Good evening, everyone. This is the Central Nervous System Community Session, our first session out of three. And welcome. And our topic tonight is on adult rehabilitation care of persons aging with acquired disorders, CNS disorders, and neurodevelopmental disabilities. This is part one. I'd like to mention also before we begin some housekeeping issues. If you can move the slide to housekeeping, please. So for housekeeping notes, it's best for attendees experience during this session is all microphones have been muted. And please remain muted unless called upon. During the questions and answers, the host will be unable to unmute you. And then to ask question, please use your raise your hand feature or end unmute if you're called upon or use this chat feature to type your questions. I think for this session, we'll be probably doing the chat features and I'll be doing the question and answer at the end of each talk. And then I'd like to mention for all the CNS community members that the election is there's election coming and please go vote. It will be announced keep an eye on the link at the FIS forum, the CNS community FIS forum, there will be a link in there and then the nominees and their CVs will be a little bit about their biography will be in there. So keep an eye on the link. I'd like to introduce our speakers. We have two great speakers for tonight. And you know, one of the joys of being the moderator is I get to meet my mentors and then and meet great, amazing speakers. Tonight's topic is on aging, as I mentioned, and the reason for this is because during the poll that we sent out last year, this is one of the topics that was that was requested upon. So it is my honor and great privilege to introduce our two distinguished speakers for tonight's presentation. First is Dr. Kathleen Bell. She needs no introduction. She's the professor and chair of the University of Texas Southwestern Medical School PM&R program in Dallas, Texas, my alma mater for my fellowship. She is the holder of Kimberly Clark Distinguished Chair in Mobility Research. She is so distinguished, like she has like all this list of accomplishments. She did graduate from Temple University Medical School in Philadelphia, residency at University of Washington in Seattle, and has NIDRR's Switzer Fellowship. She's a professor in the Department of Rehabilitation at the University of Washington for 20 years before moving to UT Southwestern in September of 2014. Seattle's loss and Texas win. It's she is her research interests and publications have centered on treatment and outcomes for traumatic brain injury, and is well known in the traumatic brain injury field for self management techniques, post traumatic headaches, sleep disorders, exercise after TBI. Her current research is on concussions, sleep disorders, and autonomic nervous system after concussion. She's funded as an investigator from NIH, NIDRR, Department of Defense, PCORI, and CDC since 1998. She is currently the past president of American Academy of Physical Medicine and Rehabilitation, the co-director of Texas Institute for Brain Injury and Repair, and also the investigator for the North Texas Concussion Registry and a co-PI for the North Texas TBI model system. Our second distinguished speaker is my mentor during SCI Fellowship at UT Southwestern also, but currently Dr. Lance Getz is a staff physician at Richmond VA Spinal Cord Injury and Disorders Center and Associate Professor, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University. He served as a program director at VCU and Maguire Spinal Cord Injury Medicine Fellowship from 2013 and 2020, and also directed the SCI Medicine Fellowship at UT Southwestern from 2003 to 2010. He finished his MD at University of Iowa and completed his residency in physical medicine and rehabilitation at UMich. And he finished his spinal cord injury fellowship at VA Puget Sound Health System in Seattle. He served at American Paraplegia Society and he was given the American Paraplegia Society Excellence Award in 2017. He has distinguished VA merit grants and site investigator for multiple researches in SCI and current research is on supported employment, the exoskeletal assisted walking, erectile dysfunction, clinical practice guidelines, pressure ulcers, and to name a few. He serves as an ad hoc reviewer for numerous SCI and PM&R journals. He would like to give thanks and he is unmeritably grateful to the talented clinical rehab and research colleagues that he has, his wife of 21 years, Eva, hi Eva, and twin boys, Daniel and Devon, and all the friends that he has. And then I think he's one of the best speakers for this topic since he lived the experience of a spinal cord injury, patient with spinal cord injury since 1984. So it's my great honor and pleasure to introduce both speakers and I will have Dr. Kathleen Bell as our first speaker. Dr. Kathleen Bell. Hi everybody. Let's see if I get my screen up here. This looks like the right one. Okay. There we go. So anyway, welcome tonight. Very nice to be talking to all of you and I have to tell you right off the bat that we're not really going to be talking about kind of the clinical management of issues that arise with aging with a TBI. This is going to be a little bit more of a 30,000 foot lecture and there's a reason for that and I'll try to go into what the problem we have with wrestling with the TBI really is as we go along. So I don't have any conflicts of interest that are relating to this particular lecture at all and we're going to start off by talking a little bit about some of the epidemiological changes on TBI because it really has an impact on aging with a TBI. Some of the changing course and outcomes in the older population and talk a little bit about TBI as a chronic disease model which is actually a relatively new concept as opposed to other issues that we deal with and talk a little bit about what we might be doing to improve the situation with aging with a traumatic brain injury. So I'm just going to start off with this slide because it's kind of to me really interesting because this was a study that was done I think led by John Corrigan out of Ohio State and this is looking at five-year outcomes of persons with TBI and we'll circle back to talk about this a little bit more. I think one of the things that really is interesting to me is that during that five-year time first of all fully 22% of people who sustained a traumatic brain injury died during that five-year period. That's pretty amazing. 30% got worse and almost 30% got better. Okay, so what's that all about, right? And about close to the same number stayed the same. So this is starting to illustrate one of the problems we have in terms of looking at outcomes with traumatic brain injury. So we'll talk a little bit about what the problems are with this as we go along. So this is a star here. So here we are, right, in the intensive care unit in a local trauma center and we're looking and trying to predict what's going to happen to people as they age with a traumatic brain injury. What's just going to happen to them a week after they have a traumatic brain injury? So these are two relatively recent studies. I didn't go back and look at some of the other ones, 2016, 2021. And what I will point out to you from the Rizzoli study is that they did a large population. It was a randomized controlled trial, so they did a secondary data analysis and they looked at three very typical measures to look at to predict outcome with traumatic brain injury. One is the abbreviated injury scale for the head, the second is the Marshall classification for CT scores, and the last one is pupillary reactivity. So the interesting thing was they were able to predict if somebody was going to die and they were able to predict an acceptable outcome, whatever that is. However, if you look at the sensitivity and the specificity, it's pretty bad, 72% sensitivity, 62% specificity. So the problem is that we can tell if somebody's going to die or live, but we can't tell very much else about them at this point in time. And that's really, that's been borne out time and time again in a number of different studies is that we don't have a good way of predicting prognosis in traumatic brain injury. And at this point in time, despite all of the work that's been done over the last, you know, really 15 years with sports concussions and with military conflicts in Iraq and Afghanistan, we still really do not have a reliable physiological or serum biomarker that we can use to predict outcome. And as you can see, using things like CT scans and other types of clinical measures acutely don't really help us very much. So what's getting things a little bit more mixed up at this point in time in terms of looking at outcomes and aging is the changing epidemiology of brain injury. And you can kind of look at this graph and say, aha, this is really interesting. So if you look at the time from 2006 to 2014, we can see some real trends here and it's not hard to do. You don't have to be a statistician to look at this one, right? So what we can see are things like motor vehicle accidents have decreased substantially, at least hospitalizations related to motor vehicle crashes. That's gone down by 20, 29%. But what we can also see really clearly is what has increased particularly over the last, you know, last six or seven years, falls. Well, this is going to predict something to you about what's happening with the kind of epidemiology of traumatic brain injury in hospital for moderate to severe brain injuries. And here's the rest of the story, right? So if you look at the hospitalization by age group, you're really seeing a change now. So the pink, the pink graph at the top, the pink line is over 65. Okay. So you can see that actually hospitalizations for brain injury is decreasing in every single category except for our friends over the age of 65. And this is near and dear to my heart because I'm over 65. And in fact, individuals over the age of 75 have the highest incidence of hospitalization after traumatic brain injury. And they're more likely to die, not surprisingly, from their injuries than other age groups. Now, one difference that you will see between the group down here that's decreasing and the over 65 group is that while through most of ages, men have a substantial weight over women in terms of the incidence of traumatic brain injury and hospitalization, that is not the case over 65. As a matter of fact, women outnumber men as they get older. And part of that may just have to do with just mortality in general. So the reason this is an issue is because it's changing the whole face of aging with a traumatic brain injury. It's very different now than it was 20 years ago. Why are TBIs increasing in older adults? Well, first of all, we have mandated the use of seatbelts. We have mandated, I like that word mandate, I'm using it purposefully now. We have mandated the installation of airbags in cars. And so these have really decreased the mortality associated with and morbidity associated with motor vehicle crashes. The other thing is just that the elderly are staying alive longer, and they're also more mobile than they used to be. In fact, it's interesting that one of my goals in life when I was living up in the Pacific Northwest was to get a free ski pass. And when I first started skiing, I didn't start until I was like 40 years old, when I started skiing, at that time, you could look at the ski pass prices, and they would say over 65, ski for free. I thought, okay, I'm going to make it to that. And then I noticed about five or 10 years later, it was over 70, ski for free. And then I noticed a little later that there was no ski for free, because there were too many people over the age of 70 up on the ski slopes at that point, right? So older adults have a lot of other comorbidities, though, that really predispose them to having traumatic brain injuries, like things like diabetes, which increases in prevalence as we age. Diabetics are twice as likely to fall. They have neuropathies, they have other reasons for poor balance, they have poor eyesight, they have less cardiorespiratory fitness and less strong muscles. So there's lots of reasons diabetics are going to fall. Older adults are much more likely to be taking medications like anticoagulants, which really increases the risk of severity of brain injury. And the other thing that I'll just throw in here that we'll talk about a little later is we don't actually know much about the risk of premorbid mild cognitive impairment or other AD, Alzheimer's disease, and related conditions on outcomes for older people. So this is really changing the way we have to look at traumatic brain injury now from before. And again, just another point of why traumatic brain injury tends to be more frequent in older people. Again, there's this mystery TBI that we all know about where people come into the emergency room with increasing confusion and balance loss and maybe some incontinence over a period of a couple weeks and nobody knows why. Turns out they have a big subdural and nobody knows why because they didn't fall and we don't know what happened. But of course, because of the physiological and anatomical changes in the brain and the dura, people are much more prone to having stretch on the vessels that traverse the space and they're more likely to have bleeding. And again, we talked about anticoagulants. What we see all the time with patients who have brain injuries in this age group, even mild traumatic brain injuries, is there's a normal finding of chronic microvascular disease. There's usually, there's not infrequently some volume loss. There may be some occult cognitive impairment, which doesn't appear to be related to the TBI. And there's all sorts of alterations in dynamic cerebral autoregulation so that people may have a very different pathway for recovery. There's one other thing that I'm going to bring up about the aged person with a traumatic, new traumatic brain injury, because I think this is really interesting. There is some very early, this is just published last year, and this really got my attention. This is a study from Norway in which they looked at, they compared the intensity of treatment for traumatic brain injury in the elderly compared to the intensity of treatment to other age groups. And I'm not going to take you through all of these, but I think you can see that this is age, down here on the left is age 25, and it goes up to age 75, right, in each of these graphs. And this is mild brain injury, moderate brain injury, severe brain injury. But I think you can see that there's a lot of differences in just the waveforms here in terms of what kind of treatment intensity patients were getting. And what they found is that trauma team activation, advanced imaging, invasive ICP monitoring, and ventilator treatment all declined significantly with increasing age. But the thing that really got my attention is, you know, I'm not that surprised that, you know, once you get over the age of 80 or so that there's some, I don't know, maybe some reservation in being extremely aggressive. But you can actually see that these changes in the intensity of treatment start at around age 55 or 60. I don't consider that to be highly elderly. So I think this is very interesting, and we don't have any kind of data on this in the United States, but I think it's something that I'd certainly be interested in looking more about. I'm not going to try to get you through this whole thing either. This was a, but this gives you some idea, again, as to why we're seeing changes in aging with a traumatic brain injury and what might be impacting that. This was a study done by Hilary Thompson up in University of Washington, and she looked at elderly people in the emergency room who came in with either mild to moderate traumatic brain injuries as compared to younger people with traumatic brain injury. And the interesting thing that she found, which you will see repeated often in studies is that the younger people with traumatic brain injuries had many more, had more mental health complaints, and the older people with traumatic brain injuries had more physical complaints. So for whatever reason, older adults are more likely to experience fatigue, balance, coordination problems. Younger adults, however, endorse more things like anxiety and depression. So that is going to have an impact on what we're looking at. And then looking at hospital readmissions, again, there's a difference in how people are readmitted to a hospital after they've had a brain injury. So it turns out, looking at this study from 2018, which used a giant national readmission database, it turns out that the youngest group, those below the age of 40 who were discharged after traumatic brain injury hospitalization, had their highest readmission rate during the first week. But obviously, I think the older people had highest rates of readmission, but later, much delayed. So it's interesting that there's an implication for how we deal with people after a brain injury, and those who are younger have more psychosocial problems, which result in earlier problems with coping with traumatic brain injury, whereas those who are older tend to have more medical problems. So yet another difference between them. So again, considering here, again, looking at the effect that this tremendous increase in older patients with traumatic brain injury is having on the whole outlook for aging with a traumatic brain injury, there's a lot more people over the age of 65 who are getting their first major traumatic brain injury. Age is generally, but not specifically, a negative predictor for outcomes after traumatic brain injury. So you can actually do quite well after traumatic brain injury, although in general, the older you are, the worse you'll do. These may actually play a much larger role than the actual injury in the eventual outcome, especially when you look at older people with a mild traumatic brain injury. We may be restricting treatment unnecessarily in elderly persons with a traumatic brain injury. And again, I keep including myself in this because I am officially an elderly person now. So if I were admitted to an emergency room, I would be less likely to get aggressive treatment than many of you who are listening in today. And also, older people with traumatic brain injury may have different presentations over time than younger people with traumatic brain injuries. So now we'll kind of seek into aging with a traumatic brain injury. And we're still going to stay pretty much up at this 30,000-foot level. Now, I think that I will say, in general, traumatic brain injury has been viewed as an incident, a traumatic event, rather than being viewed as a permanent condition. Now, clearly, people who have very severe brain injuries with motor deficits have been viewed as having, you know, maybe more of a chronic problem. But I think when you get into the more mild or moderate injuries, people have not. It's been viewed as a single thing, over and done with. Certainly, that's the way insurers and payers have looked at it. But what we're really finding now that we're starting to get some data, and we have less data than, for instance, in spinal cord injury. The spinal cord injury model system started about a decade or so before the traumatic brain injury model system. So they actually have a more extended period of data to look at as people were aging. So we know now, looking at things, although we don't have a lot of detail about this, because this is literally just coming off the press in a lot of these areas, we know a little bit more about neurological system permanent conditions, because it's pretty obvious. If you have post-traumatic epilepsy, it's pretty obvious. We know cognitive disorder, which is basically the definition, you know, of a traumatic brain injury. We know that there are behavioral and mood disorders. We'll talk a little bit more about neurodegenerative processes, because we think that there's a connection, but it's a little tenuous. We know now that there's a real issue with sleep disorders, and this is fairly new, hot off the press. This was, you know, for obstructive sleep apnea. We really just got the statistics on this a couple of years ago in a project that was led by Dr. Risa Nikasi-Richardson down at the VA in Tampa, where we looked at obstructive sleep apnea over kind of a national study and found that amazingly, shockingly, of people who were on inpatient rehab units in both civilian and VA centers, 61% of them met the criteria for obstructive sleep apnea, and that's shocking. That's absolutely shocking, and this was a group that was not all really severe, that was not very old, and that was frankly not very obese, so they didn't really meet a lot of the risk factors that you would expect for obstructive sleep apnea. We know that there's an issue with neuroendocrine disorders, although I think we're still trying to paint the picture of what that means and in whom that is a problem. What we're finding out now over the last few years is that there's really a difference in the cardiovascular system after brain injury. We know that acutely there's disordered autonomic responses because we know all about autonomic storming with severe brain injuries in the intensive care unit, but of course what we've found out over the last 10 years is that this disordered autonomic response actually occurs in mild brain injury and in the whole spectrum of brain injury, and we don't know much about how it varies with recovery and what impact it actually has on many of the symptoms after brain injury. We do know, however, and try to explain this one right, that people who've had brain injuries have a higher rate of coronary artery disease than people who have not. Now maybe part of it has to do with the metabolic system because we know from the last cycle of the TBI model systems that, in fact, 50% of people with a moderate to severe brain injury will move from being a normal weight to being clinically obese within about 5 to 10 years after their brain injury. So we know that this group tends to really have clinically significant obesity. We know also there's problems with sexual dysfunction, bowel and bladder incontinence, and those sorts of things. So this is really a multi-organ condition that doesn't go away over time, and there's no cure for brain injury. There's no cure for brain injury. So there really is, it's been really noted, I think, by people like Brent Maisel and John Corrigan, Flora Hammond, that indeed this is a chronic disease and we need to treat it as such and look at a disease management approach for traumatic brain injury as opposed to an event management approach. Some of the mortality statistics have been fairly stunning, I think, after traumatic brain injury, and Cindy Harrison Felix has done a series of reports on this, as have some other groups, and you can see from this list that it's fairly remarkable. Okay, so seizures, we'll buy that, 37 times more likely to die from seizures. Okay, we'll take the 49 times more likely to die from aspiration pneumonia for people who have severe brain injuries. But some of these are a little mind-boggling. People who have had traumatic brain injuries are three times more likely to die from suicide. They're three times more likely to die from circulatory disorder. So we're starting to see this bigger picture evolve about, really, what traumatic brain injury means on a larger kind of whole body sense. I'm going to kind of steer you away from the left couple of graphs and look at the right side of the bigger graph over here. This is some of the work by Karg and, again, at five-year outcomes. And the other, I think, really remarkable thing from the study was, if you ask people and self-report, how are they doing five years after a brain injury, the results are, these are people who report that they have deteriorated since their prior follow-up in the TBI model system. So over the past three to four years, people feel that they have deteriorated. And it's amazing to me that, okay, I can buy the 80-plus years that people are deteriorating. Okay, that's going to happen. But look at this, 40% of people in the age of 40 to 49 feel that they have deteriorated over this five-year period. 36% of people 30 to 39. Look at the people from 16 to 19, 39% of them. So we obviously have a problem on our hands. So it's interesting, now, this is very interesting, that Flora Hammond just published this year a study looking at 15- to 15-year follow-up in the TBI model systems. And the fascinating thing is there are no major functional changes between 6 and 15 years. So there's a big, big functional change that happens in the first five years. And, of course, this is the farthest out we've gotten so far at looking at functional change. But we suspect that there's going to be a real decline, particularly in that older age group as well. So what's accounting for this decline over this period of time? TBI may, may trigger a progressive degenerative process. We think, for instance, Parkinson's disease or Parkinsonism is probably linked to traumatic brain injury. The other ones we can talk about a little bit. We know that there's frontal lobe damage, which is pretty endemic to traumatic brain injury, which causes problems in self-regulation. So people can really have risky behaviors, alcohol intake, drug intake, maybe, you know, getting involved in assaults. It's not unlike, it's not unusual for some of my patients with a little frontal lobe dysfunction to end up being divorced, arrested, lose their jobs, get assaulted because they run off at the mouth a little bit. So there's all sorts of reasons that people can indulge in risky behavior. We know that TBI causes a loss of functional independence, which can interact with regular aging, increasing poor health. And I think one of the really key things is that TBI really exacerbates social factors, which may have existed or may not have existed at the time of injury. So as people age with a traumatic brain injury, they tend to have an increasing lack of social support and an increasing number of environmental stressors. They may lose their income. They may lose their health insurance. There are really a lack of resources after the first year for rehabilitation because this is considered a traumatic event, not a chronic illness. And there's poor access for a lot of people to health care just because people can't drive. So these all interact with what we mentioned before with health conditions. So again, kind of a summary of factors. People are older at brain injury now. So the age, the average age of brain injury is moving up. The declines are not all related to the age at injury. We know that people will tend to have more risk factors after brain injury, including alcohol intake, social deprivation, unemployment. And the outcomes are particularly poor for those who are unmarried or who become divorced. Mental health challenges, greater functional disability at hospital discharge. And it's interesting, if you look at the youngest group of people, not the oldest group, but the youngest group, their overall life expectancy decreases by 16 years. So this is really, so we think that there might be some detectable, but missed opportunities to identify patients who are at risk for poor outcomes and to deploy interventions. I'll tell you a little bit about that in a few minutes. I'm going to take about two minutes to just talk about other things with neurological morbidity after traumatic brain injury. So, you know, it's very difficult to study this, and it's very difficult to know the differences between previously existing or what would have existed neurodegenerative diseases and what's going on, what's triggered from a traumatic brain injury. So this is very, very difficult to study for a lot of reasons. One is that there's a real delay in the presentation for neurodegenerative diseases. It's not something that happens in four or five years. It's something that happens over 20 to 25 years or more. So it's hard to find that. And I know some of us are starting to do research on more elderly people with brain injuries to see if we can see kind of a real connection between physiological markers and the onset of neurodegenerative disease. The evidence at this point does favor a link to Parkinson's disease, but it's a lot less certain for Alzheimer's disease. Okay, so those dementias, it's not really clear that there's a link with a single TBI. Now with multiple recurrent mild TBIs, we think that there's a pretty low prevalence of neurodegenerative disease, but we don't really have great evidence. What are some of the problems? Number one, we still don't know how to define concussion or MTBI. Literally, we don't have great definitions. We don't have a way to mark a concussion or a TBI. If you go down, you lose consciousness in front of somebody, okay, we can say you've had a mild TBI. Otherwise, we don't really always know exactly whether somebody did or did not lose consciousness. So it's very hard to define this. And we also have a lot of problems with study design and that sort of thing. Now, chronic traumatic encephalopathy is something that, of course, over the last 10 years has become, you know, a far more public thing. The problem is we still don't really know what chronic traumatic encephalopathy is, who gets it, whether it's preventable, or what risk factors contribute to it. Because it's a pathology-driven diagnosis, we have a hard time studying people before they're diagnosed with CTE. There are some studies now that are starting to look backwards at well-characterized populations, like in places like Kaiser Permanente and Group Health, where people have gotten their healthcare someplace over a long period of time and starting to look at whether or not we can attach risk factors to those with pathology findings. But it's a very complex pathology, involves a lot of different things, so it's difficult to find those markers and figure out what a path for intervention is. So again, challenges in studying this population, a lot of heterogeneity about the mechanisms of injury, a lot of heterogeneity about resulting injuries, poorly understood variability in host factors. So there's lots we don't understand about how that affects outcome and how that affects aging with a brain injury, cerebrovascular status, genetic factors, your neuroinflammatory response, your pre-injury lifestyle, it's every social factors, all of which have impact. Again, I'm just going to really flip over psychiatric, but this is obviously a huge problem post-traumatic brain injury, too, in terms of aging with a traumatic brain injury. So I'm going to pretty much wrap it up here. So we are starting to look at what can we do to look at chronic effects of traumatic brain injury in a more systematic fashion and to develop a way to intervene. So there's a number of things going on. There's certainly a large project being led by Flora Hammond at this point in which we're trying to really study methods of doing this and we'll be simultaneously running feasibility trials on a number of different interventions and system approaches to following traumatic brain injury. But we think that we're going to really need to have a structured baseline assessment and longitudinal surveillance, which outside of the TBI model system we do not have. We need something like an ASIA exam. We need to identify and optimize the window of opportunity for recovery. We need to really emphasize the use of self-management techniques in traumatic brain injury because it's going to have a huge impact until we find something that can turn around the neurophysiology of brain injury. And we're going to need to have periodic boosters of therapy for things like musculoskeletal, spasticity, and cognitive behavioral problems. I'm just going to note that there's lots of works in progress that are starting to look at things. Like I said, we're looking at objective evaluation, developing predictive algorithms, looking at health systems models for assessment and treatment, looking at ways of affecting exercise for cognitive preservation, weight management to prevent comorbidities, self-management training to help to ameliorate risky behaviors, lifestyle factors, disease management, and life satisfaction. So this is a little graph of what a self-management cognitive behavioral intervention looks like using problem-solving treatment. I'm not going to go through this because I've run out of time. So let me just, on my last slide, thank my collaborators at UT Southwestern and Dallas-Fort Worth. I was very concerned coming down here seven and a half years ago that I would be all by myself and doing things and research and whatnot. And I found this wonderful, wonderful group of people to work with, and I'm very grateful to all of them. So there are some things in the bibliography, and that's what I'm sticking with here. OK. Thank you. So now it's time for questions and answers from the audience. There's nobody who did any questions, but I do have some questions. It seems that some of the complex things that are being seen, like the tau and the TDP43 dysfunction, neuroinflammation, are seen also in other populations like ALS and Alzheimer's population, right? Yeah. I think that many of us don't exactly know. I'm trying to get this to go back up so I can actually see people, and I'm having a hard time dealing with. I guess I will just stop sharing and see if I can get my screen back. Oh, there we go. At least I can see people now. No, so that's right. So the whole meaning of neuroinflammation after central nervous system injury is, I think, still being sorted out. We certainly know it happens. We know it happens even in mild traumatic brain injury. And I think that studying mild traumatic brain injury is going to help us sort out what's happening in more moderate to severe brain injuries, which are just so, so complex that it's difficult to sort things out. But without a doubt, neuroinflammation is a big issue with the development of cognitive issues. And perhaps these other ones like neuroendocrine problems, autonomic nervous system reactivity. So, yeah. But do we know what to do about neuroinflammation right now? We do not. So, I mean, that's one of the problems with talking about aging with a traumatic brain injury. You know, you just have to keep your eye on things and do your best, because right now we've had very few drug studies that help. We have very, very few physical means of making a big difference. I mean, we can treat spasticity, we can treat contractures, that sort of thing. But in terms of changing the course of aging and really keeping people healthy after traumatic brain injury, we are literally in the last few years just learning more about what the problems are so we can start addressing them. We're behind spinal cord injury. If I'm a family member and what would you advise? Oh, so there's a question here before I go to my question. Dr. Caldera said she has several patients with severe TBI that seem that after 15 to 20 years, declining mobility and even worsening dystonia. She cannot always find a cause and looking at CT labs, sleep, EEG. Just comment, just a comment and wondering if you've seen this too. Yeah, I agree with Dr. Caldera. And I think this is really interesting that we see this kind of decline in that first five years. Then we see people be pretty kind of quiescent over the next 10 years. And I suspect the next time we look at this, we're going to start seeing, we're going to start picking this up. Because I think clinically speaking, we all see that, that we see people as they start to age, we start to uncover more problems. We treat their spasticity and find out they have dystonia. I mean, that's a classic, right? But I agree that this is an issue. And I think that what's happening is we are seeing accelerated brain aging. But we don't really know, we don't have a good method for really examining this and distinguishing it from normal cognitive aging. And we certainly don't have much to do in terms of intervening at this point in time. So this is in some ways a very unsatisfactory lecture to give because all I can say is, gosh, you know, we don't really know what's causing this. We don't really know what to do about it other than symptomatically treating patients at this point in time. But I think one of the main take homes is monitoring, monitoring and surveillance. And realizing that everybody has to keep a sharp eye on people to prevent them from losing function as they age. And we don't have a good system for doing that with traumatic brain injury at this point in time. And I do think that one of the things we can learn from our companions in spinal cord injury world is what they have done to really create surveillance to follow people and to try to, you know, try to get things quickly before they become big problems. I think we'll end for the sake of time. I do have more questions to pick your brain, Dr. Goh, but I probably would just send you an email about it. For the sake of time, I'm going to go and pass it on to our next distinguished speaker, Dr. Lance Getz. Lance, take it away. Okay. Let me share my screen. Okay. Let's see. Let's see if this comes up. And there we go. Okay. That's the AAP Menard slide. So when I was asked to, you know, Marilyn asked me to do this, I thought, okay, I'm going to be sharing, I decided that I would go with kind of a systems-based approach and in the process sort of my own dirty laundry, if you will, of my personal experience. Here's my affiliations with both VCU Health and the VA where I've been for essentially 25 years. Hopefully this talk will keep your attention. That's Jesse, one of our multiple animals. And despite the logos on the previous slide, I don't have any, I don't have any, the views are mine, not the views of VCU Health, U.S. government, the Department of Veterans Affairs, and none of the research that I'm involved with is on aging. So this is, this is the way we're set up in the VA spinal cord injury and disorders system of care. And so unlike Southwest Airlines, I guess we use a hub and spokes system and where we in Richmond are one of the largest in the, in the U.S. for the VA spinal cord injury disorder system of care. And so for primary care, people will get the primary care at these different sites, you know, Baltimore, DC, Durham, throughout North Carolina, and then they'll come for specialty care, annual evaluations, et cetera, to our site. We've all about 1500 people with SCI, MS, ALS related things. And we probably pre COVID would offer about 700 or so comprehensive team-based annual evaluations per year. So my objectives for this slide are for this talk are talk about changes in body systems in person with SCI's age, and I won't be able to obviously completely cover medical and rehabilitation approaches, but some, some key ones that I have dealt with in terms of mitigating effects of aging and what we do. And then again, my personal perspectives, and hopefully as we go through some, some of the things will maybe be Ripley's believe it or not, or a humorous or something like that. Just noted that this, this our Bibles, if you will, is spinal cord injury medicine by Kirschblum. This is where this problem ranks as a 58th out of 60 chapters. So it's at the end of the book. And I think that it it's, it's importance is greater than that. So this is important because of two things. Not only do we have, we have our folks that are living with SCI for many, many years, like myself. I've been injured for 37 and a third years, but we also have people getting, getting the injury at at older ages. So, and we've kind of plateaued in our life expectancy. And, but, and, you know, there, I'm, I see people who've lived 50, 55, even more years with SCI, but the age, the life expectancy is still several years less than non-injured persons with similar profiles. And with each successive cycle of data, we're now about 45 or 50 years out of model systems data. Each year agent injuries is, is, is higher averages at higher with each cycle. And with, with Dr. Bell was talking about TBI and the falls, I was thinking, and those people getting brain injuries, I was thinking about, well, there's a subset of those people that are falling because they've got cervical stenosis and balance problems and they're falling and getting a spinal cord injury, maybe a brain injury as well. But anyway, these old people, older folks that come into SCI getting their injury from a fall at 60, 70 years of age have a much different medical picture, as you might suspect with lots of additional comorbidities. Anybody have pictures of their children as embryos? When you do, if you're my age now and use assisted, have used assisted fertility, you get very early pictures. So causes of death. Pneumonia and septicemia are most common. It used to be sort of a board's question that urinary tract and causes such as urosepsis and renal failure were the number one cause of death, but right after World War II, but that's no longer true. It's still very important, of course. But so cancer, urinary causes and GI causes and suicide have been steady or declining as in their rates and cardiovascular, sort of what we think of as the epidemic in America, if you will, with diabetes, metabolic syndrome, and then brain disease, strokes, cerebrovascular disease are increasing as causes. If you have a higher level injury, a complete injury, older age at SCI, you have a shorter remaining life expectancy. So here it is. Here is recent data from the model systems database showing a respiratory system, number one, infective and parasitic. I don't know how much parasitic there is out there, but when I think of infective, of course, I'm thinking of not pneumonia, but other infections and UTI or urosepsis being the highest there. And then, of course, similar to the general population, cancer, heart disease, et cetera. This is a screenshot from the National Spinal Cord Injury Statistical Center. So the clearinghouse, the database clearinghouse, if you will, for all the model systems, which has been at UAB. And I hope you can see this, but for example, if you plug in your data, I plugged in my age, 57, my injury date, 1984, your sex, ethnicity, and then level of education is actually a very high, very important predictor, if you will, of survival. And then type of insurance, believe it or not, helps predict outcomes, whether you're not on a ventilator, then etiology, violence has a worse outcome, injury level, and then your completeness. And you can see what your life expectancy is thought to be. So it looks like I'm going to live to be 76.3 years, hopefully, but a non-injured person would be expected to live an additional about five years. So for any person, you can go in and you can do that. So this is a friend of mine, Jim Krause, who has been doing model systems data mining for almost 50 years now. And recently was funded with a grant in 2016. And so data should be coming out of it. Currently, in the next couple of years, we should be seeing more and more. But he talked about what are called negative health spirals. So he said, a lot of times we see that people with spinal cord injuries are healthy for a very long time, but then all of a sudden, one thing goes wrong, which leads to another, and they just aren't able to recover. And I see that in my VA population quite a bit. And some folks may be injured for 35 years, and then they get their first pressure ulcer, that sort of thing, or a first fracture. That's a negative health spiral. And if we can identify what precipitates it, maybe we can help to avoid those types of things. This is an overview. I apologize for the kind of blurriness at the top, but it's an overview of basically sort of body system by body system, usual aging versus aging with SCI. And we'll go through that in a little bit more detail. But you can see, one of the things that impresses me about this is, look at how big GU system is in terms of the complications, and and how many different ones there are. And I've experienced many of these. So you can see people requiring catheterization, DSD, thickening of the bladder wall, leading to decreased compliance, upper tract deterioration, hydro, nephrosis, stones, strictures, epididymitis, more UTIs, and renal deterioration. And then bladder cancer is controversial to some people, but it's not controversial to me. When we look at our database in Richmond, the risk of bladder cancer is many, many fold higher than the general population. And when we published a paper with our data looking at ethnic disparities, and really the one thing that struck me the most about that data is really our challenge, and admittedly, our failure to really give people low pressure storage and emptying of their bladder to protect their upper tract. So I'm going to go through some of these in more detail, or as we go on, I'm not going to go through the whole slide. So back to genitourinary system changes. Bladders can get thick and smaller. Hopefully we can prove that Botox changes that someday. But this is in the non-SCI, excuse me, but the same thing's happening in SCI because of DSD. Increased uninhibited bladder contractions, residual urine, and UTIs as people without SCI get older. And then in post-menopausal changes that happen in women and BPH in men. With SCI, as I mentioned, detrusor sphincter dyssynergia, trabeculation, thickening of the bladder, increased pressure in the bladder, leading to hypertrophy and decreased compliance and upper risk for upper tract back pressure. I tell my patients, you just don't want back pressure on your kidneys. And then of course, decreased function. Barbie Darwish reported that the average person with SCI, whatever that is, got about 2.5 UTIs per year. So you imagine some people are getting none, but some people are getting 2.5 and some people are getting more than that. Times how many X years of injury, you can do the math if someone's been injured 30 years, 40 years, 50 years. And then of course, so our goals for this are number one, really to prevent that upper tract deterioration. Do what we need to do to get low pressure, especially for our upper motor neuron, bladders especially. And then preventing affections, preventing trauma, and then social continence as well. And so I've experienced, you know, the challenge of this personally with strictures, with epididymitis. And some of these things don't happen for many, many years, but then they start happening a little bit more. We know that indwelling catheters increase risk for infection stones and cancers. Some of our folks really don't have a choice between, unless it's a major diversion surgery and they don't want that. And so they're left, if they don't have caregivers or hand function, they're left with perhaps a suprapubic catheter. And so we're doing the best we can with that. As I mentioned, epididymitis, orchitis, prostatitis, acute and chronic prostatitis, urethral stricture, hematuria, and autonomic dysreflexia. Inderprakash estimated that about 80% of AD causes or related to the bladder with bowel being a dissonant second. So we do yearly annual evaluations at the VA. We offer them to everybody in our registry. And a big portion of my part of that, we have the therapists and the psychologists and social workers, everybody's seeing them every year. But a big portion of what I'm focusing on for my folks is surveillance, serum creatinine, cystatin C, if they have a lot of atrophy, 24 hour urine. Our basic image is the renal and bladder ultrasound. If they have abnormalities, we've been moved to a non-contrast CT. And then cystoscopy, which especially for folks with chronic indwelling catheters. With the most recent guidelines, it's actually not recommended, but I know that our urologists are going to continue to do it based on our personal experience with bladder cancer. And of course we push every year, we push very hard for smoking cessation. Prostate cancer is a question mark. We're actually looking at national data using the corporate data warehouse to see how the PSA is different. It may be lower, but we have a subset of folks that are having acute and chronic prostatitis and a subset of those do have elevated PSA. Unfortunately, some of those folks are going on and getting biopsies when actually, you know, we don't know if they have cancer and they may really, some of those folks are just found to have inflammation. So there's a potential for some morbidity there and we need to do a better job of figuring out who really needs those biopsies. It is reported that when prostate cancer is found, it's a more advanced stage compared to the general population. So I mentioned we want low pressure storage and emptying. We want complete emptying. We want frequent emptying and we want to choose the right catheter so we avoid trauma. There's my embryos again. My wife was nice enough to allow me to put this in. So GI tract, motility is already an issue, but motility increases even more as we go, as we get older and with each successive year, especially at the splenic flexor distally and the distal colon. Difficulty with evacuation and colonic dilation and impaction become more likely. And incontinence is a bigger issue in people who don't have the hand function to do their own bowel care. Loss of volitional control gets worse with age for some of those people who are incomplete. And people with SCI may do infrequent bowel care for convenience. But what we think and need to know more over time is how is that affecting them in the long term if they're getting a dilated bowel who can't function if you think about the Starling curve or the efficiency of a stretched out muscle not being able to contract. As people get older, they may need increased time for bowel care and emptying. They're at risk for things such as a sigmoid volvulus. So you can imagine that if you have a stretched out mesentery how you'd be more likely to twist on that mesentery. And then from valsalva and just lack of pelvic floor tone sometimes. There's increased risk of hemorrhoids which can bleed and prolapse especially in lower motor neuron folks. So we don't recommend bowel care any less than every other day ideally. You hear people sometimes doing their bowel care every third, fourth day and we try to avoid that. We have some new things like transanal irrigation. I won't use the trade name and other procedures that can be done for people who have really an end stage dilated bowel. I'm going to show you pictures of these. And the negative of some of these things such as an ostomy is aesthetics but the positives are we know that people have decreased bowel care time, better continence, it saves you at least two transfers a day. And people who get ostomies report increased quality of life and many people report that they wish they had had that ostomy done earlier or younger. This is just a picture in there of a person with a very dilated sigmoid colon. This is the antigrade continence enema. It's been mostly used in kids with spina bifida but there are just a few cases of it being used in SCI where you flush fluid through the colon and it can be done two or three times a week to empty the entire colon. I apologize for the trade name but it's the only item of its type which is transanal irrigation which is a soft silicone balloon that you use to pump fluid in and then you pull it out and you can empty your bowel with this very well. And there was actually a multi-center study in Europe, five big centers, so it's one of the few really good studies that showed that it was preferred and more effective for people with a subset of people with very, very refractory neurogenic bowel. And if people want an ostomy and they're worried about aesthetics I see one option that you can consider is just using a wrap to cover it up. So skin. We know that pressure ulcer incidence increases with age. It's higher in people with tetraplegia. And as people get older, just like everyone without SCI, there's thinning of the skin, decreased arterial flow, especially in people with vascular disease, pelvic atrophy, and even though the evidence for a lot of our preventive techniques is weak, it's really all we have. So we really emphasize education, self-monitoring, palpation, mirrors. One of my former bosses used to say an ounce of prevention is worth a pound of flesh. And it's unfortunate that so much of the money in skin care or pressure ulcer care is treatment, and so little of the money that's out there is on prevention. So we're doing yearly evaluations and PRN evaluations. We try to get people to come in early with the first sign or call us the first the first sign of any problem. And we look at their posture. There's this phenomenon that's been coined called skin failure, sort of like heart failure, which emphasizes the idea that not all pressure ulcers can be prevented and not all can be healed. And flaps, we're selective about who we flap because we know that there's a potential for prolonged hospitalization and other complications. And for some of our folks who have recurrent ulcers and may no longer be flap candidates for that fourth time or fifth time, and we try to get them to live sort of with the wound and not for the wound. In other words, not spending the rest of their life in bed. This is my arm with my psoriasis and Kevner's phenomenon from using my elbows and arms to push around and move myself like in bed or on my chair. So that's a rubbing phenomenon that makes psoriasis worse. And I won't show you my trunk, but there is also a wheelchair-induced psoriasis that you can get on your trunk. Oh, and look, as your skin gets older and you take aspirin, I didn't know this. This is my niece who's a dermatologist showed me this. This is called solar purpura. It's another fun thing. It's itchy too, by the way. We know that, so moving on, cardiovascular causes are now one of the leading causes of death in people with spinal cord injury. And I shouldn't say leading, but one of the leading. And people with spinal cord injury have really, not only the challenge of not being able to burn as many calories and the reduced ability to exercise to VO2 max, low basal monobolic rate. But if you think about the numerator versus the denominator, and the denominator is your muscle mass, the denominator is going down. So you have this, what we call obligatory sarcopenia. So your body becomes even higher percentage of fat mass because of that. And so BMI even underestimates this problem of obesity. And fat is a source of inflammation. And so we monitor, of course, a lot of it with our wound care inflammation, but we should probably be using the CRP for everybody more, and cardiac specific CRP perhaps. We check yearly lipids on our folks. And Dr. Gator, who was the chief at SCI, his research was really emphasized exercise for obesity, but not really as a weight loss technique. So the major study that, one of the major studies he did on exercise to reduce obesity showed that it wasn't really effective. People lost a couple of pounds, but what they did do was they improved their insulin resistance with arm cranker geometry. And then of course, weight training, we know more and more is a good way to build muscle mass and even lose some fat mass. Some of these interventions, unfortunately, are really time consuming and access can be an issue. We know that diet has to play an important role. It's very difficult, but diet has to play a role, very important role because exercise on its own is just not enough to burn enough calories. And this is a paper by Michael Stillman that looked at a small population and statin use in traumatic spinal cord injury, and basically found all-cause mortality reduced with statins. And we're trying to replicate this, and we're writing up a paper using the nationwide data again in the VA to look at statin use and mortality. I think I'm looking at the clock here, and so I'm going to hurry a little bit, but CNS things, a big one that is of importance in our group, and it can be very sneaky is post-traumatic syringomyelia. The other term that you may not be as familiar with is post-traumatic spinal cord tethering. And Bill Skelza and others, Scott Falsi, who's a neurosurgeon at Craig, showed that you can have no visible cavity or adhesion on MRI, but sometimes it can be still seen intraoperatively. Shunting has been the simplest technique for syrinx, but in some studies up to a high failure rate, up to a 50% failure rate. What's felt to be a more physiologic treatment in the last 20 or 30 years has been duroplasty and lysis of adhesions to restore normal CSF flow. So dural stenosis and tethering of the cord is felt to be physiologically the key in this process. It's very insidious, though, and I've seen people who just have progressive diffused wasting over time despite efforts at treatment. So there's no treatment that's uniformly successful, and we know that all these procedures can potentially make people worse. So this is the main reason that we're doing our yearly, used to be called ASIA, but now called the Osinski exam. And you can even, now they've developed an abbreviated or expedited ASIA, primarily looking at that first abnormal and first normal level, last normal, first abnormal level for changes. And we're also looking, of course, at serial functional assessments. So Barry Goldstein, when I was in my fellowship, he had published a paper that stuck with me, and I've seen cases similar to it, that showed that cavity size was not really correlating, always correlating with function. And this is from one of my Medscape online articles that I did a number of years ago. And this gentleman who has this tremendously terrible syrinx had C7 tetraplegia and was still pushing a manual wheelchair. This picture, x-ray here, is basically just to show that any time, just to emphasize that any time I see somebody with a syrinx, we need to look at their spine for scoliosis. And any time you see someone with a scoliosis, you need to look for a syrinx. There's my embryos again, age zero. So musculoskeletal system. So, you know, just these are some of the things that I've personally experienced. And I just feel like we are just trashing our arms, especially if we're pushing, and our wrists, if we're pushing manual wheelchairs. So multiple rotator cuff tendinopathies, bicipital tendinitis, acro-AC joint, sternocleidomastoid joint, sternocostal joint, lacrimal bursa, tennis elbow, pitcher's elbow. Right now I'm being bothered by a TTS complex in my wrist and left middle finger MCP, bilateral base of the thumb arthritis, mid-cervical facets off and on. So you get the picture. There's my left middle finger, which has no cartilage. So what do we do? So treatment for manual wheelchair use for these upper extremity injuries. You know, sure, we can give NSAIDs and other meds we can inject, but I try to emphasize looking at how they're pushing, adjusting the wheelchair seat height, the position of their push rim, back to front, seat backrest position, transfer technique. We have veterans transferring in and out of big trucks. Giving a power wheelchair does not eliminate shoulder problems. We've moved more to people who want to continue to push manual wheelchairs to these types of, I'm going to skip forward, these types of devices, either power push assist rims or these add-on power wheels have been very popular for folks who don't want to go to power mobility. They don't want to get a van. On the clinical practice guideline on upper extremity dysfunction, Boninger and Cooper at Pitt did some good work with what was called the smart wheel where they looked at push rim forces and basically showed that there's an ideal angle of your elbow and position of the wheel when you push that has a big effect on the forces in your shoulder. So if you're thinking about protecting the shoulder, you want to minimize those forces. And then moving on to more musculoskeletal problems. Of course you know disuse of immobilization, osteoporosis, a risk for insufficiency fractures, and unfortunately that's a real frontier, but we haven't gotten there yet in terms of treatments that have any proven long-term benefit. So the bisphosphonates have not shown long-term benefit. The rank ligand inhibitors just have not yet been studied enough. And then DJD, I mentioned a lot about that before, and then Charcot's spine, I'm going to show you just an example. Here's my spine on a DEXA scan in the lab. And this is a case that we published a number of years ago of a Vietnam vet 50 years out who came in with clunking of his spine, and were we surprised that he had this massive Charcot that was actually displacing his aorta anteriorly. Oh, there's my first fracture, 31 years post-SCI with, as you can see, a lot of bone loss upper and lower, and then when the tibia fractures the fib goes with it typically. And I was sitting on a stair glide, the seat was slick, I was tired, no one was there to help me, and I was reaching for items, and I just didn't fall, just slid, and my leg got caught under me. And there was fracture number one. I thought I was never going to get a fracture. And there's fracture number two, in 2017, where I had a new wheelchair on cobblestone at a wedding, and I was distracted. And there it is, impacted, nasty-looking femur fracture. There it is again, there's both of them. There's my gross-looking deformed leg and fracture blisters, and more fracture blisters. And the other Ripley's Believe It or Not thing out of this was I had an extensive ID workup because I had fevers for, even after these were gone, I had fevers for several weeks, and a negative ID workup, and my orthopedist attributed it to circulating TNF and other cytokines. And I have seen this in a couple of people, unexplained fevers after a fracture. Here's my embryos again. So I'm almost done here, I've got a couple more slides. So psychosocial things as we age, there's a lot of adaptation and resilience that is important as we age, but as we get older, it's important to pay attention to whether our folks are continuing to get out or stay at home. How are their intimate relationships doing? Do they have intimate relationships? Is their self-reported quality of life stable or is it declining? Mood and emotional well-being can change over time. People may experience more loneliness, not getting out, sadness and anger. When you put people on antidepressants, I always tell people, look, this doesn't have to be, if they're resistant to that, this doesn't have to be permanent. This can be something that we use for a little while to help you get through this rough patch and then we don't have to continue it long-term if you're not needing it. And of course, kudos to the Nielsen Foundation for giving grants during the COVID-19 pandemic because they recognized that this was an issue and so they give a lot of money out to places that wanted to support people during their pandemic and not just with, say, supplies, but especially with their mental health as they went, as they go through the pandemic because it just exacerbated all of these problems of isolation. I think, so, and then of course, what do we think about in physiatry? We think about function and then as we get older, we can get weak, have more fatigue, increase risk for falls and so we want to maintain fitness, but we want to preserve and protect joints. So we're thinking about things like assistive, the power assist wheels that can help us. We can focus on doing, or maybe weightlifting and cardio, but not hurting our wrists and shoulders pushing up hills. And so people may need, you know, it can be difficult for people who have lived a certain way for a long time to change and adapt, but people may need new and different equipment. We try to give the least restrictive equipment that we can. And then Steve Steens and his, some other folks, all four authors, Krauss, Steens, Winkler, and they were the authors of a book on life-clear planning with SCI. And so we know that this is a family, as people with SCI age, it's a family issue. So we want to spend, if you have a care, if you're a caregiver and you have a partner who's dependent, you don't want to spend 24-7 giving care, you want to have quality versus quantity time. And so planning for how you're going to deal with that financially so that you have money that is allotted, that can be allotted to getting some help when you can no longer do all of these things. So the time to start is yesterday. Here's my embryos at age 16 who look deceptively happy in this picture. And getting out can be a lot of different things. We have a great group in Richmond called Sportable, and there's all sorts of great activities that I've been involved in some of them. I particularly like hand cycling. This is called a SWIN car, which is a hand-driven, very, very nice, goes about 30 miles per hour, goes over huge bumps through mud puddles. And they had a group that went out to do that out in a state park near us. And then tennis is a lot of fun, shooting, or even kayaking. Being able to get out with others is really important to not only your physical health, but your mental health. I think this is quad rugby. And then even if it's not exercise, getting out with family and friends is really important. Thanks for everybody for paying attention. So I think we just have a couple minutes left. I think we have six minutes left. Does anyone have questions? While they're typing in the chat box, I have a question, Lance. That was a cool SWIN car. And you remember when you used to jet ski also in Dallas. Yeah. Right. So just a question on dual diagnosis. So we do get spinal cord with dual diagnosis with TBI and STI. What is the challenge in that in terms of aging? Yeah. So I mean, I think Kathy's talk speaks to that a lot. We don't know how people are going to function cognitively over time. But when I think of it, let's say you do have a dual diagnosis, TBI, STI, the impact of that in a person with additional having STI is going to have ramifications on, say, how well you are managing your bladder, how reliable you are with your catheterizations. If you're cathing by the clock very religiously to get your bladder empty and prevent UTIs, or if you're checking your skin every day religiously. So one of the advantages I think that we have now is all the technology. I'm busy at work. So I'm setting my alarm to do X, Y, Z. I'm setting my alarm at 6 a.m., 10 a.m., 2 p.m., 6 p.m., 10 p.m., etc. to cath, especially during the work hours. So I don't miss that. And so being able to have good reminders, avoid reminder fatigue for all of these things on our smartphone or our laptop or whatever, I live and die with my Outlook calendar. And so that's an advantage over the past generations, I guess. The other question is, you know, it is very nice, we're both at the VA, although I kind of veered out of the SCI world a little bit and more into the TBI world. But what is the, for those that are not in the VA world, the challenge is to have a coordinated care outside, like for non-veterans. So what would be your advice, like for a team, like for a physiatrist following SCI patients as they age outside the VA world, wherein we don't have, they don't have like a lot of like, you know, the annual exams, like insurance to fight for, like proper, even just proper equipments and testing and all of that. Yeah, I know. How was your experience? Yeah, I mean, when I see folks come to the VA, who are VCU or maybe, and some are in funded and some are unfunded, that really is, I do, you do see the challenge of long-term care for folks, a long-term follow-up for folks, urologic follow-up, and really maintaining that. And some folks are not getting that, fortunately. We are forced to do it. And it's good that we are forced to do it in this system of care for all of our folks. And it just becomes not even a question. This is what you're, if you want to get your medications, for example, you're going to come in, you're going to have this assessment, and we pay for their travel. So we try to provide as many incentives as we can, and hopefully, you know, we need those sorts of things in all of the systems of care. Someone asked me if, do I prefer the smart drive versus power in the wheels? And I prefer, there's only a couple of products out there, smart drive and the smooth is a newer one. And I prefer those because they're much lighter. They're like 10 to 15 pounds, whereas the power assist wheels are quite a bit heavier. And the nice thing also is that you can just pop on and off those power assist wheels very easily and transition from pushing completely versus a power, an assisted push. Okay, I think we are, we have one minute left. And then just give me some time to plug in for if there's no other questions. I don't see other questions in the chat box. So just plug in for the next part two CNS community session, which would be on the 19th, same time, 6.30 to 8 o'clock. And then the third session, which would be a continuation on aging. The second one would be on transitions of care from pediatric to adulthood and how to transition from pediatric physiatrist to an adult physiatrist. And the third one would be the different kinds of transition in the different kinds of setting in rehabilitation. So thank you for our speakers and thank you everyone for attending. And this could be, this is recording also and would be, you could repeat this session. And then after this session, please do your follow-up answers to get your CME. Thank you, everyone.

spinal cord injuries

aging

challenges

upper tract deterioration

genitourinary system

gastrointestinal problems

cardiovascular health concerns

musculoskeletal injuries

psychological impact

bladder cancer prevention

bowel care management

comprehensive care