And good afternoon. My name is Dr. Scott Stoll, co-founder of the Plantrition Project, an organization dedicated to educating, empowering, and inspiring healthcare professionals around the world with the knowledge and science of food as medicine. And today it's my sincere honor and privilege to be a part of this wonderful panel with Dr. Gwendolyn Soa, Dr. Heidi Prather, Dr. Abby Cheng, and Dr. Devyani Hunt, presenting really on the Interprofessional Lifestyle Medicine Approach for Musculoskeletal Disorders, Why, How, and What Next? You know, in 2003, I really had an epiphany when I recognized a blind spot in the care of my patients. And I just want to take at the outset a moment to recognize my attendings at the University of Colorado, including Dr. Cliff Gronseth, who really, I think, prepared me to see the blind spot by teaching me one of the mantras of the Zaytree, which is, you know, that we not only add years to people's lives, but we add life to their years. And it really set a framework for me, a lens to begin to interpret medical care and the care of patients more holistically. And I really believe it was that lens that allowed me to begin to understand that the lifestyle choices of my patients were significant, not only in the prevention of disease, but in the quality of their lives. I recognized early on, 2003, that the lifestyle choices of my patients, including the dietary choices, were directly responsible for the past medical history list that was before me. And I soon learned that that past medical history list of largely non-communicable diseases, diseases related to lifestyle choices, was undermining the quality of their life and contributing to disability, which was further undermining the quality of their life. What I didn't understand at that time was, you know, and I asked myself this question, can I do anything about this? And I learned after some extensive study that a lifestyle intervention, starting with a whole food plant-based diet, adequate sleep, managing stress, meaningful connections and community, exercise, and then focusing on eliminating toxins, has a profound impact on their lives. And in a short period of time, my practice was transformed as I saw my patients' quality of life dramatically improving and their non-communicable diseases being significantly improved, and in many cases, going into remission with discontinuation of medications. And so I began to see, and I had one of those eye-opening moments when I was reading the Global Burden for Disease study and saw that non-communicable diseases, diseases directly related to lifestyle choices, are responsible for 1.62 billion disability-adjusted life years in 2019. We also see that disability caused by these NCDs and injuries have emerged as the largest contributor to the global disease burden, according to the report from October 16, 2020 in Lancet, the largest contributor to the global disease burden. And what's so powerful is that these NCDs are largely preventable and in many cases can be suspended and reversed with a lifestyle intervention. We also see that these non-communicable diseases are responsible for 71% of the deaths globally and 60% of the disability. We also can see in financial data that the NCDs are also responsible for approximately 75% of the cost of healthcare globally. And we can see here that the non-communicable diseases contribute to musculoskeletal conditions and musculoskeletal conditions, the focus of our presentation today, contribute to significant disability as we all are aware of acutely in our practices. From JAMA in 2016, a study looking at risks related to both deaths and disability, and at the top of the list we see dietary risks contributing to the predominant risk factor for death and the predominant risk factor for disability. But it's largely something that we don't talk about in our practices because, as we know, the average medical school class receives less than 20 hours of education and nutrition in their entire course of their education. And so we're just not adequately trained to address the leading cause of death and disability. But this also from the World Health Organization highlights the fact that people living with disabilities are more likely to have unhealthy lifestyles that contribute to a greater risk of non-communicable diseases. For example, people living with disabilities are more likely to be obese, use tobacco, significant increased risk of heart disease, and have diabetes. And so that's why I've come to believe that, especially in physical medicine rehabilitation, we have a unique opportunity to integrate lifestyle medicine with the tenets of physical medicine and rehabilitation and truly help our patients to thrive. And we see that patients get into this unhealthy cycle of unhealthy lifestyle choices, largely driven by our culture today, contributing to disability, and people living with disability more likely to have unhealthy lifestyle choices. And it becomes a really challenged cycle that can be very difficult to break. However, by introducing healthy lifestyle into the practice of medicine, and specifically physical medicine, we can directly see improved quality of life and improved health span. And this doesn't necessarily have to take a long time. We can see reversal of diseases in as short as three months, and sometimes more quickly. And so we can see an immediate impact on the quality of life in our patients through the introduction of a healthy lifestyle. And much of this has been outlined in the fastest growing medical society today, the American College of Lifestyle Medicine, with over 7,000 members globally. And they're focused on the six pillars of lifestyle medicine. Physical activity, managing stress, improved relationships and sleep, avoidance of substances, and really the foundation, the critical pillar for the prevention, suspension, and reversal of disease, the utilization of a healthful diet focused on whole food, plant-based nutrition. And so this is the foundation, the kind of wireframe for our presentation today. And it is my sincere honor to introduce a true leader in the physical medicine and rehabilitation space, and also a leader in the integration of lifestyle medicine into physical medicine and rehabilitation. And she's a thought leader in so many areas. And it's my privilege to introduce to you Dr. Heidi Prather. Well, thank you, Dr. Stoll, for that great introduction. And Dr. Hunt took me to my first plantation project when I was getting my eyes were widening to this area of medicine. And I walk in and there's Scott Stoll, a physiatrist, as a pillar of the beginnings and the facilitating of research around this. So we're truly grateful that you joined us today, Dr. Stoll, as you're a pioneer in this. My job today is to encourage you as a physiatrist to think about opening your mind and opening your willpower to go out and think about enabling your patients through lifestyle-related medicine. So that's going to be my topic here today. Next slide. My only financial disclosure is that I am still a senior editor of the PM&R Journal, which means if you see me in person, I'll ask you to submit your articles there. Next slide. So musculoskeletal disease and deaths of despair are interrelated now. And we know there's this focus on this incorporation of what goes on in behavioral health and musculoskeletal disease. In fact, as many as patients with functional disability are two times more likely to die of despair, meaning either take their own life or give up on life and not seek medical treatment. Sixty-three percent of regular opioid users have some form of musculoskeletal pain. Next slide. And then we have to think about what's going to happen to us here now after the COVID-19 pandemic. This is a survey taken and published in Nature. If you look at that bottom graph, U.S. adults had symptoms of anxiety and depression, somewhere around 11 percent between January and June of 2019. At the end of December of 2020, it was 42 percent. Possibly that number is climbing even today. So this is that elephant in the room we can no longer overlook. I call it the smelly elephant in the room. We're not looking in it and we're refusing to smell it. We're going to have to take order on incorporating this, despite the fact that we have poor access to care. We're going to have to take this on. Next slide. So my goal here is to kind of set you up for why you should look at this from a musculoskeletal and spine component of adding lifestyle medicine. We know half of adults over the age of 65 have arthritis, two-thirds of the adults in this country are overweight or obese, and one percent of the adults have an ideal diet, and that's according to the American Cardiology Association. Anxiety is the number one mental illness here in the United States, and only a third of those are actually treated. 21 percent of people are still smoking. The money we spend on this is outrageous. Over $281 billion will be spent on joint pain and arthritis, and by 2030, we think we're going to have over 4.4 million lower extremity total joint procedures, costing $150 billion. Going back to that 1 percent number, because 1 percent sounds like a low number, but 147 billion costs are associated with people who are overweight, but if we had just a 1 percent decline in our obesity trajectories, if we just changed that 1 percent into a positive direction, we could save as much as $84.9 billion. $42 billion are spent on anxiety, and over half of that are folks that we might be seeing because they seek relief from a physical illness that may mimic or be inconcordant with that anxiety disorder. Next slide. So, I want to go through and show you how there's already evidence out there, and I'm going to speak just on osteoarthritis to start with today, that we already know that there's these direct links between osteoarthritis and those six pillars of lifestyle medicine that Dr. Stoll introduced. So, 20 percent of people with osteoarthritis have symptoms of depression and anxiety. Anxiety and fear of avoidance beliefs are associated with worse function in people with osteoarthritis, and depression and anxiety are associated with inflammation. Again, that's most likely mediated by unhealthy lifestyles among these individuals. Next slide. Another pillar, if we look at the other, is lifestyle impacts in osteoarthritis. The progression of OA is correlated with the upper regulation of inflammatory processes, which we know are ongoing in people with these modifiable lifestyles, including obesity, diabetes, and hypertension. Patients with type 2 diabetes are more likely and more often to have bilateral hip and knee OA. They're more likely to have a greater progression of knee OA than those without type 2 diabetes. We know metabolic syndromes are more frequent in patients with OA, and cardiovascular events are more prevalent in people with OA. So, we're caring for folks that have these coexisting lifestyle diseases, and they are probably affecting, or most likely affecting, the disorder for which we're treating them as well. Next slide. The impact, again, on some of these other parts of the pillars, so smoking, and we know the reporting of pain is much greater in folks that smoke than those that don't. And then the relationship of alcohol and OA, there's a little bit of differences in the literature, but definitely the resounding thing is chronic use is usually associated with a progression of osteoarthritis. Next slide. So, how does it get there? And I'm trying to, I've worked hard on trying to simplify this, and hopefully this one's going to work. We know folks with an unhealthy diet, sedentary lifestyle, high stress, and medications that are trying to manage all those things have microbiome dysbiosis, oxidative stress, and actual cell injury, which leads to chronic inflammation. We know that is associated with these lifestyle-related disorders, such as obesity, type 2 diabetes, cardiovascular disease, cancer, some cancers, that is, and depression, anxiety. We know this is definitely also chronic inflammation is associated with osteoarthritis, musculoskeletal conditions, spine, and chronic pain. And we know our folks have many of these chronic lifestyle-related disorders that we're treating them coexistingly. So, as Dr. Stoll talked about, the lifestyle-related disorders are talking about the mortality that happens with folks, and the things we're dealing with them on are morbidity. So, again, these things are interrelated with each other, and why not approach all of it in a similar fashion and modality in trying to help people improve their overall health? And they may be in a point that they're ready to do that when they see one of us for a pain problem. Next slide. This is a study looking at women that they're looking at their DEQHI, which is a score looking at are you in a health safety place for food safety? Do you have enough appropriate food? And they saw that women who, independent of how much osteoarthritis was evident on their X-ray, their symptom of knee pain was greater if they had poor nutrition, independent of that structural finding. We really need to start thinking about how to solve problems in a different way. Next slide. So, again, we know our patients with musculoskeletal disorders often have weight problems, disordered eating, addictions to tobacco, biopsychosocial and economic risk factors, pain processing disorders, and lack of poor education for self-management, meaning how do they manage themselves with this? And we as healthcare providers in our environment, we don't really have a lot of financial incentive to educate. We don't have comprehensive patient bill-directed integrated programs, and we don't necessarily have a model in which to show or provide services that we know have evidence that aren't always covered by third-party payers. Next slide. And because of this, a lot of us see ourselves in this cycle of pain, patientless pain, pain catastrophizing, fear-related disorders. They don't move. They don't move. They gain weight. They don't gain weight. They become obese. Disability, more anxiety, depression. We all see this commonly in patients we're treating. Next slide. And we know it's the same cycle that happens with people who develop these lifestyle-related chronic diseases. Next slide. And we know that these are also both rooted in the same thing, which is inflammation. Next slide. We know, because it's been shown now in good evidence and literature over the past almost two decades or so, that lifestyle medicine approach can improve and even reverse some of these lifestyle-related chronic diseases. So what if, next slide, what if we use lifestyle determinants to actually improve musculoskeletal spine care while we're also co-treating their lifestyle-related diseases? Next slide. So what do we do? We need to have these treatments that we apply for folks to affect the root cause and go beyond just symptom control. Next slide. And again, root cause, again, for a lot of these is inflammation. So again, we've got to start thinking about different ways to solve this problem. Next slide. So here's a busy slide with the definitions of different types of fields of medicine. Conventional medicine, again, is where we typically practice short- and long-term treatments to eliminate air-controlled disease, and our patient's pretty much a passive recipient of that. Integrative medicine takes evidence-based and some non-evidence-based and interplays those. Complementary and alternative is gaining evidence, but again, uses things oftentimes maybe outside of main pathway of Western medicine. Functional medicine is using, you know, manipulation of physiology at a micro-level and a test looking at assessing physiology via lab and other external testing. Mind-body medicine has to do with how I can train my brain to help with my body function, some evidence-based, some less evidence-based. Preventive medicine, again, kind of more in that public health world, those are all kind of those definitions. And so the definition of lifestyle medicine is really where we take those six pillars and we're using, we focus on educating and motivating patients to make a personal change themselves. So their role as a provider becomes one of more of a cheerleader and enabler and assistant versus passively the patient accepting a treatment from you. And that's a really big issue because obviously not every patient can do that. And we have to meet patients where they are on this continuum of readiness to do this. Next slide. So what I've really found life-changing for me as a practitioner is really what I'm trying to do is enable patients to set realistic next steps regarding nutrition, physical activity, sleep, managing their stress, engaging in their community, avoiding these risky substances. And the big thing is taking the time, go ahead, next, to actually measure the change, not just recommend it, say, where are you today? The goal in two weeks is to be here and we're going to measure it. And this is how we're going to measure it. And keeping us both on top of doing that. So you might be thinking about financially, how do we afford this? You're talking about services that may or may not be available to you. I completely agree. And Dr. Hunt's going to tell us how well, and Dr. Stoll is gonna tell us how well their programs are doing, but there is a financial issue related to this practice. And so my goal, I'm moving to New York now and I'll be starting a program here, is we'll be able to do some of this in employees. And because the place I work for is now self-insured, they care about saving money. So once we understand how much money we can save by practicing this way, we can then not only utilize some of that to put into our fee-for-service program, but then we can go working into bundled models of care, especially with corporate partners. And so I hope to be a part of, there's a vast number of people primarily in primary care that are working hard to getting this type of model accepted as part of mainstream for healthcare. I really hope physiatrists see they wanna be a part of that. Next slide. So at HSS, we're planning on an osteoarthritis program and there'll be two maps of conservative care. One, the lifestyle management program will be available for folks who are in this readiness for change mode that they know they're ready for change and are willing to go along for the ride in an intensive program. Next slide. So again, we got to really think about different models of care to really solve some of these really large problems. We as Musculoskeletal and Spine Providers, I think are on the hook to help with that, solving some of those issues. And I hope this inspires people to ask questions about how to do this in their community, whether in a small way or in a large way. Next slide. So thank you and thanks for inviting me and thanks for the Academy for letting this symposium be a part of the major program today. And it's my pleasure now to introduce Dr. Daviani Hunt. She is Professor of Physical Medicine and Rehabilitation. I'm so proud of that. And she is the Division Chief of Physical Medicine Rehabilitation at Washington University. And she's also now the Medical Director of the Living Well Center. And she's gonna tell us about how great the center's doing. Take it away. Thank you so much, Dr. Fraser. We are indebted to you for all you've done for the WashU Living Well Center. It's such an uphill battle to get these programs set. And it's a really steep uphill battle when it's in an academic setting. So if it wasn't for Dr. Fraser's tenacity and her wherewithal, we wouldn't be sitting here right now. So thank you, Dr. Fraser. I'm honored to be a part of this talk. And my goal for today in this segment is to give you a little glimpse of kind of the nitty gritty of how we're getting things done at the Washington University Living Well Center. And kind of, yeah, get into some of the specifics. So I have no disclosures. Like I said, our founder is Dr. Heidi Fraser. I'm the Medical Director. And Abby Chang is our Research Director. And at the center, we have, we can really hold to the six pillars of lifestyle medicine as the foundation of our programming. The concept is really simple. We want to, our entry point is the musculoskeletal problem. And our focus is to improve pain and function for patients with musculoskeletal and spine disorders while addressing their co-founding lifestyle-related chronic diseases. And improve eligibility for elective orthopedic surgeries and reduce post-surgical risks, which our partners are very into and enjoy as well as the hospital system. And achieve overall health cost savings and improve patient self-management. The concept seems simple, but the innovation is in the delivery of this healthcare. And so it's a patient-driven goal-setting model with the interprofessional team delivering the simultaneous care. And we address the root cause of pain and poor function with personalized medicine while engaging patient-directed goal attainment through lifestyle medicine. And hopefully our impact is vast. So as we facilitate patients to make lifestyle changes to improve their medical, physical, and emotional health, the impact can be improved self-management long-term, hopefully chronic disease actual reversal, and optimizing surgical outcomes. For the hospital, we can decrease cost of complications, length of stay, hospital admissions, even decrease costs for employee health. And for the whole system, significant cost avoided and significant decrease in utilization of services. So what does our center actually look like? We have an amazing cast of players here, an interprofessional care team. It's made up of our medical team, which are physiatrists, physician assistants, and nurse practitioner who are all well-versed in psychiatry as well as lifestyle medicine. We have a psychologist whose focus is pain processing and some cognitive behavioral therapy, but we also have integrated a rehab counselor who has been quintessential in really allowing patients to understand how to get from A to B. And his background is actually in physical therapy and then on top of that, rehabilitation counseling. We also have an acupuncturist who is my partner and distinguished acupuncturist, Dr. Chi Tang, the psychiatrist, and then has studied acupuncture for many years and helped even develop structural-based medical acupuncture that was used. We have a dietician who's well-versed in anti-inflammatory pathways, whole food, plant-based eating, lots of different avenues to get patients to their goals. We also have a slew of physical therapists that we work with and many of their focus is also functional in their goal setting. Medical massage team, actually, there's three medical massage therapists that we work with that work on myofascial release and also myofascial manipulation and taking the teachings of Dr. Stetto and applying them to our patients. And we have a smoking cessation program as well and a nurse coordinator who we couldn't do all these things without. So putting all these people together, this is kind of an overview of how patients get into our system. We're in an orthopedic surgery department and so we have one of the main pathways that we have is for perioperative risk reduction group. So basically trying to optimize a patient to a surgery and this could be a surgery that they may not actually be a candidate for or that they just want to optimize and decrease the risks associated with the surgery. But we also have multiple other tracks that we'll describe. But this is a good example of how a patient might come into our program if they are say a total hip patient but yet their BMI is over 35, their blood pressure is elevated, their hemoglobin A1C is greater than 7.5, they smoke, they have obstructive sleep apnea, low activity tolerance and any type of psychosocial issue that could be their barrier. We use patient reported outcome measures, promise scores. And so we get to get promise scores on physical function, pain interference, anxiety and depression on all of our patients at each time point that we see them. So if we look at their risk assessment and we see that they're high risk, meaning they have more than two of these increased risks, then it's kind of a hard stop. They're not going to go on to surgery. We're not going to offer them a hip replacement or a spine surgery. And so there's an opportunity for them to enroll in the Living Well Center. And so they'll come into our center and be evaluated by one of our medical teams. We do a full consultation with a focus on their goals, their specific goal, if it's to optimize the surgery, optimize the way, we have a few other tracks as well. And then decide if one, they would be a good candidate for it. We do a really good job of trying to look at their ability to engage and their ability and resiliency as well to see if they could be good candidates. Because we ask them to do a lot in this program. And so if we think that they're a great candidate, then they enroll in our program. And our program is designed to be about 152-ish days that they will see multiple providers, sometimes one to two in the same week, sometimes one to two in the same day. And we kind of lay out their plan. And then they get together, we get together as a team, an interprofessional team to discuss the patients. And we kind of go back to our inpatient, physiatry routes to do our team meetings. And the team meetings can be, are actually a significant part of our success. We're able to actually discuss patients, discuss their barriers. We can then also message the patients in a cohesive way. If they hear kind of the same message from a physical therapist that they hear from their physician, it makes a big difference. And then we can actually get more insight too. We get a lot of insight into how to message patients from our psychologists. So we have these interdisciplinary teams, team meetings that happen once a month. And then the patient kind of cycles through. And at the end, we hope that they're going to reach their goal. These are our current pathways. So we have a total joint pathway, which is basically a perioperative risk reduction group. So optimizing to a surgery. We have our spine pathway, which is avoiding surgery and or optimizing to surgery. A cancer survivorship pathway, post COVID long haulers, which is our newest pathway. And then select services. So this is usually a healthy patient that's seeking services in this coordinated delivery setting. And again, having very specific goals for the program. We are about to release our feasibility study. And this, we're collecting data. And Dr. Chang is going to go into a little bit further into all the data that we are collecting. We were able to use this, our first, one of our first few cohorts as for the feasibility study is 26 patients. 73% of them were spine patients in our spine pathway. And through their time with us, which was 191 days, they saw an average of 26 visits with us. And as you can see in this chart here, it was the patients were mean age of 59 overall, 69% female. And of those patients that were in the program, and we did choose these patients specifically, 81% of them completed the program and 62% of them actually met their goal, which I think is very high numbers for this type of a program. And part of that does have to do with our selection process of really looking for patients that are ready for change. And you might go around to my partners and primary care, everyone around campus and talk about the program. I used to kind of say very specific that this is the type of patients that we need, and it's more diagnosis based, but now I just say, hey, if you've got somebody that's ready to make a change and ready for a commitment, send them our way and we can optimize them. One thing that we didn't really know what would happen with, was our anxiety and depression scores. Because we know that that's a big part of what we do, but we didn't really know if it would change much, but we did see a mean decrease of 3.5 points on the anxiety score for the patients who completed the program. And this schematic over here is an idea of all the comorbidity of the patients that were in this cohort. So as you can see, obesity, 92% of them were overweight. So what we've learned, we opened our doors in June of 2020. It was supposed to be March of 2020, but that was the terrible times in the world. And so we postponed a bit, opened in June of 2020. And so we have a little bit of a slower uptick than what we expected, but we're up and going now. And we've learned a lot. So we have learned that this model works. We've been able to optimize patients to their goals month over month. If we select the right patients, that is definitely the key to success and using these readiness for change measures, resiliency, activation. And the most utilized services were dietary counseling, behavioral health, acupuncture. Those were the keys to our success. But we do know that continually, we have to work hard to enhance our referral patterns and payment is definitely our biggest obstacle. So in the fee-for-service model, it's not sustainable. So moving towards employee health, package pricing, things like that are where we're putting a lot of our efforts right now. I just want to share with you just a few quick homerun stories that we didn't think would happen. Some people became undiabetic and pre-diabetic and they are no longer pre-diabetic. This gentleman actually had claudication. These are films of his back. And as you can see, he has a failed back syndrome. He was working to optimize to his fourth surgery. He was only able to walk two blocks and he's now walking two miles. So we didn't change anything in his hardware and his back at all, but we did optimize him to activity. So his goal was to optimize to surgery and he still hasn't had it. So I think I would say that's a definite homerun. So in conclusion, we have developed successfully a patient-centered approach to care, capturing patients, ready for change, utilizing the principles of lifestyle medicine. We're optimizing patient outcomes while decreasing costs and improving access to surgery. And this care is delivered in a true patient-centered interdisciplinary approach, utilizing the key services that really typically aren't available to patients and producing lasting effects and attainment of these goals. So I will stop here and would like to introduce our next speaker. And this is Dr. Gwen Soa. It's a pleasure to introduce you as a friend and colleague. She's accomplished lab-based translational researcher, clinical researcher, professor and chair of the PM&R department at University of Pittsburgh. Thank you so much. And such a pleasure to be part of this team today. It's very exciting to see how far this work has come and how all of these experts have really pushed this field forward. So thankful to all of them. And definitely agree with what's been said in terms of this being firmly rooted in PM&R. So it is our opportunity. And I will say personally that when we started in this approach, it really, not only is it fulfilling as you've heard others say, but it's really reinvigorated my own clinical practice. And it's a really exciting avenue. So I would encourage, as others have said, for everyone to get involved. I think one of the biggest challenges that I see is lifestyle changes are hard and they're expensive. And so one of the things that we've been thinking about a lot is how to choose the right treatment for the right patient at the right time. To increase the likelihood of success for all patients, the sustainability of some of these programs. And so I'll share with you some of our thoughts about how we might be able to do that. My disclosures are largely related to funding related to some of the data I'll show you today. So again, the right treatment for the right patient at the right time. If we're able to phenotype patients in more sophisticated ways and look at all aspects, all of the different contributors they have to their experience of musculoskeletal pain or other conditions, then we're more likely to be able to tone in on the exact right treatment. And very similar to what Dr. Hunt explained, we have an interdisciplinary program that we started here. We're now in about six years into our experience with this. And like I said, it's truly been reinvigorating to many of us in our practices. Our patients can come through a number of different portals identified by their primary care, our health plan, a specialist, but they come into a nurse care coordinator who helps to triage what these patients need. Not everyone sees all the resources that are embedded within our programs, but we try to tailor that and personalize it to what that individual's biggest barrier is and what we think will help them toward recovery. So we have physiatry, physical therapy, we have dieticians, psychologists, sleep medicine, nurse coordinators who do smoking cessation, brief addiction counseling, et cetera. And very much like Dr. Hunt was saying, we use a interdisciplinary model where we're regularly powwowing about these patients and talking about them in care conferences to make sure that we're all on the same page delivering that same message, because I absolutely agree that that is key to how we move things forward. So by doing this, we're able to address some of the key barriers to recovery. So things like mobility, the pain itself, inflammation, which as you've heard, it can be largely dietary related, medical comorbidities, which creates that vicious cycle, the anxiety and depression that we commonly see and fear avoidance and fear of movement. By bringing all of these disciplines together and centering them around the patient, we have a higher likelihood of removing the barriers that people have to recovery. So here's some of the early outcomes we had with our experience. And this was, again, we've been about six years in, this was the first year of the program. We found that we had a very complex patient population. So 82% of our patients were classified as medium high risk, in this case, based on start back tools. Some of the early wins is a high percentage of our patients were following up with outpatient PT longitudinally. And 24% were actually able to show significant improvements within that first year in their patient specific functional scale scores. And while that might seem somewhat underwhelming, if you've worked with this patient population, starting to see some people move the needle in terms of their own function can be very, very rewarding. And close to 30% was statistically significant differences in their ODI for our spine population. We were able to accomplish that with low utilization. So only 5% of our patient population had advanced imaging orders. We had very high patient satisfaction scores. Physician communication domain in particular was in the 96th percentile on patient satisfaction. So these were some very early wins that were able to garner the attention of our health plan. And in thinking about sustainability of these programs, one of the things you have to show is that you're able to move the needle on some of these expensive resources to then reinvest those funds back into the program itself. Another early win was with opioid utilization. Of course, this is a big driver for some of the barriers that we see to patient's recovery and a significant burden on our population. This, in our system for all low back pain, at the time we started the program, opioids were actually the top prescription spend for our patient population. Through the program, we were able to bring that down to the sixth top spend. So we were able to not only not have new starts for opioids, but able to get many of these patients off of their opioid medications and onto a much more productive treatment plan. but can we do better? And this is where we start to think about personalizing this. And this is where we leaned into our big data sets and ask the question, can we take this a step further and phenotype patients in a way that might be able to help us in an even more personalized way than we're able to do with our patient reported outcomes? So what we're able to do, what this graph shows you is the results of phenotyping over 550,000 patients with low back pain. And we looked at those patients who at some point were prescribed an opioid. And we looked at what were the clinical characteristics of that patient discontinuing that opioid versus remaining on that opioid. And that's what you see here. All these different colors are clusters of patient phenotypes that gave us information about whether that patient was at high risk to remain on the opioid or come off of the opioid. Again, giving us a little bit of insight into what were the barriers that that individual person has. So we're able to dig into each of these phenotypes and say, what are the key drivers of this phenotype? And is it something that's modifiable? Is it something either we know, we've thought about or maybe something unrelated? And so we've been using this information to try to help us create a more personalized plan for our patients. But we can use this for other things other than opioid utilization. Here's an example where we used it for shared decision-making for epidural steroid injections. So using the same type of thing, we were able to pull information out of the electronic medical record for our large cohort. And in this case, we were able to identify 10 distinct phenotypes, which is what you see in the center of the screen there with the different colors of likelihood to either improve in response to an epidural or even worsen in response to an epidural. And what's interesting here is you can see on the left, the key drivers for that were many of the comorbidities we've been talking about today that coexist with patient's pain. Congestive heart failure, fibromyalgia, irritable bowel, et cetera. So by using their comorbidities, their medication use, other aspects of their care, in this case, we also used their level of disability. We're able to then predict for that individual person, what was their likelihood to improve? And this is an example of a patient who had a moderate degree of disability related to their pain, but essentially no comorbidities. So you see the green bar there, decent odds to improve in response to an epidural. If instead we look at a patient who is taking a muscle relaxant, an opioid, a non-steroidal, an antidepressant, has fibromyalgia, IBS, anxiety, and depression, you can see how dramatically that shifts that. Now, again, you might say, well, that's kind of our sniff test on when we decide to send a patient for an injection or not. But in fact, this can be a very powerful shared decision-making tool where you can show an individual patient what is their likelihood based on our data in our system for their likelihood to respond or not respond? And what of those things are modifiable? So to use that as a coaching tool, look, if we're able to get you to quit smoking, this is how it changed your likelihood to respond to a certain intervention. So it can be a very helpful tool in that regard as well. But can we use things outside of the electronic medical record? These examples were things that we could just pull from patients' comorbidities, but can we take it a step further and actually start to look into individual personal biology? So this was a study that we did, again, looking at epidural steroid injections, where we brought people in who, 18 or older, who were undergoing an epidural as part of their routine clinical care. So we didn't decide who would and would not receive an epidural. We looked at responders or non-responders. Responders were defined by 50% or greater improvement in their numeric pain rating scale. And probably no surprise to many of those here, we found 17 responders and 31 non-responders. And again, these were patients with axial back pain, for which an epidural isn't necessarily indicated but often performed. So we looked at that and also showed that the responders were also associated with a clinically significant change in their ODI, their Osteosteroid Disability Index, giving us some confidence that how we were defining responders and non-responders was actually useful clinically. And then we looked at a number of different measures. We looked at protein-based biomarkers. We looked at other patient-reported outcomes. But what we looked at that was really interesting was genetic biomarkers. And this is some example of that data where we looked at single nucleotide polymorphisms in this patient population. And in this example, we were able to demonstrate that in a molecule, neuropeptide Y, which is a pain neurotransmitter, that there were differences in the presence of the single nucleotide polymorphism in that pain neurotransmitter, depending on whether you were a responder or a non-responder. What was even more dramatic was when we looked at a single nucleotide polymorphism in catecholamine methyltransferase. And you can see how different that was in terms of whether you carried that or not, your likelihood of being a responder to that injection. Of course, catecholamine methyltransferase is a key control point for the dopaminergic and neuroepinephrine signaling pathways. So something that has a big impact on our patient's experience of pain. And so again, starting to think about how can we use that information to specifically tailor our approach to the individual patient in front of us. So can we put this all together? And actually we can in ways combine clinical and biologic data to give us improved outcomes. So we looked at, this is a graph that just shows responders and non-responders, red and blue peaks. If we use the clinical data only to predict. And in fact, you can see some separation, but some overlap telling us there was a fair amount of uncertainty in how we could predict if someone was gonna respond or not. We did the same thing with the single nucleotide polymorphism data. Again, you see some separation, but some overlap. But if we took this and combine this with clinical single nucleotide polymorphism as well as circulating protein levels, what we started to see was a very nice separation of those peaks, giving us even more predictive capacity about whether someone was going to respond to an intervention or not respond to an intervention. And this is exactly where we're looking forward to taking this as a next step and helping us to identify how we can individualize these approaches from a lifestyle medicine approach to the individual's particular barrier. So this is the program that we have funded. It was funded about a year and a half ago by NIH. We're one of three mechanistic research centers that was funded in the country. We've been collaborating closely with the University of Michigan and UCSF where we are recruiting here at Pitt, 1000 subjects with chronic back pain. And what we are doing is phenotyping them in a very broad way. So we're doing biologic phenotyping where we're collecting bio samples, saliva, blood, genetic markers, spinal tissues, if they go on to surgery and importantly stool to look at microbiomes. We're very interested in looking at the microbiome and these individuals to see if that has an important predictive capacity or something that obviously can be addressed from an intervention standpoint. We're also looking at the behavioral and psychological context of all of these patients. So social determinants of health, behaviors and lifestyle factor, psychological factors and how those might be modifiable down the road as we think about phenotyping these patients and looking at what are their key barriers. And then finally looking at the biomechanics. So looking both at laboratory-based biomechanics, so segmental kinematics in the lab, looking at segmental motion with spinal monitors, but then looking in the field and looking at things with just general activity level and motion in their daily activities. Bringing all of these things together in a way that we hope can better help us personalize and direct the specific intervention. Of course, it takes a village to do this. And so this is our team that's been working on this, a true interdisciplinary approach. So we have molecular biologists, physiatrists, physical therapists, biostatisticians, engineers, chiropractors, psychologists, all working together on this challenging project, which we hope will then be able to be leveraged into something that we can use in the interdisciplinary environment clinically. And I'll just leave you with how we wanna bring that full circle. And this is a very exciting project that we have ongoing right now, where we're in the midst of building our Mercy Vision and Rehabilitation Tower, which will co-localize some of our clinical activities with some of our research activities in the same space so that we can more seamlessly go bench to bedside and bedside to bench. So a very, very exciting time. And we're very optimistic that though this is a challenging problem that we can continue to move the needle. And so I will stop there and I will pass it off to Dr. Abby Chang, who I'm very thankful, she'll bring us home today. And I'm very thankful for her bringing this incredible group together over this important topic and inviting me to participate. It's been a pleasure to get to know her and her very important work. She's the Research Director, as you've heard, of the Director of the Living Well Center at WashU. And so thankful for you for bringing this group together. So please, Dr. Chang. Thank you. And thank you to everyone for listening. I love the chat that's happening and I would encourage all the speakers to kind of keep an eye and answer questions that start coming to you. I am going to very briefly high-level overview, give you an idea of why I think it's really important for us for everyone who's getting very excited about doing this to incorporate research into your program because like we've been talking about, we have to prove the value of these programs in order to make these sustainable. So I would say on a broad scale, people think about clinical care as being as efficient as possible, minimizing burden to patients and providers. Research, on the other hand, is very data-driven. There's lots of nitty-gritty that may not necessarily be the most efficient for providers and patients. But if you think about it, to really take care of patients, physiatry, lifestyle medicine, and anything, we need a lot of information. So if we can do this and collect it in a very efficient way that works with the clinical workflow, we can accomplish our clinical and research missions together. At the Living Well Center, we do this as a very team-based approach. So we have monthly meetings with our clinical and research teams together. Our nurse coordinator who coordinates our patients' schedules and their care plans also obtains our research consent so that all of the data we get from patients for clinical care goes into our research repository. And then on the flip side, our research data is facilitating quality improvement initiatives like understanding referral patterns and a cost-avoidance analysis so we can really prove the value of our program to third-party payers. So I don't have time to get into the nitty-gritty of how we collect data at the Living Well Center, but I want to highlight a couple key resources, the first being an electronic database system. We use RedCap, but there are others available. So when a patient comes into the Living Well Center, they check in at the front desk and they're given a tablet. The front desk staff person scans the QR code. It goes straight to the questionnaires we ask the patient, which goes straight into our database. That tablet follows the patient from check-in to check-out. It goes next to the clinical staff member that takes care of the patient, and they put in BMI, blood pressure, objective metrics. Then it goes to the provider, and the provider can see real-time all of the data that's just been collected from the patient and the clinical staff. And then they input just a few variables to say what's their assessment, what's the plan. And those variables are used on a research side of things, but also for the clinical team. So then the tablet goes back to our nurse coordinator. She can understand what the orders are, what the plan is. She documents research consent. And then anybody who worked with a scribe, the tablet can go to the scribe as well to input all the data into the medical record as we need. So it really is a key workflow where we use our research and we adapt it to make sure it fits with clinical care, because we know it's not going to be sustainable unless we can do this in an efficient manner. The other thing I just want to highlight is questionnaire. So people are starting to ask in the chat, how do I get started? This is a lot. The ACLM and the Loma Linda University developed a lifestyle assessment short form. They also developed a long form if you want more data, but it's a great place to get started in terms of finding questions and kind of content related to lifestyle medicine that you can ask. I will say these are relatively recently developed, so there's not a lot of psychometric validation in the literature about them, but it is just a good resource to kind of know about. So we have a few minutes left. I want you as viewers to kind of think of yourselves as clinicians in a lifestyle medicine type of setting and think of a patient. And then we're going to move into a Q&A session and the speakers can talk about their approach to this patient. And you can ask any other questions as well. Please continue to leave them in the chat. But I would say a traditional patient we might see in the Living Well Center is a 50 year old female coming in for right hip pain. She has known moderate to severe hip arthritis. She doesn't want surgery. And right now the surgeon says she doesn't even qualify for it because her BMI is over 40. Her hypertension is controlled on two medications, but she's an insulin dependent diabetic. Her A1C is elevated. Her anxiety is not well controlled. And she says she's just at the end of her rope. She's tried physical therapy and injections, kind of works, but nothing has been sustained. She feels like her pain and her anxiety keep kind of bringing her back down. And at this point she says she's got to do something. She has grandkids on the way and she wants to be part of their lives. And that usually it's one of the drivers that kind of brings people to be ready for a lifestyle change. So at this point, we will move into the Q&A session. I want to be able to pull up the chat so I can filter questions as they come in. But as we do, Dr. Stoll, I want to start with you. So some of the direct messages I'm getting to are where to begin? How do we do this? And how do you get a mentor? How do you, where do you go? Can you start us off with that? Yeah, thank you. Thank you, Abby. And thanks to all of you who are watching. I was actually just scrolling through all the participants and it's so wonderful to see that we've had such a nice group this afternoon. We really appreciate your time. Two really good places to start are the American College of Lifestyle Medicine. They just finished their annual conference, but they have tremendous resources available online. And also the Plantrition Project. It's an organization that we started. We have an annual lecture series that we just started in the spring where you can log in and view the lecture series, but we also have our conference and lots of downloadable resources. So that's PlantritionProject.org and LifestyleMedicine.org are two great places to get started. Thank you so much. Another question I'm seeing is, is anyone willing to mentor me? That was a direct message to me, but I think it was to the group. Do you have any other recommendations to any of you? I think we're all open to talking offline even after the assembly and after the session as well. Yeah, there are lots of opportunities for mentoring, even in our organization. I don't mind taking on people that are passionate about making changes and mentoring people. I believe that's one of the things that we should be doing later in our careers is actually mentoring people that have the same passion. So I'm happy to do that. We also have other people I know in the community that we can connect you with based upon your interests. And you can just connect them with me, Abby, that might be the best way to do it. And I'll take that on personally. That sounds great. Another question is coming in. I think let's go to Dr. Hunt or Dr. Soa for this. So the participant is asking, what characteristics do you look for in a patient that you think would be an indicator that they might have success with an intensive lifestyle medicine program? Is it grit, determination? Can you measure this quantitatively? Can one of you guys take that away? I can start and then Gwen, you can add to it too, of course. But I would say what we look for, we do have a few measures that we use in our intake form. So one is a readiness for change measure, patient activation measure, a readiness ruler. So getting kind of a percent of kind of where they think they are and their ability to change. So we look at those measures, but also some of it is talking to the patient and seeing what they, getting kind of a general idea of what you think they'd be up for. Yeah, I would agree with everything. And we don't do a formal measurement of it, though I'm making notes as Dr. Hunt's talking about that. And we haven't done a formal measurement of it, but what we have done is done a lot of education and outreach with our referral sources. So in our system, most of our referrals for these patients are coming from primary care or orthopedic surgery or neurosurgery. And so what we've done is worked with those folks, in particular, the primary care docs who have a really good sense of, is this patient ready to make that change? The other thing we've done is we have done direct reach out through our health plan. Our insurance division has sent mailers out and allow people to self-select. So when they're calling us based on an informational mailer, we know that they're at least engaged in starting the process. But also being very forthcoming at that first visit about what the program entails and the amount of commitment that patients really need to have to this and making sure there aren't unrealistic expectations, I think has been really helpful in that as well. And then we have about one minute left, Dr. Prather, I wanna give you a chance to respond to that as well. And then in addition to that, I think your reputation in the field is a visionary. In 10 years, what do you envision lifestyle medicine and physiatry to look like in the field of healthcare? Thank you. I echo behind Dr. So and Dr. Hunt. The big thing, when Dr. Hunt and I started this back at WashU, because we got to work together there on this, I really thought I knew who these patients were, but really that trans-theoretical model of change, using that measure, I think is the key. The most hardest patients, I thought this person's not ready, but they were ready and you can really do an assessment. So I really encourage you to use that. The other question is how confident are you in that change? When you can get people on a scale of seven to 10, they're ready. Six, they got the running shoes, you need to show them the door, help them through the door, that kind of thing. I hope everybody who's attending this is somebody who'll lean into this process and system management that we know our patients really need and become a part of the process of working towards this being a model of care. And we have to work together towards it in order to get it paid for. So I hope in 10 years that this becomes not only mainstream and educational realms, but we are starting to see more and more of these types of programs popping up and that physiatrists who are really good at interprofessional care are leading some of these programs. Okay, I think we're right at time. I want to thank everyone for joining. This was really exciting and fun to get together. Please do follow up with us afterwards. We would love to continue the conversation and move physiatry and physiatrists into the forefront of lifestyle medicine even more. Thank you. Thanks everyone.

lifestyle medicine

musculoskeletal disorders

prevention

treatment

non-communicable diseases

personalized lifestyle interventions

interdisciplinary approach

recovery barriers

patient phenotypes

improve outcomes