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The core faculty of the fellowship includes 6 Board Certified pain physicians whose practice primarily involves interventional treatments to patients suffering from a variety of painful conditions.
The University of Kansas Medical CenterThe University of Kansas prohibits discrimination on the basis of race, color, ethnicity, religion, sex, national origin, age, ancestry, disability, status as a veteran, sexual orientation, marital status, parental status, gender identity, gender expression, and genetic information in the university's programs and activities. In December 2013, I submitted a 161-page letter to the Accreditation Council for Graduate Medical Education (ACGME) requesting that regional anesthesiology and acute pain medicine be considered for fellowship accreditation, with a lot of help from a small group of fellowship directors and colleagues from obstetric anesthesiology who recently went through the ACGME accreditation process for their fellowships.
Over 80% of practicing #pain physicians in the US focus only on chronic pain and not acute. As with other medical subspecialties, acute pain medicine has emerged due to the need for trained specialists—in this case, those who possess the knowledge, skills, and abilities to efficiently manage a high volume of inpatient consultations, anticipate the analgesic needs of a wide range of patients based on preoperative risk, use a multimodal approach to manage and prevent pain when possible, and aggressively treat severe acute pain when it occurs to prevent it from transitioning into chronic pain. Raj PP, Montgomery SJ, Nettles D, Jenkins MT Infraclavicular brachial plexus block–a new approach.
Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation (4). The practice of anesthesiology in the United States is evolving, and there is a greater emphasis on demonstrating value. To date, anesthetic interventions focused on targeting acute pain have not demonstrated long-term functional benefits (12,13).
In summary, the PSH is a model that can be applied many ways to provide coordinated care of the surgical patient from the decision to proceed with surgery through convalescence. Mariano ER, Walters TL, Kim TE, Kain ZN: Why the perioperative surgical home makes sense for veterans affairs health care. Walters TL, Mariano ER, Clark JD: Perioperative Surgical Home and the Integral Role of Pain Medicine.
Mariano ER, Miller B, Salinas FV: The expanding role of multimodal analgesia in acute perioperative pain management. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER: Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA.
Kim TE, Mariano ER: Developing a Multidisciplinary Fall Reduction Program for Lower-Extremity Joint Arthroplasty Patients. Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually (1). In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting (2). While opioids are still important pain medications, they should be combined with other classes of medications known to help relieve postoperative pain unless contraindicated.
Non-steroidal anti-inflammatory drugs (NSAIDs): Examples include ibuprofen, diclofenac, ketorolac, celecoxib. Acetaminophen: Acetaminophen acts on central prostaglandin synthesis and provides pain relief through multiple mechanisms. The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated. When compared to opioids alone, epidural analgesia produces lower pain scores and shorter time to achieve physical therapy goals (3).
The saphenous nerve is the largest sensory branch of the femoral nerve and can be blocked within the adductor canal to provide postoperative pain relief and facilitate rehabilitation (8, 9). In actual knee replacement patients, quadriceps function decreases regardless of nerve block type after surgery but to a lesser degree with adductor canal blocks (11).
According to a large retrospective study of almost 200,000 cases, the incidence of inpatient falls for patients after TKA is 1.6%, and perioperative use of nerve blocks is not associated with increased risk (14). In addition to a femoral nerve or adductor canal block, a sciatic nerve block is sometimes offered to provide a “complete” block of the leg. For more information about anesthetic options for knee replacement, please see my post on My Knee Guide. Mahoney OM, Noble PC, Davidson J, Tullos HS: The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Raj PP, Knarr DC, Vigdorth E, Denson DD, Pither CE, Hartrick CT, Hopson CN, Edstrom HH: Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery.
Chan EY, Fransen M, Parker DA, Assam PN, Chua N: Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Chen J, Lesser JB, Hadzic A, Reiss W, Resta-Flarer F: Adductor canal block can result in motor block of the quadriceps muscle. Abdallah FW, Brull R: Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? Mariano ER, Kim TE, Wagner MJ, Funck N, Harrison TK, Walters T, Giori N, Woolson S, Ganaway T, Howard SK: A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty. For FY2014, the elements of value-based purchasing have been updated to include the Clinical Process of Care Domain, Patient Experience of Care Domain, and a new Outcomes Domain. The Patient Experience Domain is assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
How do we as anesthesiologists address the need for acute pain medicine physicians and have a positive impact on the patient experience? There remains substantial controversy related to the potential association between regional anesthesia and inpatient falls (5, 6). Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW.
Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER. Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER, Mazumdar M. In December of 2013, I submitted a 161 page letter to the Accreditation Council for Graduate Medical Education (ACGME) requesting that regional anesthesiology and acute pain medicine be considered for fellowship accreditation with the help of my fellowship director colleagues. There is clearly room and a need for a subspecialty training program in acute pain medicine that can focus on improving the in-hospital pain experience. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a random sample of patients who have received inpatient care and receive government insurance through Center for Medicare and Medicaid Services (CMS). By the time they complete the core residency in anesthesiology today, not all trainees have gained sufficient clinical experience to provide optimal care for the complete spectrum of issues experienced by patients suffering from acutely painful conditions, including the ability to reliably provide advanced interventional techniques proven to be effective in managing pain in the acute setting (8-12). In a survey of fellowship graduates and academic chairs published in 2005, 61 of 132 of academic chairs responded (46%), noting that future staffing models for their department will likely include an average of 2 additional faculty trained in regional anesthesiology and acute pain medicine (13). Currently, there are over 60 institutions in the United States and Canada that list themselves as having non-accredited fellowship training programs focused on regional anesthesiology and acute pain medicine on the ASRA website.
As with other subspecialties, acute pain medicine has emerged due to the need for trained specialists—in this case, those who understand the complicated, multi-faceted disease processes of acute pain, and its potential continuity with chronic pain, and can apply appropriate medical and interventional treatment in a timely fashion. Ready LB, Oden R, Chadwick HS, Benedetti C, Rooke GA, Caplan R, Wild LM: Development of an anesthesiology-based postoperative pain management service. Winnie AP, Collins VJ: The Subclavian Perivascular Technique of Brachial Plexus Anesthesia.
Raj PP, Parks RI, Watson TD, Jenkins MT: A new single-position supine approach to sciatic-femoral nerve block.


Raj PP, Rosenblatt R, Miller J, Katz RL, Carden E: Dynamics of local-anesthetic compounds in regional anesthesia. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT: A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery.
Hargett MJ, Beckman JD, Liguori GA, Neal JM: Guidelines for regional anesthesia fellowship training. Guidelines for fellowship training in Regional Anesthesiology and Acute Pain Medicine: Second Edition, 2010. Guidelines for fellowship training in Regional Anesthesiology and Acute Pain Medicine: Third Edition, 2014. Primary Care Approach to Knee Pain Bradley Sandella, DO, ATC Director of Sports Medicine Sports Medicine Fellowship Program Director.
Other modalities a Taping a Widely employed, multiple trials have shown not significant benefit* a McConnell taping a Bracing a No good data to demonstrate benefit a Patella stabilizing brace a Palumbo knee brace a Corticosteroid injection * Aminaka N, Gribble, PA. Statistics a 100,000 ACL injuries a year a Female athletes at 2-8 times increased risk for ACL injury than male athletes in comparable sports a Women experience ACL tears up to nine times more often then men.
One plausible cause a Dynamic Neuromuscular Imbalance a Women run, land, and jump differently a Female athletes land with greater maximal valgus angle* a Significant differences between dominant and non- dominant knees* a Female athletes rely less on hamstring and more on quadriceps and gastrocnemius++ a Upon landing, women tend to land with less knee flexion* * Mandelbaum BR et al.
Hip and Thigh Pain Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship Director, Sports Medicine Director, Interventional Pain MedStar. Incidence Hip and Thigh pain are very commonly the chief complaint of office visits – Account for 0.61% of all visits – About 1 in every 164 encounters Runners report an average yearly hip or pelvic injury rate of 2% to 11%.
Incidence NHANES III – 14.3% of patients aged 60 years and older reported significant hip pain on most days over the previous 6 weeks. Fellows will receive multi-disciplinary training with rotations through Physical Medicine & Rehabilitation, Neurology, and Psychiatry during the course of the 12 month program. While chronic pain can sometimes be palliated, “acute” pain (new onset, often with an identifiable cause) must be aggressively managed and, ideally, eliminated.
With no requests for further information, the Board of Directors of the ACGME informed me in the fall of 2014 that Regional Anesthesiology and Acute Pain Medicine (RAAPM) will be the next accredited subspecialty fellowship within the core discipline of Anesthesiology. By the time they complete the core residency in anesthesiology today, not all residents have gained sufficient clinical experience to provide optimal care for the complete spectrum of issues experienced by patients suffering from acutely painful conditions, including the ability to reliably provide advanced interventional techniques proven to be effective in managing pain in the acute setting (8-12).
Although no one can make this guarantee, there are good reasons to think that there will be growing demand for RAAPM graduates in the future. Currently, there are over 60 institutions in the United States and Canada that list themselves as having nonaccredited fellowship training programs focused on RAAPM on the ASRA website.
The RAAPM fellowship graduate must be a physician leader who is capable of collaborating with other healthcare providers in anesthesiology, surgery, medicine, nursing, pharmacy, physical therapy, and more to establish multidisciplinary programs that add value and improve patient care in the hospital setting and beyond. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: second edition, 2010. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: third edition, 2014.
In the United States, healthcare reform has been focused on achieving the “triple aim” as described by Berwick (1). Preoperatively, anesthesiologists and pain medicine specialists have an opportunity to influence patient care by identifying patients who are considered high risk for surgery and tailor an individualized preoperative preparation plan for them. Anesthesiologists have historically been successful in establishing perioperative clinical pathways that improve acute pain management especially in orthopedic surgery, and setting up regional anesthesia and acute pain medicine programs has played a key role (6). Perhaps implementation of a PSH with better care coordination that includes individualized preoperative preparation and follow-up after surgery during rehabilitation will have greater potential for positive long-term outcomes.
Besides providing anesthesia care in the operating room, anesthesiologists are dedicated to providing the best perioperative pain management in order to improve patients’ function and facilitate rehabilitation after surgery. This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain. However, higher dose of local anesthetic (numbing medicine) may lead to muscle weakness that can limit activity (4).
When compared to opioids alone, a femoral nerve block provides better pain control and leads to higher patient satisfaction (5). In healthy volunteers, quadriceps strength is better preserved when subjects receive an adductor canal block compared to a femoral nerve block (10). Recently there have been reports of quadriceps weakness resulting from adductor canal blocks and catheters that have affected clinical care (12, 13). Patient factors that increase the risk of falls include higher age, male sex, sleep apnea, delirium, anemia requiring blood transfusion, and intraoperative use of general anesthesia (14). A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States.
Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis.
This requires a systems-based approach led by physicians dedicated to understanding acute pain pathophysiology and investigating new ways to treat it. The Board of Directors of the ACGME informed me this past fall (2014) that they have approved our fellowship to be the next accredited subspecialty within anesthesiology. Yes we do, and this one year post-residency program does include the “Acute Pain Inpatient Experience.” However, this requirement may be satisfied by documented involvement with a minimum of only 50 new patients and is not the primary emphasis of fellowship training in the specialty. Such a program should advance, in a positive and value-added fashion, the present continuum of training in pain medicine.
Anesthesiology is a hospital-based medical specialty, and anesthesiologists are physicians who focus on the prevention and treatment of pain for their patients who undergo surgery, suffer trauma, or present for childbirth on a daily basis. We need physician leaders who can run acute pain medicine teams and design systems to provide individualized, comprehensive, and timely pain management for both medical and surgical patients in the hospital, expeditiously managing requests for assistance when pain intensity levels exceed those set forth in quality standards, or to prevent pain intensity from reaching such levels. Since 2002, the group of regional anesthesiology and acute pain medicine fellowship directors has been meeting twice yearly at the ASRA Spring Annual Meeting and ASA Annual Meeting which takes place in the fall. The fellowship-trained regional anesthesiologist and acute pain medicine specialist must be capable of collaborating with other healthcare providers in anesthesiology, surgery, medicine, nursing, pharmacy, physical therapy, and more to establish multidisciplinary programs that add value and improve patient care in the hospital setting and beyond.
Effectiveness of a Neuromuscular and Proprioceptive Training …Amer Journal of Sports Medicine. Common treatments provided include epidural steroid injections, facet injections, spinal cord stimulation, intrathecal pump implantation, vertebral augmentation, kyphoplasty, radiofrequency ablation, neurolytic blocks, and a multitude of other interventions.
For Pain Medicine fellows, the required “Acute Pain Inpatient Experience” may be satisfied by documented involvement with a minimum of only 50 new patients and the spectrum of pain diagnoses and treatments that they are required to learn during one year is vast. In a survey of fellowship graduates and academic chairs published in 2005, 61 of 132 of academic chairs responded (46%), noting that future staffing models for their department will likely include an average of two additional faculty trained in regional anesthesiology and acute pain medicine (13).


Since 2002, the group of regional anesthesiology and acute pain medicine fellowship directors has been meeting twice yearly at the ASRA Annual Spring Meeting and the American Society of Anesthesiologists (ASA) Annual Meeting in the fall.
This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. For example, the patient with chronic pain treated with long-acting opioids may benefit from optimizing the preoperative analgesic medication regimen, even tapering the opioid dose, or prescribing cognitive, behavioral, or physical therapy prior to elective major surgery like lower extremity joint replacement. In addition to improvements in functional outcomes, a PSH may be able to provide patients a smoother transition from hospital to home in terms of pain management and decrease the incidence of chronic pain after common elective procedures like joint replacement (14).
However, to be effective, anesthesiologists as leaders of the PSH need to target improvement strategies beyond pain outcomes and the immediate postoperative period. In addition, epidural analgesia can lead to common side effects (urinary retention, dizziness, itchiness) and is not selective for the operative leg, meaning that the non-operative leg may also become numb. One area of controversy is whether a single-injection nerve block or catheter-based technique is preferred. The bottom line is that all knee replacement patients are at increased risk for falling due to multiple risk factors, and any clinical pathway should include fall prevention strategies and an emphasis on patient safety. Arguably, the benefit of a sciatic nerve block does not last beyond the first postoperative day (15).
Pain medicine is a board-certified subspecialty of anesthesiology, physical medicine and rehabilitation, and psychiatry and neurology; graduates from any of these residency programs can apply to the one year program. A hospital’s survey scores are publicly disclosed and make up 30% of the formula used to determine how much of its diagnosis-related group payment withholding will be paid by CMS at the end of each year. The mission statement for the Acute Pain Medicine Special Interest Group within the American Academy of Pain Medicine provides additional justification.
Despite not being an ACGME-accredited fellowship, this group, recognizing the lack of formalized training guidelines, voluntarily began to develop such guidelines as the foundation for subspecialty fellowship training in existing and future programs. Fellows will become adept at the use of fluoroscopy and ultrasound to provide accurate and effective treatments.
Further, Pain Medicine is a board-certified subspecialty of Emergency Medicine, Family Medicine, Physical Medicine and Rehabilitation, and Psychiatry and Neurology, in addition to Anesthesiology; graduates from any of these residency programs can be accepted into the one-year Pain Medicine fellowship and will not be as familiar with surgical or trauma-induced acute pain as an anesthesiology residency graduate.
The mission statement for the Acute Pain Medicine Special Interest Group within the American Academy of Pain Medicine provides clear justification. RAAPM fellowship graduates are the only physicians who can say that their subspecialty training is entirely dedicated to improving the patient experience. Despite not being an ACGME-accredited fellowship, this group, has been voluntarily engaged in developing and refining training guidelines as the foundation for the fellowship. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists (ASA) in the past 5 years that may serve as an integrator to help hospitals achieve the triple aim (2). During the intraoperative period, anesthetic protocols provide consistent care for surgical patients, and implementing clinical pathways that include regional anesthesia techniques have been shown to decrease perioperative opioid use and improve outcomes. For example, concerns regarding quadriceps muscle weakness with femoral nerve blocks (7) and the potential for falls (8) have led to innovations in selective nerve block techniques for knee replacement patients (9) and greater achievements in functional rehabilitation (10). Finally, more health economic research is needed to prove the financial benefits of a PSH in terms of cost savings for hospitals. Opioids only attack pain in one way, and just adding more opioids does not usually lead to better pain control. There is evidence to support the use of continuous nerve block catheters to extend the pain relief and opioid-sparing benefits of nerve blocks in patients having major surgery like knee replacement. Surgeon-administered local anesthetic around the knee joint (local infiltration analgesia) can be combined with nerve block techniques to provide additional postoperative pain relief for the first few hours after surgery (16, 17).
The concept of an anesthesiology-led acute pain management service was described first in 1988 (2), but arguably the techniques employed in modern acute pain medicine and regional anesthesiology date back to Gaston Labat’s publication of Regional Anesthesia: its Technic and Clinical Application in 1922, with advancement and refinement of this subspecialty in the 1960s and 1970s (3-7).
These guidelines were originally published in Regional Anesthesia and Pain Medicine in 2005 (14), then were subsequently reviewed, revised, and published as the 2nd edition in 2011 (15), and have been recently updated again (16). Significant exposure to cancer pain management and advanced interventional techniques for the management of its pain is one of the cornerstones of the fellowship. At that point, which may be as early as the end of this year, institutions with RAAPM fellowships will be invited to apply for accreditation. Anesthesiology is a hospital-based medical specialty, and anesthesiologists are physicians who focus on a  daily basis on the prevention and treatment of pain for their patients who undergo surgery, suffer trauma, or present for childbirth. These guidelines, originally published in Regional Anesthesia and Pain Medicine in 2005 (14) with a revision in 2011 (15) have been recently released as the third edition (16).
PSH is defined as “a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence” (3). By establishing a PSH model, anesthesiologists have greater opportunity but also greater responsibility for reducing perioperative complications that may or may not typically be considered within the realm of anesthesiology (11). When a continuous femoral nerve block catheter is used, the pain relief is comparable to an epidural but without the epidural-related side effects (6). Fellows will be encouraged and provided ample opportunity to participate in research and attend at least one national pain meeting during the fellowship year. The survey consists of 32 questions and is intended to assess the “patient experience of care” domain in the value-based purchasing program.
Formal ACGME program requirements will serve as a measuring stick to hopefully ensure that the certificates that RAAPM fellowship graduates receive from all accredited programs will share some common value. In reality, a PSH can take many forms, and the concept is analogous to the “Perioperative Medicine: the Pathway to Better Surgical Care” initiative by the Royal College of Anaesthetists in the United Kingdom. In the United States, the patient experience of care is one of three domains that influence hospital incentive payment amounts from the Center for Medicare and Medicaid Services. One legitimate concern raised over the use of femoral nerve blocks in knee replacement patients is the resulting quadriceps muscle weakness (7). The concept of an anesthesiology-led acute pain management service was described first in 1988 (1), but arguably the techniques employed in modern acute pain medicine and regional anesthesiology date back to Gaston Labat’s publication of Regional Anesthesia: Its Technic and Clinical Application in 1922, with advancement and refinement of this subspecialty in the 1960s and 1970s (2-6).
A hospital’s survey scores are publicly disclosed and make up 30% of the formula used to determine how much of its diagnosis-related group payment withholding will be paid by CMS at the end of each year.
Patient experience is assessed using a survey, and 7 of 32 questions directly or indirectly relate to pain management (5).
Finally, a recent survey study shows that the great majority (83.7%) of practicing pain physicians in the United States focus only on chronic pain (7). After the immediate postoperative period, integrated pain management can help patients achieve physical therapy goals and facilitate the transition to after-hospital rehabilitation. For challenging patients with chronic pain, this process may require careful coordination between the in-hospital anesthesiologist, outpatient pain clinic physician, and primary care physician (4).




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