor surface anatomy palpation accuracy, suggesting that new methods of teaching musculoskeletal (MSK) examination need to be found. This study describes the design of a novel MSK ultrasound course that integrated ultrasonography skills with palpation skills. Ultrasound was used to teach, validate, and refine physical medicine and rehabilitation residents' palpation of MSK structures. Surface anatomy palpation is intimately related to ultrasonography as clinicians should use palpation to guide their ultrasound examination rather than purely follow an algorithm. This study assessed whether the ultrasound course improved physical medicine and rehabilitation resident palpation accuracy at 12 upper limb structures. Palpation accuracy was tested at the beginning of their residency training and retested several weeks after completion of the ultrasound course's upper limb component, to assess retention of skill. There was significant improvement (P < 0.05) in 9 of 12 sites from pretesting to posttesting. Mean postcourse palpation accuracy was within 1 cm for 8 of 12 structures. This study demonstrates that an integrated MSK ultrasound and palpation curriculum improves palpation accuracy at multiple MSK structures and this improvement is retained. Physical medicine and rehabilitation residencies should consider integrating palpation skills into their ultrasound curriculum to improve the caliber of their trainees.