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Review Article| Volume 26, ISSUE 3, P483-489, April 2023

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Educational Curriculum for Peripheral Nerve Stimulation Developed by the North American Neuromodulation Society

Open AccessPublished:December 16, 2022DOI:https://doi.org/10.1016/j.neurom.2022.09.015
Educational Curriculum for Peripheral Nerve Stimulation Developed by the North American Neuromodulation Society
Next ArticleDiaphragm Pacing: A Safety, Appropriateness, Financial Neutrality, and Efficacy Analysis of Treating Chronic Respiratory Insufficiency

      Abstract

      Background

      Peripheral nerve stimulation (PNS) is an effective neuromodulation therapy for chronic neuropathic and nociceptive pain. Although the total number of PNS implantations has increased over the last decade, no curriculum exists to guide training and learning of this therapy. The goal of the North American Neuromodulation Society (NANS) education committee is to develop a series of competency-based curriculums for neuromodulation therapies. The PNS curriculum is the latest part of such series, following the curriculums for spinal cord stimulation and intrathecal drug delivery system.

      Materials and Methods

      A multidisciplinary task force (anesthesiology, physical medicine and rehabilitation, neurosurgery, preventive medicine and public health, and neurology) was created by the educational committee of NANS to develop a PNS curriculum in accordance with the Accreditation Council for Graduate Medical Education (ACGME) milestones. The curriculum was created based on the best available evidence and expert knowledge (from our task force members) of available PNS systems. The final PNS curriculum was approved by the NANS board.

      Results

      A PNS curriculum was developed by the task force. Milestones included professionalism, practice-based learning, interpersonal communication, medical knowledge, systems-based practice, procedural skills, and patient care. Each milestone was defined into three categories: early learner, advanced learner, and practitioner.

      Conclusions

      This manuscript provides a PNS training curriculum developed by a multidisciplinary task force of the NANS educational committee in accordance with the milestones described by ACGME for basic learners, advanced learners, and practitioners. This curriculum will help provide a structured training and evaluation process for obtaining proficiency in PNS treatment(s).

      Keywords

      Introduction

      Peripheral nerve stimulation (PNS) is a neuromodulation therapy focused on pain management by electrically modulating peripheral nerves.
      • Henderson J.M.
      Peripheral nerve stimulation for chronic pain.
      Curr Pain Headache Rep. 2008; 12: 28-31https://doi.org/10.1007/s11916-008-0006-5
      ,
      • Slavin K.V.
      Peripheral nerve stimulation for neuropathic pain.
      Neurotherapeutics. 2008; 5: 100-106https://doi.org/10.1016/j.nurt.2007.11.005
      PNS continues to evolve with accrual of prospective studies. Our understanding of this nascent and burgeoning therapy has increased significantly over the past decade with the development of novel waveforms and identification of new neural targets.
      • Deer T.
      • Pope J.
      • Benyamin R.
      • et al.
      Prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin.
      Neuromodulation. 2016; 19: 91-100https://doi.org/10.1111/ner.12381
      PNS now most often involves a minimally invasive procedure where an electrode array (lead) is implanted using ultrasound and/or fluoroscopic guidance or open surgical approach along a named peripheral nerve or branches of a named nerve. Peripheral nerve field stimulation (PNfS) is a similar neurostimulation modality that involves stimulation of fine branches of terminal nerves,
      • Petersen E.A.
      • Slavin K.V.
      Peripheral nerve/field stimulation for chronic pain.
      Neurosurg Clin N Am. 2014; 25: 789-797https://doi.org/10.1016/j.nec.2014.07.003
      but there is no implantable system that is specifically approved by the US Food and Drug Administration for PNfS applications.
      Much of the prospective data in support of PNS therapies has been produced within the past five years. Until that time, most studies were performed with repurposed spinal cord stimulation (SCS) technology. Recently, the number of manufacturers of specifically engineered PNS systems has increased in tandem with the number of clinical (procedural) approaches, resulting in an expansion of indications and implantation techniques. The increased complexity and utilization of diverse technologies mandate proper training of physicians in its application for better patient outcomes.
      The training, experience, and conceptual knowledge may vary vastly among a diverse background of specialties that deal with PNS in clinical practice. As with any other neuromodulation therapy, appropriate patient selection, surgical implantation technique, and follow-up care are the key to success with PNS therapy.
      American Council of Graduate Medical Education (ACGME) – accredited Multidisciplinary Pain Management fellowship programs and Neurosurgical training programs are responsible for providing competency-based training in advanced neuromodulation therapies, including PNS.
      • Henderson J.M.
      • Levy R.M.
      • Bedder M.D.
      • et al.
      NANS training requirements for spinal cord stimulation devices: selection, implantation, and follow-up.
      Neuromodulation. 2009; 12: 171-174https://doi.org/10.1111/j.1525-1403.2009.00211.x
      ,
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      The Education Committee of the North American Neuromodulation Society (NANS) convened to create a training curriculum for the specialists who will be involved with PNS therapy (Table 7, Table 1, Table 2, Table 3, Table 4, Table 5, Table 6).
      Table 7Core Attributes of Neuromodulation Competencies.
      Patient care and procedural skills
       Patient selection
       Ultrasound knowledge and interpretation
       Radiographic knowledge and interpretation
       Trialing
       Surgical skills
       Intraoperative troubleshooting and management
       Complication management
       Long term care
      System-based practice
       Coding and billing
       Practice management
       Economics
       Safety and systems
      Medical knowledge
       Physiology of pain
       Targets of stimulation
       Modes of stimulation and programming
       Anatomical and physiological knowledge of peripheral nerves
      Interpersonal and communication skills
       Relational
       Technology
      Practice-based learning
       Research
       Lifelong learning
      Professionalism
       Diversity and inclusion
       Compassion
       Accountability
      Table 1Patient Care and Procedural Skills.
      Early learnerAdvanced learnerPractitioner
      Patient selection
      • Slavin K.V.
      Peripheral nerve stimulation for neuropathic pain.
      Neurotherapeutics. 2008; 5: 100-106https://doi.org/10.1016/j.nurt.2007.11.005
      ,
      • Deer T.
      • Pope J.
      • Benyamin R.
      • et al.
      Prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin.
      Neuromodulation. 2016; 19: 91-100https://doi.org/10.1111/ner.12381
      ,
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Naidu R.
      • Strand N.
      • et al.
      A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions.
      Bioelectron Med. 2020; 6: 9https://doi.org/10.1186/s42234-020-00045-5
      ,
      • Chakravarthy K.
      • Nava A.
      • Christo P.J.
      • Williams K.
      Review of recent advances in peripheral nerve stimulation (PNS).
      Curr Pain Headache Rep. 2016; 20: 60https://doi.org/10.1007/s11916-016-0590-8
      , 
      • Lee P.B.
      • Horazeck C.
      • Nahm F.S.
      • Huh B.K.
      Peripheral nerve stimulation for the treatment of chronic intractable headaches: long-term efficacy and safety study.
      Pain Phys. 2015; 18: 505-516
      , 
      • Oswald J.
      • Shahi V.
      • Chakravarthy K.V.
      Prospective case series on the use of peripheral nerve stimulation for focal mononeuropathy treatment.
      Pain Manag. 2019; 9: 551-558https://doi.org/10.2217/pmt-2019-0028
      , 
      • Deer T.R.
      • Mekhail N.
      • Provenzano D.
      • et al.
      The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee.
      Neuromodulation. 2014; 17 ([discussion: 550] http//doi.org/10.1111/ner.12208): 515-550
      , 
      • Deer T.R.
      • Krames E.
      • Mekhail N.
      • et al.
      The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states.
      Neuromodulation. 2014; 17: 599-615https://doi.org/10.1111/ner.12204
      • i.
        Recognize evidence-based indications for peripheral nerve stimulation
      • ii.
        Conduct comprehensive history, clinical examination, and recognize signs/symptoms of common indication
      • i.
        Identify medical, surgical, and psychologic requirements for candidacy
      • ii.
        Describe the effect of other treatments (opioids) on outcomes
      • i.
        Develop individualized neuromodulation treatment plan
      • ii.
        Provide adequate patient counseling/education and manage patient expectations to encourage compliance
      • iii.
        Define benefits of peripheral nerve stimulation compared to other forms of therapy.
      • iv.
        Counsel patients about peripheral nerve stimulation vs other surgical and neuromodulation options
      • v.
        Identify the role of diagnostic peripheral nerve blocks in patient selection
      Radiographic knowledge and interpretation
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Provenzano D.A.
      • Hanes M.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management.
      Neuromodulation. 2017; 20: 31-50https://doi.org/10.1111/ner.12565
      ,
      • Sayed D.
      • Chakravarthy K.
      • Amirdelfan K.
      • et al.
      A comprehensive practice guideline for magnetic resonance imaging compatibility in implanted neuromodulation devices.
      Neuromodulation. 2020; 23: 893-911https://doi.org/10.1111/ner.13233
      • i.
        Interpret radiographic anatomy
      • ii.
        Identify different radiographic modalities (x-ray, CT) available to augment decision-making process
      • iii.
        Demonstrate basic knowledge of MRI safety with implanted devices
      • i.
        Determine appropriate preoperative radiographic evaluation
      • ii.
        Practice principles of radiation safety
      • iii.
        Practice principles of MRI safety with implanted devices
      • i.
        Identify hardware migration/malfunction on radiographic imaging
      • ii.
        Incorporate radiographic imaging results in decision-making and complication management
      • iii.
        Formulate individualized therapy and device plans based on MRI conditionality/compatibility and patient conditions
      • iv.
        Identify conditions that alter MRI compatibility (lead fracture, high impedance, etc)
      Ultrasound knowledge and interpretation
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Anderson T.A.
      Ultrasound for interventional pain management: an illustrated procedural guide.
      Anesth Analg. 2020; 131: e61-e62https://doi.org/10.1213/ANE.0000000000004870
      , 
      • Ilfeld B.M.
      • Grant S.A.
      • Gilmore C.A.
      • et al.
      Neurostimulation for postsurgical analgesia: a novel system enabling ultrasound-guided percutaneous peripheral nerve stimulation.
      Pain Pract. 2017; 17: 892-901https://doi.org/10.1111/papr.12539
      , 
      • Ilfeld B.M.
      • Said E.T.
      • Finneran J.J.
      • et al.
      Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the femoral nerve for postoperative analgesia following ambulatory anterior cruciate ligament reconstruction: a proof of concept study.
      Neuromodulation. 2019; 22: 621-629https://doi.org/10.1111/ner.12851
      • i.
        Describe basic ultrasonography principles
      • ii.
        Describe basic sonoanatomy
      • iii.
        Demonstrate hand-eye coordination for basic ultrasound-guided musculoskeletal and pain procedures
      • i.
        Recognize methods for ultrasonic image optimization
      • ii.
        Identify variability in sonoanatomy
      • iii.
        Demonstrate ability to target specific structure under direct ultrasound guidance
      • i.
        Apply ultrasonography principles to obtain appropriate target anatomy
      • ii.
        Interpret hardware migration/malfunction on ultrasound imaging
      • iii.
        Incorporate ultrasound evaluation in decision-making and complication management
      Trialing
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Mekhail N.
      • Provenzano D.
      • et al.
      The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee.
      Neuromodulation. 2014; 17 ([discussion: 550] http//doi.org/10.1111/ner.12208): 515-550
      , 
      • Deer T.R.
      • Krames E.
      • Mekhail N.
      • et al.
      The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states.
      Neuromodulation. 2014; 17: 599-615https://doi.org/10.1111/ner.12204
      , 
      • Deer T.R.
      • Provenzano D.A.
      • Hanes M.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management.
      Neuromodulation. 2017; 20: 31-50https://doi.org/10.1111/ner.12565
      ,
      • Deer T.R.
      • Lamer T.J.
      • Pope J.E.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) safety guidelines for the reduction of severe neurological injury.
      Neuromodulation. 2017; 20: 15-30https://doi.org/10.1111/ner.12564
      • i.
        Recognize the indications for trialing
      • ii.
        Perform preoperative evaluation
      • i.
        Recognize optimal trialing technique
      • ii.
        Identify risks, benefits, cost-effectiveness of performing a trial
      • i.
        Define validity and identify parameters of trial success
      • ii.
        Manage trial complications and troubleshooting
      Surgical skills
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Provenzano D.A.
      • Hanes M.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management.
      Neuromodulation. 2017; 20: 31-50https://doi.org/10.1111/ner.12565
      ,
      • Deer T.R.
      • Lamer T.J.
      • Pope J.E.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) safety guidelines for the reduction of severe neurological injury.
      Neuromodulation. 2017; 20: 15-30https://doi.org/10.1111/ner.12564
      , 
      • Massie L.
      • Ali R.
      • Slavin K.V.
      • Schwalb J.M.
      Concurrent placement of bilateral suboccipital and supraorbital nerve stimulators using On-Q∗ tunneler: technical note.
      Oper Neurosurg (Hagerstown). 2018; 15: 720-724https://doi.org/10.1093/ons/opy036
      , 
      • Eckmann M.S.
      • Bickelhaupt B.
      • Fehl J.
      • et al.
      Cadaveric study of the articular branches of the shoulder joint.
      Reg Anesth Pain Med. 2017; 42: 564-570https://doi.org/10.1097/AAP.0000000000000652
      • i.
        Identify basic instrument sets and practice basic surgical skills
      • ii.
        Describe basic aseptic practices and describe principles of wound healing
      • i.
        Master advanced surgical skills, including tunneling techniques if warranted
      • ii.
        Identify optimal lead location based on individual systems available
      • iii.
        Adopt proper anchoring systems if indicated
      • iv.
        Utilize intraoperative image guidance for optimal lead placement
      • i.
        Develop individualized neuromodulation plan in complicated and previously trialed or permanently implanted patient
      • ii.
        Define appropriate surgical approach for procedure based on individual characteristics
      • iii.
        Identify and manage complex anatomic situations and/or comorbidities
      Intraoperative troubleshooting
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Chakravarthy K.
      • Nava A.
      • Christo P.J.
      • Williams K.
      Review of recent advances in peripheral nerve stimulation (PNS).
      Curr Pain Headache Rep. 2016; 20: 60https://doi.org/10.1007/s11916-016-0590-8
      ,
      • Deer T.R.
      • Provenzano D.A.
      • Hanes M.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management.
      Neuromodulation. 2017; 20: 31-50https://doi.org/10.1111/ner.12565
      ,
      • Deer T.R.
      • Lamer T.J.
      • Pope J.E.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) safety guidelines for the reduction of severe neurological injury.
      Neuromodulation. 2017; 20: 15-30https://doi.org/10.1111/ner.12564
      ,
      • de Leon-Casasola O.A.
      Spinal cord and peripheral nerve stimulation techniques for neuropathic pain.
      J Pain Symptom Manage. 2009; 38: S28-S38https://doi.org/10.1016/j.jpainsymman.2009.05.005
      • i.
        Identify intraoperative concerns (patient positioning, nerve injury, hemostasis, etc)
      • i.
        Optimize use of intraoperative imaging modality (ultrasound vs fluoroscopy)
      • ii.
        Describe nerve stimulation parameters and its role in lead location
      • i.
        Identify system malfunction through sequential troubleshooting
      • ii.
        Identify the factors that could necessitate the replacement of malfunctioning hardware
      • iii.
        Confirm and document final lead location
      Complication management
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Krames E.
      • Mekhail N.
      • et al.
      The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states.
      Neuromodulation. 2014; 17: 599-615https://doi.org/10.1111/ner.12204
      ,
      • Deer T.R.
      • Provenzano D.A.
      • Hanes M.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management.
      Neuromodulation. 2017; 20: 31-50https://doi.org/10.1111/ner.12565
      ,
      • Deer T.R.
      • Lamer T.J.
      • Pope J.E.
      • et al.
      The Neurostimulation Appropriateness Consensus Committee (NACC) safety guidelines for the reduction of severe neurological injury.
      Neuromodulation. 2017; 20: 15-30https://doi.org/10.1111/ner.12564
      ,
      • Sharan A.
      • Huh B.
      • Narouze S.
      • et al.
      Analysis of adverse events in the management of chronic migraine by peripheral nerve stimulation.
      Neuromodulation. 2015; 18 ([discussion: 312]. http://doi.org/10.1111/ner.12243): 305-312
      • i.
        Describe preoperative screening, decolonization, and proper use of antibiotics
      • ii.
        Recognize guidelines for antiplatelet and anticoagulant when operating close to peripheral nerves
      • i.
        Identify early signs and symptoms of complications (infection, loss of efficacy, and neurological dysfunction)
      • ii.
        Practice timely management of complications
      • iii.
        Counsel family and patient regarding complications and management options
      • iv.
        Perform adequate, transparent, and appropriate documentation
      • i.
        Practice in accordance with the latest evidence-based guidelines for complication management
      • ii.
        Identify unique patient factors that would necessitate deviation from guidelines
      • iii.
        Identify conditions requiring shared decision-making and multi-disciplinary management
      • iv.
        Participate in multi-disciplinary peer conferences in relation to complications
      Long term care
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Patel J.
      • DeFrancesch F.
      • Smith C.
      Spine Intervention Society’s Patient Safety Committee. Spinal cord stimulation patients with permanent pacemakers and defibrillators.
      Pain Med. 2018; 19: 1693-1694https://doi.org/10.1093/pm/pny049
      • i.
        Identify interactions with other therapies and treatments (pacemakers, diathermy, other implantable devices, etc)
      • i.
        Perform evaluation for loss of efficacy (progression of disease vs device malfunction vs new pathology)
      • ii.
        Demonstrate knowledge and understanding of reprogramming process
      • i.
        Distinguish device vs therapy failure from loss of efficacy or new pathology
      • ii.
        Formulate treatment plan for loss of efficacy
      CT, computed tomography; MRI, magnetic resonance imaging.
      Table 2System-Based Practice.
      Early learnerAdvanced learnerPractitioner
      Coding and billing
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Navalgund Y.
      Medical necessity, documentation, coding, and billing for spinal cord stimulation.
      https://www.asra.com/guidelines-articles/original-articles/chronic-pain-medicine/chronic-pain-medicine/asra-news/2019/05/01/medical-necessity-documentation-coding-and-billing-for-spinal-cord-stimulation
      , 
      • van Gorp E.J.A.A.
      • Adang E.M.M.
      • Gültuna I.
      • et al.
      Cost-effectiveness analysis of peripheral nerve field stimulation as add-on therapy to spinal cord stimulation in the treatment of chronic low back pain in failed back surgery syndrome patients.
      Neuromodulation. 2020; 23: 639-645https://doi.org/10.1111/ner.13032
      , 
      • Chen H.W.
      • Bercik R.S.
      • Werner E.F.
      • Thung S.F.
      Cost-effectiveness of percutaneous tibial nerve stimulation versus extended release tolterodine for overactive bladder.
      J Urol. 2012; 187: 178-184https://doi.org/10.1016/j.juro.2011.09.052
      • i.
        Use accurate diagnosis and proper documentation
      • i.
        Describe cost-effectiveness, preauthorization/pre-certification of neuromodulation therapies
      • i.
        Describe local coverage determinants, policies, and optimal reimbursement regarding peripheral nerve stimulation
      Practice management
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Navalgund Y.
      Medical necessity, documentation, coding, and billing for spinal cord stimulation.
      https://www.asra.com/guidelines-articles/original-articles/chronic-pain-medicine/chronic-pain-medicine/asra-news/2019/05/01/medical-necessity-documentation-coding-and-billing-for-spinal-cord-stimulation
      ,
      • Lu Y.
      • Xie D.
      • Zhang X.
      • et al.
      Management of intractable pain in patients with implanted spinal cord stimulation devices during the COVID-19 pandemic using a remote and wireless programming system.
      Front Neurosci. 2020; 14594696https://doi.org/10.3389/fnins.2020.594696
      , 
      • Deer T.R.
      • Esposito M.F.
      • Cornidez E.G.
      • Okaro U.
      • Fahey M.E.
      • Chapman K.B.
      Teleprogramming service provides safe and remote stimulation options for patients with DRG-S and SCS implants.
      J Pain Res. 2021; 14: 3259-3265https://doi.org/10.2147/JPR.S332966
      , 
      Centers for Medicare & Medicaid Services
      Medicare telemedicine health care provider fact sheet.
      https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
      • i.
        Work with other team members (trainees, APPs, etc)
      • ii.
        Identify and use various telehealth platforms.
      • i.
        Identify site of service differential (office-based, hospital-based outpatient department or ambulatory surgery center)
      • ii.
        Identify billing and compliance requirements of various telehealth platforms.
      • i.
        Develop referral network and relationships with complementary specialists
      • ii.
        Incorporate telehealth and virtual programming in clinic workflows and research protocols.
      • iii.
        Create safe and reliable systems for managing complications
      Economics
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Mekhail N.
      • Provenzano D.
      • et al.
      The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee.
      Neuromodulation. 2014; 17 ([discussion: 550] http//doi.org/10.1111/ner.12208): 515-550
      ,
      • Deer T.R.
      • Krames E.
      • Mekhail N.
      • et al.
      The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states.
      Neuromodulation. 2014; 17: 599-615https://doi.org/10.1111/ner.12204
      ,
      • van Gorp E.J.A.A.
      • Adang E.M.M.
      • Gültuna I.
      • et al.
      Cost-effectiveness analysis of peripheral nerve field stimulation as add-on therapy to spinal cord stimulation in the treatment of chronic low back pain in failed back surgery syndrome patients.
      Neuromodulation. 2020; 23: 639-645https://doi.org/10.1111/ner.13032
      • i.
        Uses resources responsibly
      • i.
        Cites literature data when applicable on cost-effectiveness and outcomes to support utilization
      • i.
        Designs and implements cost-effective care pathways
      Safety and systems
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Define medical errors, near misses, and sentinel events
      • ii.
        Utilize protocols and checklists for patient hand-offs, medication orders, and emergencies
      • i.
        Identify the principles of conducting root cause analysis
      • ii.
        Participate in process improvement activities
      • i.
        Analyze and implement processes driven by root cause analysis recommendation
      • ii.
        Design and lead process improvement activities
      APP, advanced practice provider.
      Table 3Medical Knowledge.
      Early learnerAdvanced learnerPractitioner
      Physiology of pain
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Yaksh T.L.
      • Chaplan S.R.
      Physiology and pharmacology of neuropathic pain.
      Anesthesiol Clin N America. 1997; 15: 335-352https://doi.org/10.1016/S0889-8537(05)70337-0
      , 
      • Omoigui S.
      The biochemical origin of pain--proposing a new law of pain: the origin of all pain is inflammation and the inflammatory response. Part 1 of 3--a unifying law of pain.
      Med Hypotheses. 2007; 69: 70-82https://doi.org/10.1016/j.mehy.2006.11.028
      , 
      • Omoigui S.
      The biochemical origin of pain: the origin of all pain is inflammation and the inflammatory response. Part 2 of 3 - inflammatory profile of pain syndromes.
      Med Hypotheses. 2007; 69: 1169-1178https://doi.org/10.1016/j.mehy.2007.06.033
      , 
      • Nijs J.
      • Torres-Cueco R.
      • van Wilgen C.P.
      • et al.
      Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain.
      Pain Phys. 2014; 17: 447-457https://doi.org/10.36076/ppj.2014/17/447
      • i.
        Describe neurobiology of pain
      • i.
        Application of pain pathophysiological basis of disease to specific presentation of pain syndromes
      • ii.
        Describe natural history/temporal course of pain presentations
      • i.
        Comprehend underlying relationship between individual painful etiologies and peripheral/central pain sensitization
      Targets of stimulation
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Naidu R.
      • Strand N.
      • et al.
      A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions.
      Bioelectron Med. 2020; 6: 9https://doi.org/10.1186/s42234-020-00045-5
      ,
      • Deer T.R.
      • Mekhail N.
      • Provenzano D.
      • et al.
      The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee.
      Neuromodulation. 2014; 17 ([discussion: 550] http//doi.org/10.1111/ner.12208): 515-550
      ,
      • Deer T.R.
      • Krames E.
      • Mekhail N.
      • et al.
      The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states.
      Neuromodulation. 2014; 17: 599-615https://doi.org/10.1111/ner.12204
      ,
      • Ilfeld B.M.
      • Said E.T.
      • Finneran J.J.
      • et al.
      Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the femoral nerve for postoperative analgesia following ambulatory anterior cruciate ligament reconstruction: a proof of concept study.
      Neuromodulation. 2019; 22: 621-629https://doi.org/10.1111/ner.12851
      ,
      • Stanton-Hicks M.
      • Panourias I.G.
      • Sakas D.E.
      • Slavin K.V.
      The future of peripheral nerve stimulation.
      Prog Neurol Surg. 2011; 24: 210-217https://doi.org/10.1159/000324298
      , 
      • Abd-Elsayed A.
      Wireless peripheral nerve stimulation for treatment of peripheral neuralgias.
      Neuromodulation. 2020; 23: 827-830https://doi.org/10.1111/ner.13131
      , 
      • Tamimi M.A.
      • Davids H.R.
      • Langston M.M.
      • Krutsch J.
      • Yakovlev A.
      • Barolat G.
      Successful treatment of chronic neuropathic pain with subcutaneous peripheral nerve stimulation: four case reports.
      Neuromodulation. 2009; 12: 210-214https://doi.org/10.1111/j.1525-1403.2009.00216.x
      , 
      • Deer T.R.
      • Levy R.M.
      • Verrills P.
      • Mackey S.
      • Abejon D.
      Perspective: peripheral nerve stimulation and peripheral nerve field stimulation birds of a different feather.
      Pain Med. 2015; 16: 411-412https://doi.org/10.1111/pme.12662
      • i.
        Demonstrate knowledge of peripheral nerve system
      • i.
        Identify optimal peripheral nerve targets for specific indications
      • i.
        Individualize applications of stimulation targets based on anatomical variability and case complexity
      Modes of Stimulation
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Identify waveforms and novel sites of stimulating peripheral nerves
      • i.
        Describe differences between programming parameters specific to PNS
      • i.
        Design a salvage plan for failures or loss of efficacy by altering programming parameters
      Anatomic consideration
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Mekhail N.
      • Provenzano D.
      • et al.
      The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee.
      Neuromodulation. 2014; 17 ([discussion: 550] http//doi.org/10.1111/ner.12208): 515-550
      ,
      • Deer T.R.
      • Krames E.
      • Mekhail N.
      • et al.
      The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states.
      Neuromodulation. 2014; 17: 599-615https://doi.org/10.1111/ner.12204
      • i.
        Describe anatomy of peripheral nervous system and associated structures
      • i.
        Identify various anatomic variabilities of peripheral nervous systems
      • ii.
        Identify anatomical alterations due to surgical interventions
      • i.
        Anticipates anatomic variability and barriers within subjects, which can be potential surgical risks
      Table 4Interpersonal and Communication Skills.
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      , 
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      Early learnerAdvanced learnerPractitioner
      Relational
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Describe the requirements of proper consent
      • ii.
        Communicate clearly and compassionately with patients, families, and colleagues
      • iii.
        Acknowledge procedural pause
      • iv.
        Perform adequate and transparent documentation
      • i.
        Identifies and incorporates patient preference in shared decision-making in complex patient care conversations and the plan of care
      • ii.
        Recognize the appropriate components of procedural pause
      • iii.
        Document appropriately unexpected events
      • iv.
        Establish a therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds
      • i.
        Obtains proper consent
      • ii.
        Role models effective communication and development of therapeutic relationships in both routine and challenging situations
      • iii.
        Lead procedural pause
      • iv.
        Develop systematic process for documentation
      Technology
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      ,
      • Deer T.R.
      • Esposito M.F.
      • Cornidez E.G.
      • Okaro U.
      • Fahey M.E.
      • Chapman K.B.
      Teleprogramming service provides safe and remote stimulation options for patients with DRG-S and SCS implants.
      J Pain Res. 2021; 14: 3259-3265https://doi.org/10.2147/JPR.S332966
      ,
      Centers for Medicare & Medicaid Services
      Medicare telemedicine health care provider fact sheet.
      https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
      • i.
        Uses HIPPA safeguards for PHI and EMR
      • ii.
        Uses EMR and radiology access systems for timely reporting of clinical information and documentation of patient care
      • i.
        Designs and implements an EMR template
      • ii.
        Uses electronic medical record to close the loop on communication internally and externally
      • i.
        Uses EMR and documentation for research
      • ii.
        Utilize EMR to optimize care pathway for PNS
      • iii.
        Utilize appropriate telemedicine and remote programming methods
      EMR, electronic medical record; HIPAA, Health Insurance Portability and Accountability Act; PHI, protected health information.
      Table 5Practice-Based Learning.
      • Deer T.
      • Pope J.
      • Benyamin R.
      • et al.
      Prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin.
      Neuromodulation. 2016; 19: 91-100https://doi.org/10.1111/ner.12381
      , 
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      Early learnerAdvanced learnerPractitioner
      Research
      • Deer T.
      • Pope J.
      • Benyamin R.
      • et al.
      Prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin.
      Neuromodulation. 2016; 19: 91-100https://doi.org/10.1111/ner.12381
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Perform literature review
      • ii.
        Identify gaps in literature to formulate a research question
      • iii.
        Demonstrate ability to write a research protocol
      • i.
        Describe the ethics and regulatory aspects of human subject research
      • ii.
        Critically analyze published literature
      • i.
        Setting research in practice location
      • ii.
        Identify levels of evidence and implement into practice
      Lifelong learning
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Awareness of practice improvement data (systematic reviews, practice guidelines, etc)
      • i.
        Participate in evidence-based practice improvement
      • ii.
        Organize educational activities at program level
      • iii.
        Teach colleagues and other health professionals in both formal and informal settings
      • i.
        Develop educational curriculum and/or assessment tools
      This current document provides a roadmap for a competency-based curriculum analogous to the training requirements created for SCS and intrathecal drug delivery systems (IDDS).
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012

      Materials and Methods

      An international multidisciplinary diverse task force was formed by the members of education committees of NANS and the International Neuromodulation Society (INS), which included neurosurgeons, anesthesiologists, physiatrists, neurologists, and preventive medicine/public health specialists. All participating members were volunteers solicited through the education committees of NANS and INS based on their expertise in PNS supported by practice volumes, research, and scientific publications. Although the curriculum is conceptualized with the existing competency and educational milestones-based American graduate medical education model, the task force was international, with representation from other countries.
      • Philibert I.
      Evolution and application of the competencies and educational milestones in physician graduate education in the United States.
      Educación Médica. 2015; 16: 17-24https://doi.org/10.1016/j.edumed.2015.04.006
      The core attributes of neuromodulation competencies share a considerable overlap of constructs among the other two published curriculums (SCS and IDDS) by NANS educational committee, as evidenced in Table 7.
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      Table 6Professionalism.
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      , 
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      Early learnerAdvanced learnerPractitioner
      Compassion
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Demonstrate good patient care, autonomy, respect, and respond to patients’ needs
      • i.
        Able to appropriately handle ethical challenges and serve as a mentor
      • i.
        Participate in improving quality of care, mitigate impact of diverse patient characteristics on patients’ outcomes and develop physicians’ wellness programs
      Accountability
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142
      ,
      • Chaiban G.
      • Abdallah R.T.
      • Abd-Elsayed A.
      • et al.
      North American Neuromodulation Society educational curriculum for intrathecal drug delivery systems implantation and management.
      Neuromodulation. Published online January 14. 2022; https://doi.org/10.1016/j.neurom.2021.11.012
      • i.
        Admit to committing any errors, recognize own limitations, seek assistance, accept feedback, and lead effective M&M discussions
      • i.
        Assume effective leadership, able to resolve conflicts, and effectively manage personal stressors
      • i.
        Serve as a role model, manages COI effectively, recognize and respond to physician impairment, whether in self or others
      COI, conflict of interest; M&M, mortality and morbidity.
      A hybrid meeting that included in-person and virtual platforms was convened in September 2021. The proposed competencies were discussed and debated among members of the task force. All proposed competencies were developed using iterative contribution, vetting, and in-depth discussion. Quorum consensus was used to mitigate differences among task force members. In rare cases, when a consensus could not be reached, the executive leadership of the committee decided on the final recommendations. The structure of the document progresses vertically and includes six competencies: patient care and procedural skills, systems-based practice, medical knowledge, interpersonal and communication skills, practice-based learning, and professionalism (Table 1). The levels of training progress horizontally from the stage of the early learner to the established practitioner.
      The entire document was exhaustively reviewed for accuracy, inclusion, and relevance by the task force members. The curriculum was finally peer-reviewed by the educational committees of both NANS and INS before being reviewed by the NANS board.

      Discussion and Recommendations

      PNS is a minimally invasive image-guided treatment modality that is not as widely practiced by pain management practitioners and neurosurgeons compared to SCS therapy. The field of PNS and its technologic advancements are evolving at a very rapid pace.
      • Deer T.R.
      • Esposito M.F.
      • McRoberts W.P.
      • et al.
      A systematic literature review of peripheral nerve stimulation therapies for the treatment of pain.
      Pain Med. 2020; 21: 1590-1603https://doi.org/10.1093/pm/pnaa030
      ,
      • Deer T.R.
      • Naidu R.
      • Strand N.
      • et al.
      A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions.
      Bioelectron Med. 2020; 6: 9https://doi.org/10.1186/s42234-020-00045-5
      The proposed curriculum is an attempt to standardize educational competencies for PNS application. The progressive levels of training are at the forefront of consideration during the development of this document such that a natural path of lateral progression from early learner to practitioner evolves. The proposed path of lateral progression is also in accordance with the ACGME milestone documents.
      • Aggarwal A.
      • Barad M.
      • Braza D.
      • et al.
      Pain Medicine Milestone: The Accreditation Council for Graduate Medical Education.
      https://www.acgme.org/globalassets/pdfs/milestones/painmedicinemilestones.pdf

      Recommendations

      We hereby suggest similar recommendations as provided in our initial guiding document developed for the SCS curriculum.
      • Abd-Elsayed A.
      • Abdallah R.
      • Falowski S.
      • et al.
      Development of an educational curriculum for spinal cord stimulation.
      Neuromodulation. 2020; 23: 555-561https://doi.org/10.1111/ner.13142

      Recommendation 1: Adoption of Horizontal Framework Curriculum

      The Curriculum provides a framework that can be used to stratify trainees into early learner, advanced learner, and practitioner categories based on areas of competency delineated in the document.

      Recommendation 2: Adoption of a Vertical Framework Curriculum

      Training in PNS includes not only medical knowledge but also procedural competence to successfully implant a device in a patient. The curriculum delineates six competency categories as provided by the ACGME and its respective milestones project.

      Recommendation 3: Adoption of Modular Content Segments Curriculum

      The curriculum provides a modular framework to assess level of knowledge and skill necessary to transition from one group to another, for example, early learner to advanced learner.

      Recommendation 4: Curriculum as an Evaluation Tool

      The curriculum can be used as guidance for developing evaluation tools for trainees.

      Recommendation 5: Curriculum as Credentialing and Certification Tool

      The curriculum provides an outline to develop examination and assessment tools that can be administered to ascertain competencies needed to obtain certification/privileges for PNS procedures.

      Conclusions

      An international multidisciplinary task force of NANS and INS education committee members created a PNS training curriculum that defines ACGME milestones for early learners, advanced learners, and practitioners. The curriculum can be adopted by training programs, hospitals, or any other entities to ascertain that appropriate standards are met by physicians performing PNS procedures. The document represents a core framework for the holistic development of the necessary skills and traits that the task force is recommending by expert consensus. We believe further work will be necessary to adjust these standards as the field of peripheral neuromodulation continues to evolve.

      Authorship Statements

      Hemant Kalia, Alaa Abd-Elsayed, Mark Malinowski, and Rany T. Abdallah designed and conducted the study. Hemant Kalia prepared the manuscript draft with important intellectual input from Alaa Abd-Elsayed, Mark Malinowski, Rany T. Abdallah, Adam Burkey, Eellan Sivanesan, Tariq Malik, Reda Tolba, Yashar Eshraghi, Kris Ferguson, Maricela Schnur, Ahmed Raslan, Maged Guirguis, Marc Russo, and Konstantin V. Slavin. All authors approved the final manuscript.

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      Article info

      Publication history

      Published online: December 16, 2022
      Accepted: September 20, 2022
      Received in revised form: August 15, 2022
      Received: June 1, 2022

      Footnotes

      Source(s) of financial support: This study was supported by the North American Neuromodulation Society.

      Conflict of Interest: Hemant Kalia serves as a consultant for Abbott, Omnia Medical, and Averitas Pharma. Alaa Abd-Elsayed serves as a consultant for Medtronic, Abbott, Stimwave, Sollis, and Avanos. Mark Malinowski reports consulting and speaker fees from Abbott, Nalu, and SI-Bone. Rany T. Abdallah reports consulting fees from Avanos and Medtronic and payment or honoraria from Abbott, Avanos, and Medtronic. Reda Tolba reports consulting fees from Medtronic and Abbott. Maged Guirguis serves as a consultant for Saluda, Nevro, Avanos, Boston Scientific, Averitas Pharma, Pacira, and Omnia Medical; institution research PI for Nevro, Avanos, Nalu, Saluda, Boston Scientific, and Abbott. Konstantin V. Slavin serves as a consultant/adviser for Abbott, ATI, Biotronik, Boston Scientific, Medtronic, Neuramodix, Nevro, Nuvectra, SPR, Stimwave, and Thermaquil and has minor ownership or ownership option in Higgs Boson, Neuramodix, Stimwave, Thermaquil, and Vycor Medical. Adam Burkey serves as medical adviser for Nevro. The remaining authors report no conflict of interest.

      Identification

      DOI: https://doi.org/10.1016/j.neurom.2022.09.015

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