APP Leaders Take the Stage at the NYNJ Pain Medicine Symposium
November 23, 2021
Our esteemed advisory board members, Ashley Comer, MSN, APRN, FNP-C and Kristen Klein, AGNP-C, took the stage at the 2021 New York and New Jersey Pain Medicine Symposium: Evolving Advanced Pain Therapies.
If you missed it, here are the key takeaways from their Advanced Practice Providers (APP) educational sessions:
Perioperative Pain Management: Impact of COVID-19 on Clinical Practice
Ashley Comer, MSN, APRN, FNP-C
Ashley is part of a busy practice in West Virginia. When the shutdown occurred in March 2020, she immediately partnered with her office manager and spent the weekend implementing telemedicine capabilities. What they thought was problem solving to manage patients for the “2 weeks to flatten the curve,” turned into a longer-term requirement and now a preferred and permanent part of the way they practice.
Telemedicine Is Here to Stay
Although in-person visits have obvious benefits, Ashley and her team have been pleasantly surprised by the advantages telemedicine provides:
Increased ability and efficiency in collecting patient history and symptoms. When patients are in their homes, they are often more comfortable and therefore more open to sharing the information needed to complete their assessment.
Reduced missed patient visits
Less time, resources, and physical demand on patients. Finding a ride, being in the car, and waiting in the reception area all take a toll on pain patients. Telemedicine removes these barriers so more patients are able to get access to Ashley and her team quicker, and with less hassle. If the patient needs to be seen, the assessment and imaging order can be done in advance. This way, when they come into the office, they are further along in their diagnosis and treatment planning, and the number of visits required are reduced.
Ability to care for patients who live further from the practice or who wish to avoid exposure to potential illnesses
Tips for Success
Ashley shared the following tips for a successful telemedicine visit with your patient:
During physical exams, don’t limit your visit to audio-only. Take advantage of the video capabilities and get the patient moving so you can observe their function.
Model what you would like them to do (eg, loading positions, mobility tests)
Ask them to point and show you where they are experiencing discomfort
Use all the tools you have at your disposal, including:
Screen sharing, which allows you to review:
Digital educational materials
In addition to developing a new skillset with telemedicine and increasing her adeptness around collecting the patient story, Ashley also noted a rise in APPs coming together online. She emphasized that educational webinars and social media are great sources of information and collaboration with her peers.
Options for Chronic Pain Control: Lumbar Spinal Stenosis, Beyond Epidurals
Kristen Klein, AGNP-C
Kristen works with a large population of Medicare-aged patients, so lumbar spinal stenosis (LSS) is a predominant condition treated in her practice. Historically, there was a gap in the treatment algorithm, so IPM practices had to choose between epidural steroid injections (ESIs) and open surgery. Now, these practices have new options, including the mild® Procedure. Kristen shared some recommendations for APPs managing mild® patients in their practice:
Assess patients: Neurogenic claudication (NC), known as the Shopping Cart Syndrome, presents as symptoms in the lower back, legs, and buttocks when walking or standing that are relieved with sitting or flexion—like leaning over a shopping cart
Take a good history: Patients experiencing NC often sit or reduce their mobility to avoid pain, and often associate these symptoms with just “getting older and slower.” Therefore, they might express pain, but without prompting, may never mention their functional limitations or that they spend the majority of their day sitting. Spend time with patients to identify their symptoms and more importantly, their functional limitations. Ask how long they can stand/walk before they experience symptoms or need to rest, and which activities of daily life are limited by their condition.
Look at your own imaging. Don’t rely on just the reports as they often don’t include the full picture.
Set patient expectations. Educate them on what to expect on procedure day and the reconditioning requirements so they know mobility improvements will happen over time, not immediately.
Don’t solely focus on pain. Reference their baseline walking/standing time and their activities of daily living goals. Compare their outcomes to baseline and discuss progress and mobility goals to work towards.
Interested in learning more about APP educational opportunities?
Benyamin RM, Staats PS, MiDAS ENCORE Investigators. mild® is an effective treatment for lumbar spinal stenosis with neurogenic claudication: MiDAS ENCORE Randomized Controlled Trial. Pain Physician. 2016;19(4):229-242.
Mekhail N, Costandi S, Abraham B, Samuel SW. Functional and patient-reported outcomes in symptomatic lumbar spinal stenosis following percutaneous decompression. Pain Pract. 2012;12(6):417-425. doi:10.1111/j.1533-2500.2012.00565.x.
2012 data from Health Market Sciences report for Vertos Medical 2013.
Data on file with Vertos Medical.
Staats PS, Chafin TB, Golvac S, et al. Long-term safety and efficacy of minimally invasive lumbar decompression procedure for the treatment of lumbar spinal stenosis with neurogenic claudication: 2-year results of MiDAS ENCORE. Reg Anesth Pain Med. 2018;43:789-794. doi:10.1097/AAP.0000000000000868.
Based on mild® Procedure data collected in all clinical studies. Major complications are defined as dural tear and blood loss requiring transfusion.
MiDAS ENCORE responder data. On file with Vertos Medical.
Jain S, Deer TR, Sayed D, et al. Minimally invasive lumbar decompression: a review of indications, techniques, efficacy and safety. Pain Manag. 2020;10(5). https://doi.org/10.2217/pmt-2020-0037. Accessed June 1, 2020.
Deer TR, Grider JS, Pope JE, et al. The MIST Guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Pract. 2019;19(3)250-274. doi:10.1111/papr.12744.
Hansson T, Suzuki N, Hebelka H, Gaulitz A. The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum. Eur Spine J. 2009;18(5):679-686. doi:10.1007/s00586-009-0919-7.
Treatment options shown are commonly offered once conservative therapies (e.g., physical therapy, pain medications, chiropractic) are not providing adequate relief. This is not intended to be a complete list of all treatments available. Doctors typically recommend treatments based on their safety profile, typically prioritizing low risk/less aggressive procedures before higher risk/more aggressive procedures, but will determine which treatments are appropriate for their patients.
Although the complication rate for the mild® Procedure is low, as with most surgical procedures, serious adverse events, some of which can be fatal, can occur, including heart attack, cardiac arrest (heart stops beating), stroke, and embolism (blood or fat that migrates to the lungs or heart). Other risks include infection and bleeding, spinal cord and nerve injury that can, in rare instances, cause paralysis. This procedure is not for everyone. Physicians should discuss potential risks with patients. For complete information regarding indications for use, warnings, precautions, and methods of use, please reference the devices’Instructions for Use.
Patient stories on this website reflect the results experienced by individuals who have undergone the mild® Procedure. Patients are not compensated for their testimonial. The mild® Procedure is intended to treat lumbar spinal stenosis (LSS) caused by ligamentum flavum hypertrophy. Although patients may experience relief from the procedure, individual results may vary. Individuals may have symptoms persist or evolve or other conditions that require ongoing medication or additional treatments. Please consult with your doctor to determine if this procedure is right for you.
Reimbursement, especially coding, is dynamic and changes every year. Laws and regulations involving reimbursement are also complex and change frequently. Providers are responsible for determining medical necessity and reporting the codes that accurately describe the work that is done and the products and procedures that are furnished to patients. For this reason, Vertos Medical strongly recommends that you consult with your payers, your specialty society, or the AMA CPT regarding coding, coverage and payment.
Vertos Medical cannot guarantee coding, coverage, or payment for products or procedures. View our Billing Guide.
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Hall S, Bartleson JD, Onofrio BM, Baker HL Jr, Okazaki H, O’Duffy JD. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med. 1985;103(2):271-275. doi:10.7326/0003-4819-103-2-271.
Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence & association with symptoms: The Framingham Study. Spine J. 2009;9(7):545-550. doi:10.1016/j.spinee.2009.03.005.
Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998;14(2):148-151. doi:10.1097/00002508-199806000-00010.
Mekhail N, Costandi S, Nageeb G, Ekladios C, Saied O. The durability of minimally invasive lumbar decompression procedure in patients with symptomatic lumbar spinal stenosis: Long-term follow-up [published online ahead of print, 2021 May 4]. Pain Pract. 2021;10.1111/papr.13020. doi:10.1111/papr.13020
Friedly JL, Comstock BA, Turner JA, et al. Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial. Arch Phys Med Rehabil. 2017;98(8):1499-1507.e2. doi:10.1016/j.apmr.2017.02.029
Pope J, Deer TR, Falowski SM. A retrospective, single-center, quantitative analysis of adverse events in patients undergoing spinal stenosis with neurogenic claudication using a novel percutaneous direct lumbar decompression strategy. J Pain Res. 2021;14:1909-1913. doi: 10.2147/JPR.S304997
Pryzbylkowski P, Bux A, Chandwani K, et al. Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections [published online ahead of print, 2021 Aug 4]. Pain Manag. 2021;10.2217/pmt-2021-0056. doi:10.2217/pmt-2021-0056
Abstract presented at: American Society of Pain and Neuroscience Annual Conference; July 22-25, 2021; Miami Beach, FL.
Mobility Matters: Low Back Pain in America, Harris Poll Survey, 2022. View data and full summary at knowyourbackstory.com.
Deer TR, Grider JS, Pope JE, et al. Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2022;15:1325-1354. Published 2022 May 5. doi:10.2147/JPR.S355285.