managing the pain crisis during the COVID-19 pandemic. We have a stellar group of physicians here. Dr. Nagpal is going to speak about challenges. Dr. McKay will speak about non-medication approaches to pain care. And Dr. Renssara is going to speak about social isolation and pain solutions. Like I said, this is an awesome group. Dr. Nagpal is a fellowship trained pain specialist at UT San Antonio, and he will really get into the nitty gritty of some of the challenges we've seen and some of the steps forward. Dr. McKay is also a fellowship trained pain physician in Texas, and she will circumvent the non-medication approach to sort of supplement managing opioids and other ways to help with pain. And Dr. Renssara is going to take us to the next level and really look at the whole biopsychosocial approach to pain and consider social isolation, as well as ways that we can access our patients and let them feel less isolated, maybe with different technologies and other ways, especially in a pandemic and even not in a pandemic. And the reason really is the why. This is a white paper that myself and some of the other speakers wrote, and the pandemic has been a challenge. It's been a challenge for all of us, but I think it's important to emphasize that role that physiatrists play and that we really are vital. Unfortunately, we've seen some skyrocketing numbers of abuse and other things trending in many states with the pandemic. And I think that just emphasizes how vital we are and the importance of medication, non-medication ways to address pain. So without further ado, I will hand it off to Dr. Nagpal who will get us started. Thank you. Hello, everybody. Thank you for joining our session. We're really excited to speak with all of you on this very important topic. And it's my hope that everybody is comfortable with the notion that this pandemic has really caused a lot of problems for all of us. But what I would like to particularly discuss today is how it changed pain practices specifically. These are my disclosures and none of them are relevant to today's talk. Today, we're gonna talk about the changes that were forced upon us as pain medicine practitioners who are also physiatrists and ways that we can identify the changes that occurred that led to us pivoting. And also we'll talk about some changes that we can sort of embolden within ourselves to make ourselves sustainable for future pandemics or future crises. As Dr. Sharma pointed out, several of us who are speaking on the panel today were privileged to be authors of this white paper regarding lessons learned from the impact of COVID-19 on pain management care as a part of a white paper series that was published earlier this year on all of the various subspecialties of physiatry and how we were all impacted. And a lot of the information from my talk right now will come from this manuscript. But the emphasis that we're gonna make right now is on the fact that as subspecialists in interventional pain care, we were particularly disturbed by this pandemic and so were our patients. So I'd like to point out that this is not going away anytime soon. And it's not just because of this over here which we've all grown to hate, the COVID molecule, coronavirus. This is a rhinovirus molecule, a rendering of it. And this has caused a lot of consternation too. And so we have to be flexible and malleable to know how we deal with this in the future and how we deal with our new future and our new normal. Because I've had over the last several months a lot of problems with this guy over here because I've had staff that have had to be out because they got this run of the mill rhinovirus which is the common cold. But we have to be out for one to two days to test to make sure we don't have this guy. And so that has caused a lot of changes to workforce let alone the decrease in supply of workers altogether. And for the first time in my entire career just last month, we had to cancel a day of clinic because we didn't have enough, we didn't have staff to room patients because everybody was out. And only one of those seven members of our staff that were out actually had COVID. Many of them had rhinoviruses or other illnesses or allergies even. So we have to identify what we do about the new normal and how we treat our patients under these conditions. As many, as you all know, the primary impacts that occurred on care for our patient population included changes in the delivery of care, how we manage the health and safety of our team and our patients. Our finances were dramatically affected. Training and education. This is close, near and dear to my heart because my clinic is a fully academic clinic. We have a cadre of fellows and residents and medical students at all times. And the primary drivers of the clinical care in our clinic are the trainees. And so this was really impacted across the spectrum for interventional pain care. And then of course, burnout, moral injury and wellness were a large impact on our teams and ourselves. There were many changes in delivery of care due to the two pandemics occurring simultaneously. One of which was of course, the rapid implementation of telehealth across various platforms, including both examination but also even consent to treatment. There was a lack of physical therapy available for a long period of time. And of course, we were not able to perform procedures in many circumstances for a long period of time. And so we'll go into detail on some of these things. As you all may remember, we were limiting the ability for people to be in our office. Sometimes even the doctor wasn't in the office. We were working remotely. The vast majority of people that were in the office before were out because at the time we didn't know how to keep ourselves safe. If you remember, we weren't wearing masks originally. We weren't aware that that was a pertinent portion of safety. Keeping patients safe was more challenging and more difficult virtually doing so without being able to examine them. And this probably led to increased utilization of imaging because we were at home hearing complaints and without an exam, probably the next best thing is an MRI or a CT or an X-ray to evaluate the patient's complaints. And without being able to really evaluate a patient and hear, but you know that their pain may be worsening, it may be related to psychiatric distress because of the pandemic. It may have been, it may still be that, but there was absolutely escalation of opioids in many situations because of our inability to work with patients. And we were concerned about their wellbeing and their increasing pain. Now we had to do all of the temperature checks and quarantines and masks that we still do today from a health and safety perspective. And of course, for a long period of time, there were no visitors that were allowed. We are finally allowing visitors back with patients in our clinic, but that's not necessarily ubiquitous. Lastly, of course, we do a lot of procedures that involve steroids. While there was, there are some controversial thoughts about whether steroids will, at first in the pandemic, we were worried that they might worsen the disease. Then dexamethasone was found to treat the disease. And if you're hospitalized and you have moderate to severe COVID, but that led to a dexamethasone critical shortage across the country because people were buying it up. Furthermore, now we know as people are vaccinated, if they are given a steroid injection in the peri-vaccination period, we don't exactly know whether that may blunt their ability to react accordingly and develop antibodies from the vaccine. So health and safety and how do we keep our patients safe and ourselves safe has been right in front of how we practice as interventional pain providers. Now finances, of course, have been really drastically changed. We've had new workflows. We've had to implement telemedicine, which was not paid for by anybody, but the physicians and the practices and the hospitals on the other side. Many physicians and staff were furloughed or even terminated. The reimbursement has varied from state to state, though now we have pretty generous and I would say equal across the board reimbursement for when you compare CPT code to CPT code and ICD-10 code to ICD-10 code. And pay the parity laws within each individual state that were in place before, but now are being enforced where you can hopefully get paid for the work you did in telemedicine, but it will never recuperate the capital outlay that was made to put telemedicine into everybody's EMRs in the beginning. There was another capital expenditure that many of us made and it was PPE. We're going through masks like never before. I just received notice two days ago that there is now a sterile glove shortage nationally, and we only have 24 boxes in my clinic. And there's no end in sight to when we'll be able to order sterile gloves again. So we're making decisions right now about the procedures we do, about whether we do or don't need sterile gloves. And lastly, of course, some of this was offset by many of the government loans that small businesses were able to obtain. Now, in terms of training, I can speak specifically to this as an expert in this area. Boy, with the suspension of patient care in a one-year fellowship, that was hard. That was really hard. And our fellows came out and they did well and they're well-trained, but they had three or four months where they didn't get the same training as any other fellowship class would have gotten. We weren't doing live education, so we have daily didactics in our fellowship. They were not, in that early time period, we weren't doing them. And because none of us really knew how to get Teams or Zoom or WebEx or GoToMeeting or whichever one we were gonna use up and running, it took us two or three weeks to get comfortable with that system. And even today, sometimes there's glitches with that process and it's not the same as being in-person with the expert. And you can't do things like fluoroscopy rounds, where you go into a room and you have everybody bundled up around the C-arm to look at the pictures and learn from that. We have gone back to doing that, but there was a long period where we didn't. Workshops were canceled, national meetings were canceled, and this was a lot of opportunity for networking for a lot of residents and fellows. Now, a lot of that was supplemented with National Grand Rounds from the Academy, from AAP, and webinars as well on both ends to help with facilitating education across the spectrum. And that's something that I don't think is going anywhere anytime soon. And that's a great pooling of resources that's been available for physiatry trainees across our nation, because they can really listen to an expert from anywhere, not just from their own home institution. Cadaver courses were locally implemented. I personally, we did cadaver courses for our fellows in our cadaver lab, because the medical students couldn't go to the cadaver lab. So we were using those cadavers and those cadaver labs are being done more locally rather than nationally. And then there has to be a conversation about whether it was fair, and this conversation did happen, for residents or fellows to be exposed to high-risk patients before they were able to be vaccinated. And it was even more fair to ask about medical students. And I think at this point, we all have agreed that that's part of the training, but we just didn't know at the time. And then lastly, this is a quote from our manuscript from our white paper on moral injury. And I'll just read it, because it says it better than I could. Added work hours and responsibilities, PPE shortages, potential daily viral exposure, salary cuts, furloughs, and changing family dynamics all place physicians at an increased risk for burnout and moral injury. The pandemic has exacerbated this critical national issue and brought to light the urgent need for systemic change to ensure physician safety and survival. This does not just apply to physiatrists that are pain specialists. It doesn't just apply to physiatrists. It applies to all medical healthcare members who are delivering healthcare throughout our complex system. Now, applied processes that we underwent as a response are things like rapid conversion to telehealth, like I mentioned, including this nationalized HIPAA waiver that was granted so that people can use Facebook Messenger to speak with, or, oh, I'm an Android user, so I don't remember the name of the thing where you guys get on an iPhone and talk to each other. But I use Google Duo for something like that. But you can use any of those things and it's all approved. And that's fine. But there are still privacy concerns about it. So there are versions of these face-to-face video visits that are gonna be much more private, like Zoom integrated through an electronic medical record or Doximity. And so we have to look at the future and see, is this always going to be waived by HIPAA? Are we always gonna be able to do this across state lines like we are right now? Because that was a waiver that's in place that you can deliver telemedicine across state lines, but that may not be there forever. It's something we have to think about with our pain patients. We've communicated barriers to care to our patients upfront. And this is really crucial in our field because when we're doing our quick visits, five minute, 10 minute visits, but our staff is communicating with those patients ahead of time to make sure their tech is working. And that really is taking a lot of labor hours. Also, there were a lot of audio only visits in the beginning, but I think for what we do, you need such a robust musculoskeletal exam and neuro exam that at least if you can't even see the patient, it really wasn't working very well. And then of course, a lot of what a good pain physician will do is use motivational interviewing to get their patients to alter their behaviors. And that was near impossible in a lot of telehealth settings and in other ones at work, but a lot of times it doesn't with choppy internet feeds and things of that nature. So we had to rethink the flow of the visit. We had to decide, do we need a physical exam? And in some cases we didn't. And there's an appendix on our manuscript that talks about a telehealth version of a physical exam that Dr. Mukai, my colleague actually created. And it does wonders. We're not really initially involved in the decision of what is elective in our state, at least in Texas. And so that decision was made for us. And we have to decide whether that's appropriate or we have to rethink the flow of how we interact with our patients to ascertain that we think that's true for the future, that what we do is elective. And then lastly, our front office staff became gatekeepers to health. They asked the questions, they asked the screening questions, they are involved in checking the patient's temperatures. Are we gonna ask them to do that forever? Is that how patients get in the door for their procedures? Do we cancel procedures because of something that a front office staff told us about a patient's recent history or exposure? And boy, controlled substance prescriptions. Now, when I made these slides, there was an in-person requirement waiver here in tech. Well, it's national from the DEA, but each state also has to do it. And so in Texas, we had a telehealth waiver that was renewed every 90 days for opioids or any other controlled substance prescription to be allowed on telemedicine. Well, on October 1st, it was just made a permanent rule. So where I have for now here, I guess it isn't for now anymore. Now it's permanent here, but that may not be true in every state. And then we had to decide, well, and we still have to decide, we have to as a group decide, hey, how often are we supposed to be doing urine drug screens? There's a lot of our colleagues who are doing unscrupulous things when it comes to urine drug screens. And we need to decide what is the necessary amount that is done to keep the patient safe? Because after all, we're doing them for patient safety. We're not police. We're not trying to catch anybody in the act. And if we were doing them monthly or every three months, but now you want to transition to more telehealth for patients who may not be getting prescriptions, or I'm sorry, not getting procedures, but are getting prescriptions, how frequently do you need to see them in-house to get that urine drug screening done? We are going to become, we have become very engaged and involved in the triaging of patients. Boy, during this pandemic, my surgeons that I work with really kind of leaned on us and leaned on our clinic to kind of determine when somebody really needed surgery and if they needed to come in and be evaluated for that critical non-elective surgery, or even an elective surgery that was somewhat urgent. That was true of imaging. And that's even true of conservative treatment. If we wanted to utilize our resources effectively when we send people to physical therapy, not everybody needs to go, right? So if there's gonna be decreased volume available for a physical therapist just to keep less people in their center, then we need to send the best patients to them and the ones that are most likely to improve. So in terms of outcomes that we saw, in May of 2020, 58% of practicing physicians had their work hours cut and 62% had their salaries reduced in the state of Texas. In a sample multi-specialty orthopedic practice here in Texas, there was a reduction of 50% of normal volume in overall clinic visits in March and April during the early part of the pandemic and 66% reduction of surgical volume. Now, in September of 2020, that clinic was already back up to 85% of pre-pandemic levels. And then now, but the problem is when people meet their deductibles, so coming up in, and this should say January, 2022, actually, there's a forecast to drop again because of reset deductibles and unemployment. So these are patterns we have to continue to monitor and see if there's still long-term repercussions for us as groups. In my own clinic, we had a four-week period without any in-person visits. We were down to one procedure a week from a usual 69. 75% of those visits during the first two weeks were done doing either video visits and 25% were audio visual. We slowly increased the number of procedures we did and ultimately abandoned telephone visits because we felt that they were ineffective. From a AAPMNR survey that was sent to fellows of the AAPMNR, 84% reported they didn't have telemedicine before the pandemic. And think of how quickly we pivoted. We pivoted so fast because 27% had none of their new patients as telemedicine visits after the pandemic started. And it grew so rapidly but boy only 17.9% thought that telemedicine offered satisfactory care 100% of the time. So it's telling that it, we grew it, but it's not doing what we needed to yet so we need to keep working on improving that. And this is an, this represents that as well, that if we see here, this pie chart that this large group will agree or strong or disagree or strongly disagree that telehealth was as effective as in person visit so we need to try to find a way to get closer to that being an in person visit. Our trainees were critically affected trainees that were surveyed by the AP even are 86% of them said the most likely training sites to be affected by Kobe 19. The pandemic was were outpatient clinics, and that's us that's us as interventional pain provider so they weren't getting that training that they should get. And then the most commonly selected response for in response to the question. What concerns you regarding the consequences of training of the pandemic on your training was fewer outpatient rotations by 77% of the residents who were asked external stakeholders, also spoke to us and, and the government is one of those places where we have to decide hey, we have to keep talking about this this conversation needs to continue, whether pain procedures are truly elective or not. And then instant we became institutional leaders around controlled substances and intrathecal pump management, we need to maintain that and make sure that everybody understands that we're the best people to come to for those conversations. Future threats are, we have to find out if we're not essential, I think we're essential but I'm biased and we have to prove that we're essential. We have to figure out for the chronic pain complaints associated associated with long coven syndrome, whether, how, how, how well we can treat those we have to study it to see if we can treat it. We have to make sure we're not duplicating services because that will not stand for a long period of time there's a lot of our colleagues who are in other specialties who do what we do. And then there's not even other physicians there are other CRNA is doing what we do, there are nurse practitioners and PA is doing what we do, and we need to, we need to justify and prove that we're the best at this because of our background, and then we have to have scrutiny over the evidence of the procedures we perform and we have to call out our colleagues who are doing things that are irrational. There are opportunities here because their ability to adapt is crucial. Our focus on functional outcomes will be superior for the future, rather than focusing on VAS or NRS scores, we have to embrace the value that we bring to healthcare that's critical. And then maybe we can achieve one stop shopping, can you go to one place and get your physical exam, your EMG if you need it, your procedure done, your physical therapy and have everything done in one place for chronic pain that's something that might be an opportunity for the future. So in summary, COVID-19 exposed a lot of deficiencies in our system. There's new opportunities for us to treat patients because of this pandemic. There are real threats to our specialty that have been illuminated by the pandemic, and we have some opportunities to overcome and be stronger if we adapt and continue to adapt the way we have. And so at this, and I am always available for questions through Twitter, Facebook, LinkedIn or by email. At this point I'm going to turn this over to my esteemed colleague Dr. Mukai, who's going to speak on non-opioid pharmacologic interventions for the treatment of chronic pain during the pandemic. Thank you, Amit. Let me see if I can share screen. My little talk is mostly talking about non-pharmaceutical options for managing pain. If we learned anything during the time of COVID, it's how valuable our more comprehensive and holistic training and approach to pain is in the current, you know, both COVID and opioid pandemic, being able to have options to offer our patients. And when I was doing research about the non-medication options for managing pain, it became pretty clear to me that a lot of the strategies that we would be recommending to our patients could also be applied to our own health and well-being. And just, it's pretty fitting that Dr. Nagpal mentioned the moral injury that we all suffered during the times of COVID, you know, with increasing burnout. And burnout was already an issue even before COVID. I think it's really highlighted a lot of our stressors. A lot of us went into survival mode and we're finally realizing that this is not something that we do for a few months and it goes away. It's looking like it's a more long-term thing. And, you know, a lot of us have taken the time that we've been more socially isolated to be able to do a little bit more self-reflection and figure out what we can do to survive, not just survive, but thrive and become better versions of ourselves. So, you know, I kind of think of this approach of being able to offer options to our patients and having that skillset to help ourselves as well. It's kind of like the knowledge of putting your own oxygen mask on before you put it on your kids. So it's similar to that. So there have been a few studies that have been published. A lot of them are very new studies looking at COVID-19 and its impact on our patients with pain. First and foremost, you know, we know that the definition of pain is not just the unpleasant sensation of pain itself, but it's accompanied by emotional distress. So we really need to, as physicians, focus on the emotional distress that the pain is causing, that sensation is causing our patients. So this is a Canadian study. They surveyed about 3,200 patients with chronic pain in April, May of 2020. About two thirds of them reported worsened pain. And that goes with what we all saw in practice. Dr. Nakhpal also mentioned it, that a lot of patients with chronic pain reported increased pain since COVID started. There's a higher level of perceived pandemic related risks and stress. And a lot of the patients also reported that there have been changes in their treatments, including the pharmacological but also physical psychological pain treatments that were available to our patients. Interestingly, job loss was associated with lower likelihood of reporting worsened pain. And that might be maybe a symptom of what we see in the labor market today with a lot of people quitting their jobs. That actually seems to have helped some of these chronic pain patients. About half of those surveyed reported moderate to severe levels of psychological distress and negative emotions towards the pandemic overall, and stress associated with moderate psychological distress. There was another study coming out of Spain. Again, with surveys looking at the consequence of COVID on pain intensity and emotional distress. They also looked at central sensitization and found that there were changes. There was an association between changes in daily routines with pain intensity, distress, and sensitization. We all know we all suffered a change in daily routine. Think about these chronic pain patients that really didn't have a lot of reserve for coping with change and now we're throwing them into a lot of different changes that they have to cope with. So the results of emotional distress were advanced age, difficulty in receiving care, change in daily routine, and then diminished social support. And I know there's another talk coming up after me about that diminished social support piece. And then you throw into that the opioid crisis that had been brewing even before COVID. The newest data out of the National Institute of Drug Addiction showed that in 2020 more people died of overdoses in the US than in any other year in history. 93,000 people died of overdoses in 2020 versus 72,000 in 2019. This is an increase of 30% from 2019 which is the biggest increase ever recorded. So we see that we have an opioid crisis on top of the COVID-19 crisis. And what's interesting is that they also found that the other part of opioid crisis, not just the overdose but the addiction piece, also seems to impact patients in how they were impacted by COVID. So they found there was an analysis of 580,000 medical records that showed that the risk of COVID breakthrough infection in vaccinated patients were higher in patients with substance use disorders versus those who did not have substance use disorders. So you can see it was 7% versus 3.6%. And even more significantly, within that 7% of patients who had the breakthrough infection, they were more likely to have severe disease requiring hospitalization or resulting in death. So shifting our focus to non-opioid pain management options that we can offer patients, a lot of these things we've been traditionally offering patients all along. So education is a big part of what we do. We try to educate the patients about why they're feeling what they're feeling, what is the source of their pain, talking about their psychological conditioning, coping. We've referred to biofeedback. We've also utilized integrative medicine techniques and complementary alternative medicine like acupuncture, acupressure, modalities, as well as physical therapy, occupational therapy, lots of different types of therapy including the religious counseling, but music, art, and drama, exercises such as yoga, pilates, aqua therapy. And then we've also talked about nutrition, supplements, mindfulness, meditation, guided imagery. So these are all non-opioid, non-pharmaceutical pain management techniques that can be used to help our patients. Now, of these, a lot of these require a referral either in person or virtually to other providers, and a lot of our patients may not have the resources to be able to pay for things like counseling, and during the early days of the pandemic, they didn't have access to some of these things like physical therapy. And so, you know, it became pretty clear to me that it's very important to have a couple of things in our arsenal that really doesn't cost anything, it doesn't require a lot of resources, but can be pretty effective in helping our patients. And that is mindfulness, which is kind of in the same category as meditation. So mindfulness basically refers to a meditation practice, but it doesn't have to be formal meditation. So you can, it's really more about being aware of the present moment, and not ruminating in our past or perseverating about what could happen in the future, but really trying to be present in the moment. And teaching that mindfulness has been shown to be effective in treating many conditions, including, you know, a lot of the conditions that we see in clinic, like fibromyalgia, but also psychiatric conditions like anxiety, depression, PTSD, and interestingly, things like psoriasis and irritable bowel syndrome that we think, you know, probably has some autoimmune component to the pathophysiology. There have been several studies looking at functional MRI changes in patients who start a meditation practice, and they have shown that these functional MRI changes extend into times when patients are not meditating. So it seems like the positive impact of meditation will continue even after you're done with your session. An impact has been seen in a lot of different areas of the brain, but the most important part, the most important part of the brain that seems to be impacted by meditation is the amygdala, which regulates the fight or flight sympathetic response. And the theory is that with meditation, you're able to teach our prefrontal cortex, that's more the executive functioning part of our brain to be able to control the fight or flight amygdala. A lot of times people call that the reptilian part of our brain or the lizard brain, the fight or flight response primitive brain. And then this is just a functional MRI that's showing the difference between a patient's functional MRI scan before and after they were taught how to meditate and looking at the amygdala activation and how it's less activated after meditation training. So mindfulness seems counterintuitive when you first hear about it because why would you focus on being in pain or being present in the pain experience, and patients may push back saying that too. And so, but it seems that what we want people to do is to recognize their response to the pain that they're feeling. So it's okay to identify the pain and acknowledge that you are in pain. But you also need to acknowledge how your body and your mind is reacting to that pain. So really recognizing the catastrophization and the different thoughts that you're having about the pain and teaching patients how to breathe through it, reduce anxiety and response to the pain. They looked at mindfulness programs and its effect on outcomes, and there's moderate strength of evidence that meditation practices and mindfulness can help with depression, pain and anxiety. So there were nine randomized controlled trials looking at mindfulness meditation and its effect on pain, and they looked at the different types of pain. Four trials focused on painful conditions. Two of the trials were in musculoskeletal pain. One was in irritable bowel syndrome and then one was without pain. And they found that visceral pain, for some reason, had the largest improvement with mindfulness, and then musculoskeletal pain had about five to 8% reduction in pain scores. There's a study looking at addiction in mindfulness. And so this study was done in a methadone treatment program for addiction, and they taught 30 patients in the methadone program how to meditate and how to have that mindfulness practice in their lives. And they then analyzed opioid craving, pain, and positive affective state. And after they learned how to meditate and be more mindful, these patients showed 1.3 times greater self-control over craving, more positive affect associated with reduced craving. And the theory behind that is that when patients are addicted to opioids, they become hypersensitive to pain, which is kind of counterintuitive to why these patients think that they're taking the opioids. And then they become less sensitive to the pleasures in life. And so they think that practicing mindfulness and meditation can reverse that shift, where the patients can focus on the pleasures in their life and report less pain and reduce the amount of opioids that they need to control that pain. So switching gears to mindfulness for physicians. So we just talked about burnout and moral injury, partly due to COVID, but also it's just been brewing for many years, and I've been cognizant of it because I feel like I'm kind of going into the middle of my career where the initial honeymoon period and excitement of being a practicing pain physician is kind of diminished at this point. And then, honestly, during the time of COVID, I really felt like I was under so much stress, even though I really wasn't doing the same amount of work. I wasn't seeing the same number of patients or really working in the traditional way, but I felt like I had so much more stress and burnout and depression and anxiety and really personally had a difficult time maintaining compassion with some of our more needy patients. And so when I was learning about mindfulness and meditation in the pain population, I started kind of wondering what that meant in terms of incorporating it for us as physicians and healers. So we know that burnout causes reduced sense of accomplishment, there's emotional exhaustion, and it's been reported by 30 to 40% of practicing physicians. This was done before COVID, so I'm guessing it's higher than that at this point if you were to survey practicing physicians. And 60% of physicians have experienced burnout at some point in their careers. And physicians that are burnt out are shown to be associated with less patient-centered care, there's reduced empathy and compassion, so then that means there's decreased patient compliance and physician confidence and satisfaction with care, and there's also a risk of increasing medical errors. Back in the 90s, there was a proposal in JAMA to encourage practice of mindfulness in physicians to help weather the growing stresses of medicine. Now, can you imagine in the 90s, those were probably the good old days, but even at that time, it was starting to come on people's radar that a lot of what we were doing as physicians were really not sustainable and that we really needed to figure out ways to have a better balance and more wellness in our lives. And even at that time, one of the issues with suicide among physicians is twice the national average, and why is that? And that's partly because we are not good at taking care of ourselves and understanding and acknowledging that we have stress and we have anxiety and we have depression and we may be getting burnt out from our jobs. He wrote a book called Attending Medicine, Mindfulness, and Humanity, and it's really kind of talking about becoming aware of how you're responding to stress and patients and that whole mindfulness of being present to really just meeting the patients where they're at and responding to what the patient is saying and feeling, but also being aware of how you're reacting to the patient and what you're thinking and feeling as you listen to them. Mindfulness has been introduced in academia, starting in medical schools all the way through residency training programs, and then even after we graduated from training, there's now a tri-organizational survey with AAP Menar, ABP Menar, and AAP working with Stanford that's going to be coming out surveying us practicing physicians on burnout and exploring the concept of wellness in physiatrists. It's definitely a topic that's close to my heart and on a lot of people's minds. I did find a cute article talking about six little things that you can do in your daily life in clinic, and I have tried doing this in clinic, and I think it is helpful, especially on those days when you have that one patient that really just sucks all the energy out of you to be able to have that little few minutes, a minute or two, of being able to recenter and recalibrate before I walk into the next room has been helpful. So the six steps that this article mentioned was just talking about, okay, just pause, take a breath, and then notice just anything about that moment. So whether it's the feeling of your feet on your ground or just how the air feels, whatever it is, just take a little break, and then just a real quick one-minute scan or short meditation or just being aware of where you are. And then if you know that you're feeling or thinking something, then at least label it and acknowledge that you're feeling that way. So I do feel anger. Sometimes I feel sadness. A lot of times it's frustration. But being able to say, okay, I'm feeling frustrated right now, that helps to just say, okay, I'm feeling that way. And then being able to just center yourself, kind of find your feet or find where you are standing, ground yourself. And then little things you can do to kind of take some of that autopilot mode out. So really kind of taking that moment to do something a little bit different. You can try to be mindful of the coffee that you're drinking that day and what it feels like and what it smells like, that kind of stuff, just to get your focus on something other than all the stressors and stuff in your brain. And then just kind of scanning, how do I feel? And then doing a body scan. So that's a technique that can be used to help with insomnia where you're lying there and you're just kind of focusing your energy on different parts of your body, going from head to toe and really kind of relax different parts of your body. And that can be very helpful in terms of relaxation and insomnia. I like to take short breaks. And by short, I mean a few seconds. And most of my staff, they don't even know that I'm taking these little breaks in my head. Sometimes it's just me taking a deep breath between patients or if I'm looking at an x-ray, just taking a little few seconds just to kind of, okay, that's okay. That visit is done. I'm going to move on to the next one. You know, with COVID, I've also taken to just going out to my car and sitting out there, taking my mask off and having my lunch or coffee just to have a little alone time, taking short walks. I like to go up and down my garage stairs. So just little things like that, just to incorporate into your day seems to help. This seems to help me. And doing this research also reminded me of one of the plenary speakers, I think from 2019, Bonnie St. John was that Paralympic ski medalist who talked about micro resilience. And I downloaded her audio book and started listening to the book. And I actually found that helpful. I'm probably a little bit more logical than fluffy. And so I don't usually respond very well to some of the fluffy books about, you know, about wellness, but her book was more evidence-based and citing studies and talking about very concrete steps you can take. And then the science behind why you should do those things and what the impact on physiology is. And so it really resonated with me and I would highly recommend her book, micro resilience. For our patients, we can start talking about coping and how they're reacting to the pain, how they're sleeping. I always ask about how they're sleeping, you know, and then I do sometimes talk to them about what they do in terms of things that they enjoy and activities and stuff like that. There are lots of apps out there for meditation. If the patients are interested, last year Headspace had free, I think it was a one-year membership for healthcare providers. Unfortunately, I looked again and that discount is gone, but it's probably well worth it if you want something with a little bit more structure and guidance. And then there are also Zoom communities where, you know, there are people who guide you through meditation. A lot of physicians are going into coaching and really kind of looking into integrative medicine and how to incorporate that into their physiatic practice. For example, Dr. Sharma, who's our course director, just launched the Orthopedic Integrative Health Center at Rothman Institute. And really kind of looking at a patient more holistically in terms of nutrition, their stress, sleep, activity, and coaching, in addition to the traditional orthopedic diagnosis. A lot of these options are still not covered by health insurance, but we can still discuss those options with our patients and know where to refer them if they want that level of service and care. There may even be cheaper alternatives for some of these more holistic options like acupuncture schools and virtual resources nowadays with COVID, and really meeting the patients and people around you where they are. And don't try to forge your agenda or your own, this worked for me, so it needs to work for you kind of attitude. And then really helping yourself by incorporating some of these strategies into your own life. And thank you for being here and listening. I'm going to pass the baton on to Dr. Ensrud, who's going to talk about social isolation. Thanks, Dr. McKay. Let me share my screen here. Okay, well, thanks, thanks. Well, I am now going to talk about yet another aspect. We've talked about changes to pain practice and effects of COVID-19 on pain and ways to intervene and mediate that. And I wanted to start off by and I wanted to speak about another aspect of the pandemic that has really affected our patients who experience pain, and that's social isolation. There's been a profound change in the frequency and level of interaction with other people for all of us really during this pandemic, and perhaps even greater to our patients that are dealing with pain complaints. And we can take a look at what some of those effects have been and then move on to how we might be able to mediate and improve those. So, pandemic isolation has really, in multiple studies, really been shown to exacerbate pain. This was a survey, I really like this one. It was a voluntary online survey that was conducted by the American Chronic Pain Association. And it was a survey that was conducted by the American like this one, it was a voluntary online survey that was conducted by the American Chronic Pain Association. Because I'm a big fan and advocate for patient organizations, international and peer support organization. And they surveyed over 1000 of their members, and they found that nearly half of the respondents that both their pain and stress had increased during the past year. If anything, it's surprising that it wasn't, you know, three fourths, but half is still a huge amount. And more than one third felt that they said that they felt depressed. And many described feeling isolated, and noted that they've been exercising less. This is a fantastic study published this year on loneliness, social isolation and pain, following the COVID-19 outbreak. And this was a data from a nationwide internet survey in Japan. And even though we're most of us are located in the United States, we really can learn a lot from studies done anywhere in the world. And this is such a fantastic study over 25,000 participants, age 15 to 79. So everything but other than young kids were assessed with an internet survey. And they use the UCLA loneliness scale short form three item that was used to assess loneliness. And then a modified item off of that was used to measure the perception of increased social isolation during the pandemic. And their outcome number measures included prevalence and incidence of pain, the intensity of pain, and then the prevalence of past and present chronic pain. And very strong statistical significance that increased loneliness and the severity of perceived isolation were causative or positively associated with the prevalence, incidence of pain, pain intensity, and then again, the prevalence of past and present chronic pain. So this is a huge factor in exacerbating the amount and extent of pain that our patients can perceive. Here's one. I mean, we have a lot of providers, physicians in our organization who do spine interventions. I thought this one was particularly interesting from just a couple of months ago in 2021 August, the effect of social isolation during COVID-19 on patients with chronic low back pain who underwent a spine intervention. And they looked at examining the effect of social isolation on patients with, during the pandemic on patients with chronic low back pain. And again, you know, not 25,000, but honestly a really good number of patients for a study, 145 who underwent a spine intervention during the past year were enrolled. And they used, you know, their metric for isolation was the International Physical Activity Questionnaire or IPAC. And that was used to evaluate patient activity levels. And so there, you know, there is a jump in this paper between decreased physical activity equaling social isolation. And that will be a strong correlation coefficient, maybe not quite exact, but nonetheless, there was a significant reverse correlation between IPAC walking scores, the more patients were walking and their pandemic visual analog scares scores, their pain scores. And that the level of benefit from injections decreased and the duration of their intervention effectiveness was shortened in patients who had high sitting scores. So one thing that became, you know, real apparent to me, and I'm sure many of us during this pandemic, that there became this additional factor of fear of others regarding what contact with them could do to us. I was living on a river in Portland, Oregon during most of the pandemic, where there's a nice trail, it's not very wide. And just noticing people's reactions to other people passing them the other direction was interesting and a little unnerving, frankly, and of course, my own interactions as well. But so we've begun, this is a paper on the psychological consequences of the social isolation during the COVID-19 outbreak. And it notes that we've begun to behave as if other people are potentially dangerous for our health and for the health of our loved ones. And this turn of events has cultivated a new universal belief that's based on vulnerability to harm, whereas proximity to fellow human beings poses a direct threat. That's lessening in many of the areas that we live, but still present to an extent that it just wasn't in 2019. So to date, more and more people are avoiding social relations as a choice and a decision that was initially moved by a fear of this invisible COVID-19 enemy. I mean, geez, I remember going for months with a paper towel folded in my back pocket with one side marked, so I know it was the outside, and grabbing every doorknob with that, you know, because I was worried about getting the virus, right? And the total uncertainty about what is right to do or not to do, or to say or not to say, or to think not to think, derived from information that has been, at times during this pandemic, both ambiguous and conflicting that we've received. Now, remember at the very beginning of the pandemic when we were told by the CDC that there's no need to wear a face mask, so they weren't encouraging them, certainly, and, you know, we saw how that changed. So there's been a lot of uncertainty with information that's been variable. So we can talk about how bad it's been, and everyone knows, but it's always good, you know, to move on to possible solutions, and I certainly wish pain and loneliness were as easy to fix as, you know, using a Band-Aid or doing a differential equation, and I'm not even that great at math, but I did slog through Diff-E-Q. It eventually is solvable, and these are, you know, I think it's good just from the beginning to acknowledge that these are really difficult problems, the effect of loneliness on pain, but that doesn't mean that they're not worth an effort, and it doesn't mean that we can't make some significant inroads. So just to remember, as always, and, you know, these are our human interactions, one size doesn't fit all. So one thing that became apparent during the pandemic is trying to get patients to exercise when they don't want to move and they can't be involved in programs and physical therapy is remote, and if anything, many of us became aware that there really are really remarkable avenues for this that are available and free in most instances that can really be helpful for patients. So there's lots of YouTube workouts. This is someone, an Australian, Holly Honjo on the left there, who has a really, a whole host of modified, gentler workouts on YouTube. She's, you can see her doing a modified side plank there, and I'll just refer patients to, you know, to look her up on YouTube. On the right here, we have Toronto Rehab, their Brain and Spinal Cord. They call it, I love this, the LEAP service. LEAP means living engaged and actively with pain, and you can find these on YouTube by googling Kara Kirschner, and you can see this particular one is on gentle Tai Chi and Qi Gong, and not only is it a gentle exercise, but they're also showing options that can be done in a seated position, which is very helpful, and Tai Chi in particular is really, really helpful for patients with pain. You know, earlier, Dr. Mukai highlighted the sympathetic fight or flight response, and we all know the effect that sympathetic drive has on pain, and a way that Tai Chi works is by slow inhalation and prolonged exhalation, which helps increase parasympathetic drive, which, of course, is the opposite of sympathetic drive. So this, in particular, is a very helpful exercise for patients with pain, and again, they can find this on YouTube, and it, there's no cost. I mean, they'll have to watch some ads at the beginning of the videos or try and get through those. So that, you know, there's just a lot of research behind online exercises working to motivate people. Here's a really notable guy from England on the right there who helped a lot of people during the pandemic, and on the left is a complicated table, and I just included that because it's just study after study after study showing how different types of exercise, and many of which are mild, yoga, qigong, flexibility, walking, work to have a significant effect on decreasing depressive symptoms, anxiety, stress, etc. So there's, there's really just a plethora of evidence on this. So something else I became aware of during the pandemic, they did have a lot of patients who were quite loneliest. There's something called the Unlonely Project, and this was founded in 2016. Even quite a ways, you know, loneliness has been, it's not like loneliness started during the pandemic, but this was an initiative to broaden public awareness of negative physical and mental health consequences of loneliness, which really burdens a wide range of human experience. And they have this interesting thing online called the Unlonely Film Festival, which I have referred patients to. Let me, I'm going to show you just their in, in their intro here. So these, they just googled this, their, this is actually their fifth, they have all these short films on loneliness. It's a really quite, they bring diverse perspectives on loneliness and can really be of help. So let's, let's take a look at what they have to say here. Hello, and welcome to our fifth annual Unlonely Film Festival. You'll find a wide variety of short films streaming here that bring diverse perspectives on loneliness. Some plots are uplifting, others are nerving, and some even have a comical tone. All of our films share personal stories powerfully told, and we hope they'll spark a feeling of connection between you and the characters or theme, the filmmakers, and our community. Ready for a preview? Let's take a peek. Just out drifting emotion. What is life about? Y'all okay? I don't know what I need to do. 30 years, my whole life. Sometimes the pain doesn't go away, but it doesn't have to define them. It's nice to help somebody else to see there's a better one. One of the things that helped my recovery was volunteering, because they always say, you help other people, that helps you. It just makes me feel blessed that somebody believes in me. And then the bees, oh God, you're talking about lifesavers. That's the real joy in life. Don't miss anyone, because there's so much in everyone that you can't believe. The Film Festival is now yours to explore. Look for us on each page, where we'll share what we found interesting about the film, plus give you some things to think about as you reflect on the story. We'd love for you to leave your comments and to share the film with friends. On behalf of all the filmmakers and the Foundation for Art and Healing's UnLonely Project, thanks for joining us. Okay, hope you enjoyed that. That is actually a really fun thing to refer patients to. A little bit out of the box, but it can be very helpful. There are certainly other ways to heal loneliness. One of the most effective is volunteering. We've got a paper here from 2017, the mediating and moderating effects of volunteering on pain and depression. And this was done in Kentucky, a sample of 200 women over the age of 50, and found that volunteer activities had a significant mediating effect on the relationship between pain and depression. And I think one thing that became more evident during the pandemic is that we think about volunteering, you know, being in person, and there is this, you know, extent that, as I mentioned, of fear of other people, but volunteering can be done remotely. And I looked up, this is an organization I used to work with before I went to medical school. I worked for full-time actually, Literacy Minnesota, and you can volunteer with adult literacy and do tutoring for people, either English language learners or adults who are learning to read, and you can do that remotely. And that's something that can be really, you know, I think you really have to realize things like this are mutually beneficial. They're beneficial for the person that you're helping, and they're also very beneficial for the volunteer, and certainly something that people can do remotely. Oops, here we go. So, you know, there was one thing I didn't manage to get in here that is helpful for patients with loneliness, and hopefully this guy is getting on the video here, but, you know, animals are a great thing for patients that are dealing with loneliness. You know, dogs, I mean, it's wonderful how many dogs got adopted during the pandemic. It actually became difficult to adopt a dog, but we all know that having a dog is associated with greater physical activity and walking. There's still lots of cats available during the pandemic, and they can really be helpful for loneliness. I've had patients get aquariums or fish, you know, and there's actually very good scientific research that watching an aquarium helps lower blood pressure and lower sympathetic drive. I've also recommended to people that they feed birds, which can be great. Personally, I tamed a crow that came every day during the pandemic who I named Gladys. I'm not sure that's her name. She never told me, but, you know, that was really exciting for us to have that stop by. So certainly any interaction with animals can be very helpful. So just to realize, you know, sometimes things look like they're the sunset and the day is over. This looks like maybe a sunset over Philly, but it's actually a sunrise. And there are definitely things that we become more aware of to put in our toolbox to help patients as a result of the pandemic that as things lessen and improve in the future, we'll definitely have more tools available to us that we've become aware of during this time. We're gonna end the session here. I'd like to thank Dr. Sharma putting this together. Dr. Nagpal talked about changes in pain practice during secondary to the pandemic and importantly adaptations. And Dr. McKay talked about COVID-19 relation to pain and, you know, the sympathetic effect, fight or flight and the mindfulness response and interaction that can be so helpful. I'd also like to thank Sam, our producer and Martha from the AAPMNR. It's too bad we couldn't meet in person, but we're adapting. And I look forward to seeing everybody in 2020.

COVID-19 pandemic

pain crisis

social isolation

loneliness

physical activity

online workouts

mindfulness

volunteering

well-being

emotional pain