Okay, well, let's get started, everyone. Thank you for joining us tonight. My name is Kavitha Nirikanda. I work at AAPMNR along with Sharon Popolewski, and we really appreciate all of you taking time. I know it's a very, very busy month and everyone's in the homestretch to get through the end of the year. So thank you for joining us for this first AAPMNR spasticity community call. We hope we take this time to get to know each other. Dr. Bohart is on the line and he will be leading our call. And then we have a couple of other folks on the line too that will be talking about all of the work that we're doing at AAPMNR in the spasticity space. And really tonight is a night for us to get to know each other, to have some informal discussion, and to start talking about some of the larger initiatives that we as AAPMNR want to seek funding for and really start to work on an integrative strategy for spasticity. This will be just one of many conversations that we have. We will continue this, hopefully, for a very, very long time to come. And we will hope to see a lot of you at annual assembly in New Orleans in a week. So Dr. Bohart, with that, I'll hand off to you. Thank you, Kavita. Hi, everybody. How are you? My name is Zach Bohart. I practice in the Boston area. I primarily split my time between spasticity management and that includes the baclofen pump and also botulinum toxin injections and some peripheral fenal nerve blocks as well. And I see some old friends here who have tuned in. So hello, good to see you. And I also perform some orthopedic EMGs as well. And I kind of split my time between the two, but if I really had to choose one or the other, I would really choose spasticity management. And recently I was asked by our friends at AAPNR to join the, to create kind of a spasticity community. I've been volunteering for some time now with the Corporate Relations Committee at AAPNR, which accounts for a fair chunk of the budget of AAPNR. And they asked me to create this spasticity community. And the reason why I think it's a great idea is because we're all, I've learned that we're all really kind of practicing our own little silos. And, you know, I learn a, personally, I learn a tremendous amount from when I go to either meetings or if I go to, if I just discuss some techniques for treating spasticity with other physicians who are doing it as well. And we all really learn a lot. And, you know, there's not many, you know, large spasticity practices where there's like multiple physicians practicing under one roof. We're all kind of practicing separately. So I thought it would be, and our folks at AAPNR thought it would be a good idea to try to start an online community where we can learn from each other how best to really practice the management of treating our patients with spasticity to really try to, you know, increase the overall level of care. Can we move on to the next slide? Because I'm not controlling it. There we are. I just want you to know that this call will be recorded. Just some housekeeping. I can't be shared with others who are unable to attend. This is really meant to be kind of a conversation between all of us, between Jedis, so to speak. Next slide. So first we'll just go over some of the principles of inclusion and engagement. So obviously we need to mutually respect where everybody's coming from. We value diverse group composition. We are physiatrists. We all come from a wide array of backgrounds. And the more the merrier. We also wanna value talent and skill and collaborate comprehensively. Next slide. So tonight we're first gonna talk about the AAPNR spasticity community, which is online. And then I'll hand over the baton so others can talk about how the Academy can focus on spasticity efforts and also some quality improvement initiatives as well in the next steps. And really the goal tonight is to really have an open forum, as I said. And so there will be multiple ongoing discussions as time progresses. So again, I created this spasticity community. And really the purpose of this is to foster discussion about spasticity management, really whether it pertains to toxin injections, the back of the pump, nerve blocks, but also PT and OT. What are some of the best ways we can refer and how often should it be done? Bracing, which is also an integral part of spasticity and the use of oral meds if need be. But also not only to discuss really the clinical side of this, but also to discuss also the business side of this. So how can we make this financially viable? What are some tips for either being in private practice or in academic medicine or in multi-group specialty practices? We all kind of make our practices in whatever environment we're in, I would say. And I think we've all learned tips and tricks that we can all really share with each other with regards to either billing or building your practice or marketing the practice. So it's really not just all clinical, but also I would say the business and practice building side of this as well. I've been doing a lot of teaching now for the past several years around the country to a lot of residency programs. And I've had the great fortune of having this be supported by some of our friends in pharma. And it's really become a big passion of mine teaching residents in the next generation of doctors how to A, inject, B, manage a pump, but also C, they come up to me afterwards and they ask me what are some of the ways that I can build a practice? This really sounds great. There's clear kind of pathways for musculoskeletal medicine. There's clear pathways for spine. There's obviously clear pathways for inpatient, but there's really not that many pathways that are known for comprehensive spasticity management. And really that's kind of the idea of this spasticity community. So we can all really try to learn from each other and kind of enhance the level of care across the board. Next slide. So, most importantly, this obviously isn't for any one of us, it's for all of us. So, I'd like to kind of open the floor for discussion about what you would like to see our spasticity community do. What do you think are some of the things that the APM are that we should be aiming for? What are some of the ways to kind of get the word out to let others know just how wonderful a field this is? Being a physiatrist, I really strongly feel that physiatrists are the best at taking care of spasticity. We kind of have a focus on function, we have good orthopedic training, we have good neurologic training. We obviously deal with this patient population all the time. So we are better than anybody else at really treating spasticity. And I think we can really learn a tremendous amount from each other. And I'm really happy and really psyched and delighted to play a part in APMR and really trying to get the word out and try to enhance learning. But that really comes to all of us working together. So what do you really think are some of the things that our spasticity community do? How can we market it? What should we aim for? So we can obviously keep the floor open at this point. And if anybody has any comments, that would be great. I'm happy to pick on people. I know a few of you there. Hey, Dr. Bohart. Hey, Ryan. How are you doing? Good. Yourself? Pretty good. Sorry, Dr. Hafner. How are you? No, I was not good. Okay. No, what I was going to say is, you know, I think part of what I think this community could really do is, you know, I don't know in terms of interest, but certainly I think, you know, some sort of kind of running journal club would be really, really great. You know, whether it's the ACRM, you know, the Purple Journal, Blue Journal, you know, whatever journal you look through, I mean, you know, on a given month, there's probably, you know, one or two studies on spasticity, whether it's medical management or, you know, some sort of new therapy intervention, you know, new type of bracing technique or, you know, transcranial magnetic stimulation or crown or lysis, or you name it, it's a very active field, you know, it's not something that's kind of stagnant and, you know, living on tech that we've been doing for the last few years, certainly, obviously there's mainstays of treatment, but I think, you know, in a way, you know, if there's some way to kind of, you know, collaborate and have some sort of, you know, running journal club, whether it's quarterly or something like that would be, I think, you know, pretty well received. That's a great idea. And maybe you could throw in some type of morbidity and mortality even, where we can learn from each other's blips along the way, I guess you could say. Dr. Houtrow has her hand raised. Thank you, Kavitha. You know, as a pediatric rehabilitation medicine physician, twice I had to start my spasticity practice for toxin injection. And both times at different institutions, there were different barriers to doing so. And I think this is a great community for us to kind of be able to help each other navigate those potential pitfalls and barriers to try to set up the most efficient and effective practice from the outset, to make it, you know, less challenging for new folks coming into the area of doing spasticity management, whether it's a small portion of their practice or a large portion of their practice. I think we as a group of experts, and those who are emerging experts, could be really helpful to each other in trying to help people navigate. So I wonder if there's a webinar that we could give about, you know, expanding or starting your practice and spasticity management, thinking about the things that you said, Zach, earlier about it's not just like clinically what to do, but it's about the practice part of what we do that takes some effort and some knowledge that we don't necessarily get in our residency training. So I'm really excited about what this group could do together on behalf of learning of the rest of the academy too. Yeah, Amy, I really like what you said about it being either a small part, excuse me, of what we do or a large part of what we do. And that's a message that I frequently have for residents when I'm teaching them. So you don't have to do spasticity, you know, 10 days a week. It can be, you know, one day every two weeks, let's say, and then, and I also put in that since it is such a fun thing to do that you'll start looking forward to that one day every two weeks, you know, then it might be one day a week, then it might be two days a week, you know, and then you slowly build upon it because it's such a wonderful thing to do. That's a good idea. You know, I like that. I don't see any other hands raised, Dr. Bohart, but I, oh, someone else want to take? I'm going to jump back in. Yeah, please. I want to jump back in. You know, one thing that I think is hard for those of us who aren't doing a lot of spasticity management is keeping up on like controversies and, you know, changes and approaches to spasticity management. So I really like the idea of Journal Club. And I also really like the idea of like having someone who has some expertise in the area of the Journal Club article that we're talking about, kind of contextualize it for us, maybe a little more than we would do in like a typical Journal Club. Because for me, in my very small amount of time I spent in spasticity management compared to the rest of my practice, I would love to know what's up and coming and also, you know, what things people are worried about. And so I think this is a really great opportunity for those of us who do it to kind of share that knowledge. Yeah. Also in like of similar of Journal Club, like this can be an opportunity of like collaboration if you want to do like a multi-center, anything or whatever, right? Like if you have an idea of something you want to evaluate and see, this could be a network of people you can tap to who would maybe be interested in collaborating on projects. That's a great idea. I think case studies too. Not everybody, you know, videotapes their patients or whatever, you know, how they're walking or what do we treat or how did this alter this or that or whatever. But, you know, whether, I mean, there's lots of interesting case studies of pump patients out there and, you know, how you use toxin or, you know, phenol to save some toxin to go elsewhere, things like that. Like there's just infinite like cases that you could talk about. I think that are just fascinating. And I think if you have the group that's interested in listening to it and learning from it, I think we can all certainly, we all have so many different stories I think that are worth sharing, you know. Yeah, I agree. I mean, I kind of feel that's best. This is kind of like chess or golf. You know, you can never be really good at it, you know, and you always want to be a little better, you know. And I think we can get better from learning from each other in this regard. Yeah, I agree. Are you saying something about my golf game? No, your chess game. My chess game, okay, okay. Hey, Dr. Bohart, Callie here. Callie, how you doing? How are you? Good. So I also wanted to put in a little bit of a plug for some advocacy efforts for access to spasticity care. In particular, some of the insurance barriers to toxin and dosing and just to be able to have a group where we can talk in a, I guess a more sophisticated way to legislators about improving access to spasticity care. Great idea. Yeah, you know, these private insurers are difficult, you know, a lot of them. And it can be difficult to learn how to navigate. And obviously you and I had a good mentor for that, which will help both of us. That's true. Yeah, but it's an ever-changing complex situation. And, you know, state by state. And the more we can, again, like everything else, the more we can really learn from each other, the better we can therefore take care of our patients. I agree. It could be a great advocacy message that we share with the policy group, you know, there's every year there's Hill activity and, you know, if we're really thinking about ways that we could elevate the message around access, that could be a really great thing for people going to Hill to share that message. And, you know, I mean, for, you know, and to talk about what, you know, to kind of follow up what Caroline was saying, you know, for every patient that we treat, I still think there's 10 more who aren't being treated who need it, you know, at least. And you know, where are those patients? Where are they? You know, I practice in Boston, which is kind of one of the hubs of health care. And I'm still regularly shocked at what I see, you know, and if that's in Boston, what about elsewhere? There's more of these kind of healthcare deserts, I guess you can say, you know, and, you know, where there's no physiatrists, you know, or the nearest neurologist is 300 miles away, you know, if this is here, it's everywhere. And I can't begin to tell you the nightmares I've seen these patients who have just, it's not that they're getting bad care. It's that they're getting no care with regards to spasticity, you know, and that's the problem. And so to kind of talk about what doctors, you know, it's kind of further on what Dr. Sizer was saying about advocacy, you know, that this is something that I think we're all really impassioned about. And in the pediatric world, there's really good, you know, kind of standard of care. But once they're adults, it's like, well, then what, you know, and there should be that same standard of care for adults that there is for kids. I'd like to see more of a focus on best practices for injection techniques to improve function. I think we're oftentimes just injecting to decrease spasticity, but we need to focus on the function component of that. The other thing I was going to say, I wholeheartedly agree with you that I think physiatry is by far the best at managing this. It's not even close. And I think to that idea, I think delving into things that are not as commonly taught, the details and nuances of certain things, I don't think everybody in residency or even fellowships and stuff get, you know, the same amount of education in terms of the nuances of bracing management. I think a lot, I mean, down in the Tampa area where I've kind of been practicing over the last year, I've met probably five or six different, you know, practices of orthotists who have said, you're the first doc that we've talked to in a long time that kind of has an idea of what is going on or has like good input into something. And, you know, they're like, we always just get a prescription saying brace and they're like, we have no idea what to do with this. And so it's been refreshing to hear and to, you know, to kind of reinforce, you know, not just the injections, but the bracing, all those kind of, you know, well-rounded things that we do as physiatrists that do separate us from, not to badmouth, but to say, you know, the neurologist, right? The only thing that they focus on is injections, but you ask them about a brace and they're like, I don't know. You know, it's, you know, doing a toxin injection is like saying I'm a pain doc, but I just do a knee, you know, steroid injection to the knee. That's the only thing I do. It's only one part of managing it. So I think that's really, this is an avenue where I think if we can kind of normalize education, not just in the injections, but also everything around it, as you mentioned, would be really good. Right on. Well, I mean, just to be so excited about what you guys have just been saying, right? We focus on function and what people can do. We can think about the whole patient and the context of their symptomatology and problems. And it's not just like, you know, treat them and street them out. And here's a prescription, right? Really thinking about how we can advance care for the patients we serve and then identify the patients that need to be served by us so we can serve them. I think we have a really good opportunity as a group to promote that stuff. And Amy, you're obviously in the pediatric setting. So, you know, that kind of exists for you, the kind of holistic, you know, 360 degree community exists. It doesn't exist in adults or in most places. It doesn't exist. You know, and it's always a tough conversation when I get a referral of, you know, a 19 year old with cerebral palsy and they ask me, well, and then they have a list of kind of questions that they ask of me that aren't being answered anywhere else. And I, you know, we don't really have that kind of one place that takes that multidisciplinary clinic that takes care of them. And it's a difficult conversation at that point to have, you know, and I do what I can, but, you know, we're only one person, you know, and we're only as good as, you know, the team supporting us, you know, so you're lucky being a pediatric psychiatrist that you have that, but we don't, we don't have that as adults. That's the best. Yeah, pretty much. If I could do it again. To actually piggyback on that concept, I'd be really curious to see all the different varied practice models that are in our community and what are some of the strengths and weaknesses or how, how do different practice models allow us to better access different types of patients, different patient populations? There's private practice, there's academic, there's sub-acute, acute rehab, you know, how do we, what are all the different options for treatment for practice models that are going to be sustainable, but also improve access to care for a lot of our different varied patients? Yeah, so how many of these patients are in sub-acute nursing facilities who haven't been treated since Jimmy Carter was president, you know, I mean, you know, a lot, you know, I know I'm dating myself, but yeah, and how do we reach out to them? How do we care for them? Holly Bell, can you guys hear me? Yep. Yeah. Okay. So I'm Holly currently at Shirley Ryan here for the last two years, but in my perfect segue, Dr. Sizer, at the last healthcare system I worked in, there was actually a push because there were insufficient number of neurologists and physiatrists who were injectors. They wanted me to set up a protocol for APPs to be doing botulinum toxin injections. And so again, to the point of, I know I see the shaking of heads and that's exactly what I said. The only thing that I okayed was in the headache clinic for the migraine protocol, because the migraine protocol is FDA approved and very specific. But to the earlier point that was made about our need to establish best practices, perhaps sometimes defend ourselves, that is something else that is going on in the communities that we need to make sure that we address. And this seems like a good community to do that. So I guess I would add, I work very closely with a couple of APPs. One who actually did inject for a period of time under my supervision, and I don't think we can kind of put our head in the sand because they're going to be injecting anyway. I think we need to talk about what the clinic model is that gets patients the most care. So in our clinic model, we've shifted to a model in which the APP does the follow-ups after injection. And it's similar to what they do in the pain model and that though, I get a little nervous because I do like to see them and talk about function. And sometimes I, as I say, I blow up the agenda because I go into the injection and I'm like, yeah, I don't know why you chose that. But I mean, before I put a needle in, I can do whatever I want, right? So as long as I have enough toxin, I can do whatever I want. So, but I think of looking at how we can extend our services, because the reality is, is part of the reason why people aren't being treated is because people can't even get in to see us. So, because there's just not enough of us. So we've been trying to kind of know how many, like in my community in Phoenix, how many people are injecting? What are you injecting for? What is your, how do you work to evaluate patients? Who do you work with as far as therapists? So that we can kind of help divvy up patients, frankly, because there are more patients than there are people to do injecting. And I'm kind of a transition doctor. So I do peds and adult, which is really awesome, except for the fact that since I've been taking care of injecting patients for 20 years, guess what? They continue to live and I have to continue to inject them. And so we have to come up with a way to extend what we're doing and whether that be working to get young physiatrists interested and excited about spasticity management, whether that be working with other specialties, whether that using APPs in a creative way, we really need to talk about those practice models because we can't sell it that more people need to be treated if we do not have the treaters for them. And that's, I think, what we've done here. We have sold it that everybody needs spasticity management and this multidisciplinary practice. And now we're drowning. So you kind of have to be ready to take on the market because the market is big. I find educating the therapists is a good way to get the right population because they do their gait analysis. They evaluate the spasticity. And again, I don't hesitate to ask them to give me a buzz if there is a patient in the gym that needs to be seen by me. And I'm like, yeah, this patient needs some Botox or needs some intervention for spasticity. I mean, I find the allied healthcare professionals are a good source for these patients referrals. I think though it's very institutional dependent. Not everybody have the luxury of having the gym beside their clinic. So yeah, that's what I would say. I think part of the issue too is relatively fresh out from training. And so kind of the idea of what jobs are out there in the space and in the world for somebody coming out from physiatry training. Realistically, if you look online nowadays, you're either working. You could work at potentially an Encompass hospital doing inpatient rehab. You could be a spine doc or maybe an electrodiagnostician. Maybe there's a place looking for dedicated EMGs or something like that. So when you're in training, part of it is kind of trying to bridge that gap. We know what the demand is. We know the shortage of people who treat this. But from people who are early on in their training, it doesn't seem like that. There's nobody wanting anybody that does spasticity management for a job opening. It might be an afterthought. It might be, hey, looking for a physiatrist and then can dabble in spasticity if you'd like or something like that. It's usually that's usually how it's advertised. But so it's kind of, okay, demand and supply that are here. We know how much need there is. How do we flip this whole world of what people realize and get the word out, understanding all this need and having this actually be a position that is desired by health care institutions, all those types of things? Because then that kind of starts a cycle of trainees thinking, oh, I can actually go into doing something like this. It's dedicated. It's not promoted like that. It's looked as like, oh, if you like doing this as a hobby on the side, great. If not, whatever. But there's for trainees, they need to see something. They need to see job openings or some just more need in the world for them to say, okay, you know what? I do want to do this for a career. I think the problem is reimbursement. So, for example, for code 64640, a phenol nerve block, they're listed at $150. But when it comes down to it, they're paying less than $100. And here comes the patient. You watch the patient walk. Then you have to get them on the table. Then you do the injection. Then you get them off the table. You watch them walk again. That whole thing takes an hour and you're getting $100. So, I think part of what needs to be done is to impress upon the insurance companies the need to treat spasticity to prevent complications, to improve function, and that it's going to be dollar wise to do that. The other thing is that I see a lot of people are talking about the toxins, but yet the nerve blocks and up and coming is the cryonerectomy. These are going to last much longer than the three months or so for the toxin. So, I think we need to start to educate people about how to do nerve blocks without developing the side effects. So, that's my take on it. Well, I think this is all really good. We do have some more on the agenda tonight. I love it how we're talking about kind of advocating for this patient population and promoting the field and advocacy, which is the word somebody used, which is really, you know, I think 90% of what we do in our careers. I think this is all really very good. So, thanks for jumping on, everybody, and we're going to move on to the rest of the talk. But I think this has all been really very good. So, thank you. Yeah, thank you. And what we want to just, I think this is a great, the way that conversation just ended, it's a great segue into what the Academy and the Academy Board of Governors has been discussing about in this space. And during their fall 2023 meeting just a few months ago, the Board of Governors agreed that we need a spasticity-focused strategy for AAPMNR. They had a long discussion about it, and it was premised upon all the work that PMNR already does in this space and in the Academy. We have a lot of education and dissemination of Academy work in this space that we need to get out there more. And we, you know, they felt pretty strongly that development of larger initiatives focused on spasticity is important if we can receive funding from external funders to help us support them. So, we have an opportunity, and I think we heard it a lot from all of you just now, that there is an opportunity for us to go deeper and farther in this space. And, you know, that's why many of us are here tonight, especially Sharon and I from Academy staff, in terms of helping us build the plans to get out there and go to funders and try to get some of these initiatives off the ground. So, again, the Board did agree in the fall that there is a need. These activities do align with our PMNR bold direction. PMNR owns this space. You said it yourselves just tonight. We can take the lead as the organization that represents all of physiatry in the U.S. And we can make an impact on the lives of our patients. And there are potential new opportunities for members. And I think we heard some of that, again, today in terms of the different ways that some physiatrists are building their practices. How do we get more early career physiatrists to understand this is something that they can do in their careers? It doesn't have to be 100% of what they do, but it is something that they can do. I'm going to hand off to Dr. Kwasnika, who has been a leader for not only the Academy, but for PMNR in the spasticity space. And she led a 2022 summit on spasticity. And she's just going to briefly go over all the learnings that we had from that summit and how that has really gotten us to the place where we are today. So, I just want to briefly go over what we did in this summit. It was last December. We brought together not just PMNR physicians, but we also brought together the affected population. So, organizations that represent patients. We brought together a small group of insurers. We brought together the pharmaceutical companies and that who make the products that we use. And then physicians, including ourselves and neurologists. And we talked about spasticity. And this is kind of, as we were talking about how does spasticity impact our patient population, this is kind of made by the ink factory to take the ideas and the discussion from the physicians and others and put it into a picture form. So, we all know that spasticity is prevalent, especially in stroke. And really, we came into this with, why are there so many people who have spasticity and they are not being treated? So, that was the frustrating beginning point for all of us is 35% of people had a stroke, 50% with TBI, 40% with spinal cord injury, greater than 90% of people with cerebral palsy, and then that MS population as well. And so, you have a large population of patients with spasticity. If you want to go on to the next slide. So, our membership data, when people are asked, says that, that's right, cancer patients. Our membership data suggests over 50% of physiatrists may treat individuals with spasticity. So, we have data where people have said whether they treat patients with spasticity. And up until the formation of this community, actually, there wasn't really a place for all of us to come together and talk about that. PM&R is also the highest users of spasticity related procedure codes when you look at the RUC data. So, go on. So, this is our space, basically. So, what we acknowledge is that spasticity is an area of opportunity for us, for our alignment to take a leadership role to actually lead the other medical organizations. And we have developed, including the SIPP Spasticity Program, we had Spasticity 101, and we're in the Spasticity Task Force. And so, and then that led to that Spasticity Summit, and then we'll lead to a publication and update, and then hopefully you'll hear about what comes next from that. So, we got a lot of ideas and feedback. We kind of are put in the right direction as to what we think the challenges are. But these are people who are in the room. Who are in the room. Nobody held back, which was awesome. And it was the first time I've actually sat in a small group discussion in which you might have somebody from pharma and somebody from a device manufacturer and somebody who represents stroke survivors and physicians and insurance companies and payers. And everybody was really putting away their hats of what they do, and we're trying to understand the problem, which is the first step, right? Is to try to understand from everybody else's perspective, what is the problem? What is the challenge? And why are you so passionate about this area? So, the top barriers that were identified through this are access to care, patient and caregiver support, and clinical capacity and capabilities. So, to Abe's point, it's not just about having enough physicians. It's also having the capabilities to provide the care. And so, there's many different levels in which these barriers impact, and you can see kind of in this drawing kind of how you can put those different areas together and what are the sub areas or why, you know, what are the challenges in access to care? What are the challenges in patient and caregiver support? You can go on to the next one. And then we went and talked about solutions, and we probably could have talked for another day or so, and we wouldn't have solved it anyway. But we came up with some ranking of solutions. So, each subgroup came up with solutions for their barrier, and then we went and basically voted on which ones we thought were important to us and brought that information together. It's always interesting when you do these things. So, you think that you may be, when you're in your own silo at work and you're frustrated because you can't get a high enough dose of something to treat somebody or you can't get patients into your office in time or whatever, you feel like you're the only person who has a problem. And then you sit there doing this and you think, you realize that we all are kind of circling around the same solutions. The question is, how do we then put that into action? Next. So, these are the, we're going to talk a little bit about opportunities for next steps. you know, the board is committed to us, but we also need to be able to get funding to do something bigger. This is not a little issue, right? There's lots of people involved. There's ways you can look at it from the perspective of the patient, the provider, and we are gonna need to work on obtaining some external funding for projects that really can hopefully make a difference in providing spasticity care. Is this where I go to you, Kavitha? Or is this me still? No, this is fine. I can take it on from here. So here's where we are with potential next steps, and then we're gonna dive into an area and really get some feedback from you tonight. So right now, we have our ongoing prior commitments in this spasticity space that are Academy-led on the left-hand side of the screen, and that's all the things that I'm sure you all already know about, the Spasticity 101 or Steps Spasticity course. We do have our spasticity guidance under development. We will have a course on that at AA. It should be published fairly soon. It's under review. We do have a publication on the consensus building that's coming out of the 2022 summit. We just heard that has been accepted, so everyone should see that fairly soon. And then we do have the Find a Spasticity Physician search on our website, and all of those activities are already happening. But really what's new in 2023 and what we're really trying to push for is starting with tonight, getting all of you together. We do have an annual assembly meetup on November 18th at 8 a.m. We will remind all of you about this, so please come and join us if you're gonna be in New Orleans. Let's continue this discussion. We will have industry at that discussion as well. I'm sure they will all be attending because they want to hear more and be a part of the discussion. And then we are reconvening our spasticity summit participants in December to share again what we have heard from you. That's just a small group of folks that we engaged with. Our goal is to engage as many members as we can. And then this new spasticity forum, this is an outdated slide, says application currently under review. It has been approved, but I think what we're asking for here is that we get more and more people to join the spasticity community. So here's what we have talked about and learned from the spasticity summit in general on all of these larger initiatives that we truly feel are an opportunity for us to go out and get external funding for and really make an effort to really push the needle on improving patient care for spasticity. These are just the ideas that have been brought up. And we'll be working very closely with and Dr. Hautreau's chair to get some funding and some interest out there. So one of the areas, I'm not gonna read all of these, but one of the areas that we really wanna dive into tonight is the opportunity to do initiatives in the spasticity space. We know it will take a lot of resources and energy to deploy a QI initiative. And it's not just something that any one of us can do alone. It will require a concerted effort from the academy, as well as from sites to participate in them. So we wanna use you, our spasticity community, as a source of expertise for guidance and for leadership throughout our journey and looking at all of these opportunities and building the right business cases. So I think you can expect us to engage you from our side to yours, but also the community is yours. So just like you talked about earlier today, it is a place for you all to connect with each other and not have academy or academy staff get in the way. But we will likely come to you for some advice, leadership, and expertise as we are trying to advance some of the larger initiatives that we have heard are really important. So I'm gonna dig into this quality improvement initiative, this idea that we have, and start asking some questions. We're not gonna get far tonight, and that's okay. We'll send follow-up emails, and we're happy to set up one-on-one phone calls to get more insight from you. But really our goal here is to develop a three-year spasticity-focused QI initiative plan for the academy. The plan will be used for us to go out and seek funding to support and implement the plan. And we hope that it will turn into engaging individuals and your institutions to participate in them and really help us understand a little bit more about what's going on, boots on the ground in different practices. So we've come up with two ideas in terms of a short-term project and a long-term project. I'm gonna run through those. We're right now at a very high-level part of these, so just bear with us. Our goal tonight is to just get these out in the open to you, let you start to think about them, and try to have as much discussion as we can in the next 10 to 15 minutes, and then continue this discussion as time goes on. So for now, based on all of the input that we have received from all of our stakeholders, the short-term project that we're looking at right now is to increase awareness of spasticity and potential treatment options among healthcare professionals. We are looking at this initiative being about six to 12 months. The aims of it is to swiftly improve healthcare professionals' understanding of spasticity management. Looking at pre and post-intervention assessments of design, the study will focus on the dissemination of evidence-based guidance for the diagnosis and treatment of spasticity. I mentioned that AAPMNR is developing its first set of guidance. I'm not gonna call it clinical practice guidelines because it is not that, but it will be best practices and guidance in this space. So we hope to draw from some of that as a foundation. And the objective is to address existing gaps in spasticity care by enhancing healthcare provider competency, ultimately contributing to improved outcomes and more efficient utilization of healthcare resources. So that's a short-term QI project that we're looking at building a business case for. A long-term one is more about care coordination and building a pathway and testing pathways for patients post-stroke. This is more of a long-term two to three-year QI initiative. The aim is to develop a comprehensive care coordination pathway for post-acute stroke patients with a specific focus on spasticity management as a key component of their total post-stroke care. It will be a phased approach. The initiative engages stakeholders to identify gaps, implement evidence-based guidance again, and to optimize care transitions across interdisciplinary teams. Anticipated outcomes for this one include reduced readmission rates, enhanced patient satisfaction, improved healthcare resource utilization, all while providing targeted interventions for spasticity as part of an integrated stroke care strategy. So I think you can see the difference between the short-term and the long-term. The short-term is trying to do as much as we can in a short amount of time with resources that we have. The long-term is really trying to dig deep and really trying to improve outcomes for the patients that you serve. We have some questions here, but we're happy to take any comments that you have on either of these. But specifically for that short-term project on increasing awareness, tell us a little bit about your perspectives on the current barriers to diagnosing and treating spasticity within your practice. Give us feedback on what elements you believe are crucial for the success of a short-term. This will be an educational QI initiative program aimed at bridging these gaps. Anybody wanna start us off here? I mean, you want answers? Is that what? Yeah, we are curious on your perspectives here for this. I mean, basically knowledge around the spasticity itself, who is diagnosing spasticity, access to care at the right time, the presence of other allied healthcare professionals around you to complement slash support the findings that you have, and then the resources you have in terms of management. Like for me, I'm lucky enough to have like from physical therapy to nerve block to chemo denervation to back up and pump. I don't think everyone would have the same luxury to have them all under one roof. So it's the resources available. That's I would start with. I would also point out that it really matters where the patient is when they're developing spasticity. As lengths of stay are shortening in acute rehab, a lot of these patients are developing spasticity in the subacute nursing home setting where there may not be someone there who recognizes this complication. And it can, that I've seen more often be a barrier. You know, it may be even identified in acute rehab, but then patients will go to subacute rehab and they get lost. And then we find them later. I'm sure others have seen this pattern. I would add to that, that even if you do identify in the subacute, now oftentimes getting the toxin or whatever treatment you're gonna give approved by insurance or a willingness of the subacute facility to pay for it is really quite limited. Right, right. When they're on Med-A for sure. The one thing I was gonna say in the realm of this question, one of the things that I'm working on in my clinic is, you know, I was sitting through, cause I was in private practice for a year and trying to figure out how to grow, you know, a clinic kind of organically, right? Reaching out to stakeholders, therapists in the community, everything like that. And kind of spent a lot of time in reflection, realizing, you know, we throw it around the term spasticity, spasticity a lot, right? You know, but really it's like only like the cerebral palsy patients, right? That may have been treated for years. I come in saying, hey, I need somebody to treat my spasticity. And when they say that, you're like, all right, they know, they've been around the block. They know what's going on with this, right? But when you think about it, so many patients don't come in saying, oh my goodness, I saw online you treat spasticity. That's what I have. You know, and thank goodness you treat spasticity, right? They don't come in saying that. They come in saying my walking is off. I'm falling. I feel stiff. My arm doesn't move the way I want it to, right? All these things. I'm having pain, shoulder pain, hand pain. My fingernails are digging in, whatever. Kind of flipping the paradigm and saying, you know, rather than waiting for somebody to develop something called spasticity, which they're not completely aware of what that is, or, you know, other providers don't know what it is. Most primary care physician notes, if you look at them, just says contracted, right? So, you know, rather than trying, at least my perspective is, rather than trying to educate everybody in the world about what spasticity is, like, we'll take care of that, right? When they come in and, you know, we'll diagnose the spasticity. We'll treat the spasticity. Rather than trying to educate the world about spasticity, you just say, hey, you had a stroke, you had a spinal cord injury, you had a brain injury, you need to come see me, right? And I don't want to wait until you come in and you're like this, right? Like Callie was saying, this stuff happens long after they're leaving the rehab unit now. So I'm very passionate about the idea of not just waiting for somebody to come in like this, right? Because oftentimes, as we, a lot of us will see, that may be, I don't want to say too late, but you know, you're thinking surgical or you're thinking serial casting or whatever. Rather than waiting for that, you say, I'm going to screen for this. I'm going to see you every three months, the year after your injury, and follow this along, right? Because as we all know, it may present itself three months out from their rehab, right? They're sitting at home and all of a sudden you're arranging and we're like, ooh, this is not good, right? So that's at least my two senses kind of, you know, I totally agree with this QI initiative. I think the question is, you know, do we spend efforts educating about what spasticity is or do we just educate on our role for these patients? And then, you know, we'll take care of the details, the nuances when they get to our clinic and just to kind of spread the word and awareness about, you know, at least the big picture of what we do, so. I think another potential barrier, you know, medicine has changed dramatically over the last five to 10 years, kind of the business of medicine. You know, there's frequently a disincentive to refer patients outside of your network. Well, and I don't know what the answer is to this. I don't even know if there is an answer, quite frankly. But what if, you know, a patient is part of a large network and there's nobody there who treats spasticity or there's somebody who just kind of does a little bit here and there and might not be particularly adept at it, but there's somebody around the corner who's not part of that network, who's been doing this for years, you know? How do we educate the patients and the families and the caregivers to maybe step outside of that kind of, you know, that zone, you know, to allow them to have access to the care that they need? You know, maybe there has to be centers of excellence, but then if there's centers of excellence, that can definitely exclude others who are really, you know, very passionate about treating this populace. You know, and there's obviously a financial disincentive to refer outside of those networks. So I don't really know what those answers are, but it's definitely an impediment. Steve, it looked like you were gonna say something. Yeah, I've been doing this 25 years, and the thing that has always stood out to me is the best referrers are your allied health professionals, and that educating the PTs and the OTs is really where you get the biggest bang for the buck, that they are the ones who are out there on the front lines seeing these patients in every imaginable setting. They're seeing these patients at home, they're seeing these patients when the primary care refers them to an outpatient physical therapy or occupational therapy setting, they're seeing these patients in nursing homes. So they're the people who are our allies in finding and properly referring spasticity patients to us. I would agree with that. I also think, like in my setting, one of the things, so I'm here in Phoenix at Barrow, so we really do only neuro rehab. And one of the things that has made it successful is that we kind of build ourselves as a medical home for those that will take care of all your needs for your stroke patient, your brain injury patient. Like the therapists will walk people up to our desk to make an appointment, you need to see this doctor. I know your primary care doctor sent you, but you need to see this doctor. I lectured to my stroke fellows and stroke neurologists today about spasticity. And man, they are just so excited to be off the hook for everything that they don't really think they know anything about. And I'm excited to be off the hook with knowing what the most recent literature is about, secondary stroke prevention with X, Y, and Z. So, but I think that it is given being not just the spasticity people, but the everything, like it's accepted that everybody with stroke needs to come see the physiatrist. Like, and then you can then look at them and go, hey, you know what, like you're doing great, just come back and see me in six months, or no, you need to come more frequently or whatever. Like, I think that that, it goes beyond spasticity. I think asking them to identify spasticity by the time they identified it, you're too late. And, you know, even the therapists, like they don't want you to tell them like always what to do. They want you to make their life easier. And so sometimes it's like, okay, I'll be your partner and we'll go through this. And, you know, those are the groups you wanna kind of educate what we can do as physiatrists for these diagnoses. I mean, Christina, I agree with you that every stroke should see a physiatrist. I think we would all agree on that. But, you know, just to play devil's advocate, you know, for those of us who are just doing more of the spasticity component and less the kind of global neuro rehab component, which is certainly of merit and of value, if I had every stroke patient in my institution come to me without spasticity, with and without spasticity, then I would never be able to treat somebody with spasticity, you know, because I'd be booking out a year, you know, or two years or five years, you know what I mean? So I think this kind of goes back to what we were talking about in the beginning that we have to find a way to make it work, make spasticity management work in multiple different settings. You know, if you're in a private practice setting and if you're in an MSK practice, well, then maybe you can just do one day every two weeks, just doing spasticity. If you're in more of a neuro rehab setting in a neuro rehab hospital, well then, yeah, well then you have, you know, support there for you to be able to deal with bowel, bladder, wheelchair, bracing, you know, all these other things that are of course vitally important, but aren't so easy in certain settings, you know? But the idea is to me, at least this community, to really try to raise, you know, treatment for this patient population as much as we can, regardless of what setting we're practicing in. I'm just doing a check on time. It's 7.02. I'm happy to stay on and continue the discussion if people do, but I want to be very respectful of everyone's time. So what we will do for next steps, at least from our side, and please use the Fisk Forum community, ask your questions. If you have any follow-up discussion or thoughts that you want to share, you can use that forum as a place to do that. But to follow up on our specific areas here tonight, just wanted to share, we are going to be sending out a survey on these QI initiatives to get some more detailed information from all of you and from other members as well. It will also include getting your input on the long-term QI initiative. So we hope to deploy that maybe by the end of this week, very early next week, right before annual assembly. So please be on the lookout for that. We will be sending you reminders. We would really, really appreciate all your feedback on that. Again, we have that spasticity discussion happening at annual assembly, November 18th at 8 a.m. Please attend, it should be on the app once you download the app, so you should be able to find us. If not, I think you all know how to find either Sharon or myself or email anybody at AAPMNR, we'll help you get there. We will be finalizing our QI plans by the end of this year, hopefully with more feedback from you so that we can start going out to external funders and start getting their input on them on what they might be willing to support. And most importantly, really just engaging this community ongoing on our efforts, but really hope that you all see this community as a home for you and a place for you to share your thoughts and insights and just allow us to sit back and allow you to do what you do best. I'm gonna hand off to Dr. Bohart to close out tonight. Thank you again, and thank you for being patient with us as we walk through some of the efforts that we're doing at AAPMNR. All right, well, let's all exhale. I think that was fantastic. I think we can all really try to come together and raise the standard of care for this patient population. There shouldn't be patients who haven't had proper specificity care and they had their stroke or brain injury or MS or spinal cord injury or CP or whatever it is, multiple years ago. And I think that if we kind of team together and learn from each other with regards to A, clinical care, B, tips and kind of advice on what's the best way to approach the tibialis posterior, for example, but also raising awareness and advocacy and kind of raising the bar. They did this really well in pain medicine. They're doing this very well in MSK as well. And now I think it's our turn. And I personally think that specificity is hands down the most fun that I have all week in my practice. It's a wonderful patient population to take care of. And I discussed this with the residents around the country who I lecture. And they always kind of come up to me at the end and they say, well, sounds great, but how do I do this? And I kind of scratched my head and I say, well, you know, it's tricky. But maybe if we all kind of pull together, we can make it a little less tricky to really get our field out there, promote the field and take care of these really vulnerable patients.

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patient care

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barriers to diagnosis

barriers to treatment

interdisciplinary collaboration

educating therapists

managing spasticity

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comprehensive care coordination pathway