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The Role of Musculoskeletal Ultrasound in Occupational ... · Musculoskeletal ultrasound in American Occupational Medicine Residency Programs: a survey of program directors. J Occup

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The Role of Musculoskeletal Ultrasound in

Occupational Medicine

T. Greg McKelvey Jr. MD, MPH

PGY 3

Occupational & Environmental Medicine

University of Washington

Diagnostic, Point of Care

“Prediction is difficult,

especially about the

future.”

“You have to know the past to

understand the present”

1 Hz = 1

cycle/sec

1964

Anisotropy /ˌænaɪˈsɒtrəpi/ is the property of

being directionally dependent, which implies

different properties in different directions, as

opposed to isotropy.

We have identified strong out-of-band emission at 2.3–2.5 GHz associated with several peryton events.

Subsequent tests revealed that a peryton can be generated at 1.4 GHz

when a microwave oven door is opened prematurely and the telescope is at an appropriate relative angle

2015

“No pleasure is

comparable to the

standing upon the

vantage-ground of

truth.”

1712

d. 1626 1776

1016 1916

1816

“It is not from the benevolence of the

butcher, the brewer, or the baker that

we expect our dinner, but from their

regard to their own interest.”

~1439

1793

1916 2006

“One of the essential qualities of the

clinician is interest in humanity, for the

secret of the care of the patient is in caring

for the patient”

1965

1947

1945

1941

1953 1959

“I suppose it is tempting, if the only tool you

have is a hammer, to treat everything as if it

were a nail.”

1984

1996

1998

2001

1927

1918 1940

1958

2006 2015

1960- 2010

2x

57x

~1,000,000,000,000x

US Population

US Per Capita Health Costs

Computing power

“A major hurdle in brain-machine interfaces (BMI) is the lack of an implantable neural

interface system that remains viable for a lifetime.”

Echogenicity

Anisotropy

Anechoic

Hyperechoic

Hypoechoic

Non-ionizing, low-cost, on-demand, dynamic, point-and-shoot, instant resulting, handy dandy imaging modality

But wait, there’s more...

...guideline-endorsed...

For suspected rotator cuff disease

...evidence-based...

“Interestingly, one finding of this

study is that, when performed

by specially trained operators,

shoulder US may not be

as user dependent as previously

thought since, for the diagnosis

of a full-thickness RC tear,

diagnosis was similar whether

trained radiologists, sonographers

or orthopaedists performed

the US examination.“

...payer-approved..

“The substitution of MSK US for MSK MRI, when appropriate, would lead to savings of more than $6.9 billion in

the period from 2006 to 2020.”

...fiscally-responsible..

“Our cost-savings projections assume that US can replace MRI, not that both tests will be performed in a

single patient, which might increase costs.”

“The substitution of MSK US for MSK MRI, when appropriate, would lead to savings of more than $6.9 billion in

the period from 2006 to 2020.”

However, it is important to take into consideration

that the sonographers and orthopaedists who performed

the US examination in the included articles were

specially trained, and that there is a steep learning curve to

US.14

“Therefore, the use of ultrasound at the point of care must

be linked to specific training that should be defined in curriculum

such as the one recently updated by the American Medical

Society for Sports Medicine (AMSSM).”

Non-ionizing, low-cost, on-demand, dynamic, point-and-shoot, instant resulting, handy dandy imaging modality

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination.

Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet.

Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?”

“He wanted to show that fate ruled people's lives, and that those who interfered with it did so to their sorrow”

“A recent policy change at Blue Cross

Blue Shield (BCBS) for Texas, Illinois,

New Mexico, and Oklahoma

regarding musculoskeletal (MSK) ultrasound

illustrates how the status

of reimbursement for diagnostic

imaging can change overnight.”

RENAISSANCE, REVOLUTION OR

RACKET?

Thank you all!

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Med. 2015;57(5):e55-6.3. Sayeed Y, Marrocco A, Sully K, Werntz C, Allen A, Minardi J. Feasibility and Implementation of Musculoskeletal Ultrasound Training in Occupational Medicine Residency Education. J

Occup Environ Med. 2015;57(12):1347-52.4. Sully K, Schaefer M, Allen A, Werntz CL, Ma G, Sayeed Y. Musculoskeletal Ultrasound Use Among Occupational Medicine Practitioners at the American Occupational Health

Conference. J Occup Environ Med. 2016;58(8):e315-7.5. Kane D, Grassi W, Sturrock R, Balint PV. A brief history of musculoskeletal ultrasound: 'From bats and ships to babies and hips'. Rheumatology (Oxford). 2004;43(7):931-3.6. Jacobson JA. Shoulder US: anatomy, technique, and scanning pitfalls. Radiology. 2011;260(1):6-16.7. Amoo-achampong K, Nwachukwu BU, Mccormick F. An orthopedist's guide to shoulder ultrasound: a systematic review of examination protocols. Phys Sportsmed. 2016;:1-10.8. Seo D, Neely RM, Shen K, et al. Wireless Recording in the Peripheral Nervous System with Ultrasonic Neural Dust. Neuron. 2016;91(3):529-39.9. Mariani PJ. Ultrasound use and "overuse". West J Emerg Med. 2010;11(4):319-21.10. Missing sisters- A shortage of girls will haunt India for decades11. https://www.sonosite.com/sales/reimbursement12. Radiologists Must Play Central Role in Point-of-Care Ultrasound Training13. Handheld ultrasound: Threat or opportunity?14. Adhikari S, Amini R, Stolz L, et al. Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact. Am J Emerg Med. 2014;32(6):592-5.15. Filly RA. Ultrasound: the stethoscope of the future, alas. Radiology. 1988;167(2):400.16. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5(3):182-8.17. http://www.company-histories.com/SonoSite-Inc-Company-History.html18. Sharpe RE, Nazarian LN, Parker L, Rao VM, Levin DC. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. J Am

Coll Radiol. 2012;9(2):141-6.19. http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum20. Uncertainty and the welfare economics of health care

21. The Unanticipated Consequences of Purposive Social Action

22. Roy JS, Braën C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-

analysis. Br J Sports Med. 2015;49(20):1316-28.

23. Harmon KG, O'connor FG. Musculoskeletal ultrasound: taking sports medicine to the next level. Br J Sports Med. 2010;44(16):1135-6.24. Roach NT, Venkadesan M, Rainbow MJ, Lieberman DE. Elastic energy storage in the shoulder and the evolution of high-speed throwing in Homo. Nature. 2013;498(7455):483-6.25. Dijkgraaf S. Spallanzani's unpublished experiments on the sensory basis of object perception in bats. Isis. 1960;51:9-20.26. Acebes C, Harvie JP, Wilson A, Duthie J, Bowen F, Steven M. Clinical usefulness and patient satisfaction with a musculoskeletal ultrasound clinic: results of a 6-month pilot service in a

Rheumatology Unit. Rheumatol Int. 2016;27. AIUM: Collaboration drives musculoskeletal ultrasound28. Stolz L, O'brien KM, Miller ML, Winters-brown ND, Blaivas M, Adhikari S. A review of lawsuits related to point-of-care emergency ultrasound applications. West J Emerg Med.

2015;16(1):1-4.

29. Nazarian LN, Alexander AA. Denying payments for musculoskeletal ultrasound: how did we get here?. J Am

Coll Radiol. 2010;7(8):553-6.

30. Jacobson JA. Musculoskeletal ultrasound: focused impact on MRI. AJR Am J Roentgenol. 2009;193(3):619-

27.

31. http://www.riskandinsurance.com/little-progress-reducing-shoulder-claims/

32. http://www.ob-ultrasound.net/history1.html

33. http://whywebecamehuman.com/300000-year-old-hominin-spears/

34. http://www.aium.org/resources/viewStatement.aspx?id=51

35. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Musculoskeletal.pdf