Exercise as Medicine – the Panacea of Physical Medicine and Rehabilitation-Exercise as Medicine – the Panacea of Physical Medicine and Rehabilitation

Exercise as Medicine – the Panacea of Physical Medicine and Rehabilitation

Video Transcription

Welcome to the Exercise of Medicine community session. I hope you're going to stick with us for the full three hours. We have an incredible session and we want your participation.  Again, thank you so much for joining us. Just one announcement. Unfortunately, Dr. Elliott Ross, who was meant to be speaking with us today, is not able to make it.  And so, unfortunately, we will not be hearing his presentation. This is our agenda. We've broken up the session. We're going to have a couple of talks  and then we're going to have a discussion with you, our community session members. Again, followed by two talks, community session discussion, a break, and so on and so forth.  We will hopefully finish by 5 p.m. Central Time. These are the goals of our community that were set when we established our community. And we will review these goals later on  when we have our community session discussion. But it's essentially teaching, research, clinical practice, and advocacy goals.  And again, as I said, we'll go over them a little later. This is the schedule of speakers. I'll be kicking it off, followed by Dr. Rosenberg, et cetera. You can see that yourself.  I won't belabor those points. Some housekeeping. You have been muted. And when it comes to community session times, you will be unmuted. This session is being recorded.  There is a way to claim CME credit, as you can see, and to enable your video camera as needed. You see the instructions here in terms of what you need to click on.  But please keep yourself muted during the presentations. Probably for the best experience, the questions best asked through the chat button feature, which is button C at the bottom.  And we will do our best to answer those questions. At the end of our talks, we have a few moments to answer those questions.  And then we can answer more during the community discussion session. And during the community discussion sessions, if you do want to talk, you can unmute yourself.  We will enable that. But do remember to mute yourself again when you've asked a question. Well, that's it for the introduction. And I will introduce myself. I'm Jonathan Whiteson.  I'm one of the associate professors of Rehabilitation Medicine and Medicine here at NYU Langone Health. I'm the vice chair for Clinical Operations  and the medical director for Cardiac and Pulmonary Rehabilitation. Are we able to get up the first polling question? Do I need to stop sharing? Oh, there we go.  I was going to say, do I need to stop sharing? But I don't think so. So if you can look at the polling question, and you can give an answer if you can.  So when considering exercise as medicine, the U.S. Department of Health and Human Services 2018 Fiscal Activity Guidelines  recommends 150 minutes of exercise a week as the optimal amount of exercise. Risk stratification models using the Karbonin formula to determine exercise training heart rate,  minimize the risk of cardiovascular complication during aerobic exercise. The way the scientific evidence does not support the benefit of aerobic exercise  in the prevention and management of cancer. Exercise intolerance or fatigue in patients post-COVID-19 infection is likely to be associated with muscle dysfunction.  I see people are still answering, so we'll leave it going for a few more minutes or a few more seconds.  Okay, so we're going to hold it right there. I know that people may be still wanting to answer. I see that the majority of people answered the first part  in terms of the U.S. Department of Health and Human Services recommendations. We'll come back to this in a few moments. Can I check out of this?  Are we able to stop sharing the polling question? It should be, yep, we stopped sharing it already. Oh, okay, all right, thank you.  I still see it on my slide, but that's not a problem. Anyway, I have nothing to disclose. So, exercise is medicine is actually a registered trademark  of the American College of Sports Medicine. We are called exercise as medicine. Hopefully, we're not infringing any trademarks.  But interestingly, the exercise is medicine initiative uses the terms physical activity and evidence-based exercise programs somewhat interchangeably, a valiant discussion.  But there is a difference between physical activity and exercise.  The World Health Organization describes physical activity as any bodily movement as opposed to exercise, which is something that is planned and structured,  repetitive, and has physiologic changes, leads to physical fitness. So, there is a difference between physical activity and exercise.  And when we think of exercise as medicine, we have to recognize that the medicine part implies that there is a prescription, and we need to be aware of that.  The general benefits of exercise has been known for some time. There's a lot of evidence-based around it, but certainly growing evidence about its benefit  in reducing the risk of heart disease and stroke, various different kinds of cancers, other risk factors, depression and falls, amongst other things.  As I said, there's a strong evidence base for this as well. Physical fitness is another term that's often used and discussed, and that is defined as a state of health  and well-being that may be related to our ability to perform our daily activities or our work activities or even sports participation.  But physical fitness is something that we think of as being achieved through physical exercise. And there are different components of exercise that lead to physical fitness.  And while there's probably more extensive things to discuss in this resource, flexibility, balance, strength, and endurance are aerobic exercises.  So probably the main things that one should consider. So here are the 2008 physical activity guidelines. And if you see, it says there is a minimum requirement  of 150 minutes of moderate intense aerobic exercise. Additional benefits are, I would like to say, ideally 300 minutes. So forgive me for leaving many of you  down the wrong garden path, but the question that we put in the polling question was ideal, and it is not 150 minutes. That's the minimum. 300 minutes is to be considered the ideal,  and as well, the aerobic exercise. So a lot of people will discuss 150 minutes, but in essence, we really need to do more than 150 minutes.  The physical activity guidelines were updated in 2018, and the update there, as well as the minimum of 150 minutes was any movement at any time all adds and it all benefits.  This was to make sure that people realized they didn't have to exercise at an hour at a time or half an hour at a time. Even five minutes would be beneficial.  And why do we recommend that people exercise and reach at least that 150 minute and ideally 300 minutes? Well, that's because your risk of mortality  and your risk of disease actually drops according to the amount of time that you're exercising vigorously. And so this is information that's really very important  to spread to our patients so they know what they should be doing. Unfortunately, not many people follow the physical activity guidelines. About 25% of men and approximately 20%  of women actually comply with both aerobic and muscle strengthening guidelines. So we still have a significant amount of our population  that aren't getting enough physical activity and exercise. We do know that physical exercise benefits every single organ system, and in my world, which is the world  of cardiac and pulmonary rehabilitation, there's great evidence to suggest the value of participating in a rehabilitation exercise program when it comes to outcomes.  And you can see that those people who participated in more sessions of physical exercise, cardiac rehabilitation, had reduced incidence of death and myocardial infarction.  As well, we see reduced hospitalizations with an increasing number of sessions that patients participate in. And this is very interesting, and certainly  in value-based care, that reduction in readmissions actually starts right at the word go, right at the entry into the cardiac rehabilitation program.  So exercise is very powerful and very valuable. So how do we make safe exercise an effective exercise? How do we write that right prescription?  Well, first of all, and we all understand, first do no harm, we have to recognize that exercise is a medicine. And if we're going to consider it as medicine,  then we have to write the accurate prescription. And we'll come back to the FITP, or frequency, intensity, time, and type, and progression in a few moments.  But the intensity is really, really key. And this is what I like to focus on, and I think is really essential when it comes to the outcomes from rehabilitation.  So how do we make the exercise safe? Well, we have to do a history, a physical exam, and do tests. The most valuable test is the stress test.  This is a picture of a cardiopulmonary stress test, but a routine stress test is as good. And we go through models of risk factor stratification.  And I will read this out because it's so important. Risk factor stratification is the extrapolation of medical, physiological, and functional data into a safe exercise prescription,  minimizing the risk for acute cardiovascular complications during exercise training, while maximizing the benefits both medically, physiologically, and functionally.  So it really encompasses our full evaluation and translation of that evaluation into a safe exercise prescription. In the cardiac world and in probably much of the rest  of our rehabilitation world, the risk for exercise can be considered coming down to a cardiovascular risk, arrhythmia, ischemia, and heart failure, as well as other risks.  Patients have diabetes. They may be anticoagulated, have vision issues, cognitive issues, wound and skin integrity. We'll talk about that.  Rheumatologic, neurologic, and orthopedic issues, as well as neuropathy and prophylaxial disease. So all these need to be taken into account.  When we look in the cardiac rehabilitation sphere, we look at the Karvonen formula that's helping us determine the intensity of exercise.  And that goes through this risk stratification model of really understanding the risk of someone exercising for developing arrhythmia, ischemia, or pump failure.  So for those of you who answered the polling question that the Karvonen formula is used to determine the training heart rate and safe exercise, that was the correct answer.  This is the formula. Again, I'm not gonna belabor the point for the sake of time, but this Karvonen formula allows us to risk stratify and understand people's risk for ischemia,  heart failure, and arrhythmia, and prescribe a training heart rate and intensity of exercise. So this is the right intensity that we need to achieve  in order to have the benefit, both aerobically, but also to stabilize the heart in terms of its rhythm, but also to positively impact risk factors for cardiovascular disease.  Again, for the sake of time, I'm gonna skip through these next three slides and also bring you to the point that as well as the Karvonen formula,  there are other methods of determining exercise intensity. And from my perspective, probably the next best is using the Borg rate of perceived exertion.  I'm sure you're all familiar with the Borg scale, but a rate of 12 to 14 or somewhat hard correlates scientifically proven with an aerobic stimulus.  So this is, as well as the training heart rate, a very important measure to teach patients and to have patients recognize and realize that that level of perceived exertion  really does correlate with reducing cardiovascular risk factors, improving aerobic capacity,  and reducing risk for other diseases as well. Again, just for the sake of completeness, there are contraindications to exercise stress testing.  There are reasons to terminate stress tests. I think it does behoove us to understand those if you are involved with stress testing and evaluation of patients  when they're coming for exercise evaluation.  So how do we make the exercise prescription both safe and effective?  Well, this is the FIT-P. The frequency should be at least three times a week, and preferably if we're going to get up to 300 minutes, five times a week.  The intensity can be set using the Carbolin formula for a heart rate, training heart rate, or the rate of perceived exertion, 12 to 14, somewhat hard.  The type of exercise, again, from my perspective in cardiac and pulmonary rehab, we focus predominantly on aerobic exercise, but there is tremendous value as well  to resistance exercise. The time, 60 minutes a day. So again, going from 150 up to 300 minutes a week in total.  And then progression. And remember, we need to progress people to make sure that they continue to make gains. And they also need to recognize and understand  that this is a lifelong impact.  Just to finish off, just a couple of thoughts about COVID-19 and exercise. And we recognize that COVID-19, this pandemic that has been affecting a lot of patients.  I don't know how many of you have seen patients who've had COVID-19, but we recognize that it's affecting patients' ability to tolerate exercise and even physical activity,  probably impacting the cardiovascular system through the myocardium and possibly even thrombosis. Also through the respiratory system with viral pneumonia,  possibly progressive fibrosis, pulmonary emboli. The musculoskeletal system through disused atrophy and sarcopenia. We'll talk more about that.  Dr. Prillik will present on sarcopenia. And the neurologic system through neuropathy and stroke. So COVID-19 can impact our ability to exercise through several different ways.  There was an interesting review article written and I recommend you take a look at it if you are treating patients who have had COVID-19.  And it discusses how the virus enters the cells, its interference with mitochondrial respiration  leading to cellular death.  We know that patients with COVID-19 have musculoskeletal consequences. And we know that the virus is impacting the myocyte  by direct infection, but also through pro-inflammatory molecules, as well as perhaps atrophy through corticosteroids. We know from previous SARS and COVID infections  that people are significantly impacted through various different mechanisms with muscular health and that affects their function. We also know from previous studies,  previous COVID infections, that rehabilitation programs do make a difference in improving strength and endurance. So there is tremendous value in thinking of exercise as medicine  for patients with COVID-19. Again, as well as dyspnea, a very common feature of COVID is fatigue. Is it deconditioning physiologically? Is it sarcopenia?  Is it myalgic encephalomyelitis, chronic fatigue syndrome? Each one of these may be treated with a slightly different exercise prescription. So again, it's worth considering  what's going on in your patient and achieving the right exercise prescription. Again, just in general, lockdown, even if people aren't infected with COVID-19,  lockdown and lack of access to gyms can lead to sarcopenia, muscle dysfunction, because we're not exercising so much. So food for thought.  We need to make exercise a safe prescription. Exercise is medicine. We need to think of it as a prescription and detail it out for our patients. We focus on intensity, frequency,  duration, type, and progression. We want to risk stratify. We can do harm by doing too much or too little. We don't want to extrapolate to all organ systems,  and we want to recognize the value of physical medicine and rehabilitation and exercise in COVID-19 recovery. That's it from me, from my questions, from my talk, should I say.  And let me see what I can do to stop sharing and to see if there were questions. Again, recognizing time, and we do want to move on. I see some comments in the comment box.  300 minutes a week is a very tough cell. And it says another comment says 300 minutes combined aerobic and resistance exercise. No, 300 minutes a week of aerobic exercise.  So that's the optimum ideal amount of prescription. It's one hour, five days a week. It is a tough cell, and I know that when we're telling people  that if they do 150 minutes a week, that's okay. We're sort of missing the point. They're missing the full value of exercise. It's like prescribing 20 milligrams  of antihypertensive medication when we should be prescribing, you know, 40 milligrams of an antihypertensive medication. So we do need to consider 300 minutes of aerobic exercise.  There's a question about posting the article again. All these slides will be available, and people will be able to get access to all the references.  How much is too much exercise in a young, healthy adult? Well, that slide that I showed in terms of the value of the amount of exercise, once we get past the 300 minutes a week,  there isn't that much more benefit for exercise. So those people who are running ultramarathons and doing triathlons, they don't necessarily get enhanced health  from that extra exercise. So right now, the recommendation, the maximum recommendation is 300 minutes of aerobic exercise per week. All right, with that, it is time to move on  to allow Dr. Rosenberg to present. Dr. Rosenberg, if you want to start sharing your slides, please do. Dr. Rosenberg...  So she's starting. Just as an introduction, Dr. Rosenberg did residency at Ohio State University, is an adjunct associate professor at the University of Minnesota  in the Department of Family Medicine and Community Health. She's a founding diplomat serving on the Board of Directors of the American Board of Wound Medicine and Surgery,  is a medical director of the M Health Therapeutic Lymphedema and Wound Care Program, and has been practicing wound care for over 25 minutes.  Dr. Rosenberg is going to talk about the magic of movement, wound healing with exercise. Jose, can we share Dr. Rosenberg's polling question?  And again, if you can read those through, and if you want to answer them, and Dr. Rosenberg will then take it away with her talk and answer.  All right, I don't expect this question to be easy for most people.  Okay, should we stop the polling?  And we'll just...  I can start lecturing, how's that? I want to thank you, Dr. Whiteson, first of all, for inviting me to come do this. I'm very excited about this.  Thank you for lecturing like that, that was great.  So we will get started because I don't have a lot of time here, but I'm talking about the magic of movement and how wound care and exercise go together.  I have no financial disclosures, no relationships. This is Minnesota, and yes, we do have snow today.  No, it doesn't look like that because we don't have any people on campus anymore. Thank you, COVID-19.  The objective of today's lecture is to review a couple of things. First of all, to review some of the current data on the medical benefits of exercise  and how that has impact on wound healing, to understand some of the studies that have been done on the different types of exercise and how they may be beneficial.  And then how do you get these patients to do this?  Now, why are wounds important in the first place? A lot of us haven't had as much introduction to chronic wounds, but let me say that 3.5 million breast cancer patients  are being taken care of in the United States in 2019 and 6 million heart failure patients. However, by Medicare data from 2014, 14.5% of Medicare patients  will have wound-to-wound related infections. And that corresponds to over 6.5 million chronic wound patients in the United States in a year.  The cost actually was originally estimated in 2015 to be greater than or about 37 billion. We now know per year, chronic wound care costs are 50 to $70 billion a year.  I will tell you that compares to breast cancer of 20 billion a year. This is a huge, huge problem in the United States and worldwide.  For those that don't have as much introduction to wounds, we talk about four different types of wounds. However, they really overlap. They're very multiple and multifactorial.  Venous leg ulcers are our most common types of wounds that we see in clinic. These are 70 to 90% of really pretty much the wounds we see in leg ulcers.  30% of these patients will have four more episodes in their lifetime. It's a continuing problem. They hurt, they smell, they really severely impairs patient's ability  to have a quality of life. 50% of these require over a year to heal. That's a long amount of time and a lot of money estimated at 15 billion per year. But again, this is 2014 data  and is probably higher than that now. The diabetic ulcers we talk about a lot. Why it affects 23 million in the United States and 25% of diabetics will get diabetic foot ulcers  at about a rate of 5% per year. The recurrence rate is huge, 70 to 100%. This is where PMNR I think can have incredible impact because I think part of where we can decrease this  is I see so many patients come to me who even have wounds that have healed, who their foot drop is never dealt with appropriately. So the minute they start to walk again,  they're hitting the bottom of the foot, that metatarsal pad and that first metatarsal pad and they just hit it and recur. Gait mechanics. If they have an ankle contracture,  they can't properly lift the foot. How about just basic transfers with somebody who's paraplegic or has had a stroke? They can be transferring inappropriately,  getting caught and constantly getting trauma. If they can't feel the foot and they're wearing shoes, guess what happens? Shoes that cause improper pressures on the foot  and they get recurrent ulcerations. We know in the diabetic population, 50% of these patients will get a contralateral ulcer and 12% of these will go on to require amputations.  People don't like this. They really like to save their feet. They get used to being with them. 90% of the non-traumatic amputations in the United States are due to the diabetes.  Now, what's most amazing to me is that the mortality rate from diabetes over five years with these diabetic foot ulcers is 45%. That actually beats the mortality rate  from breast cancer in five years and from prostate cancer in five years and also from Hodgkin's lymphoma.  Pressure ulcers, we talk a lot about this in rehab. We were kind of, Dr. Kotke was one of the big people in this, came from my area actually in Minnesota here.  But pressure ulcers, 2.5 million per year in acute care. Annual cost is big, $11 billion a year. Critical care seen in 22% of that population.  Mortality is increased by at least 7.3% and the cost of additional care is 43,000 per patient per admission. Arterial ulcers problem, 8 million a year.  And it's 12 to 20% of people in the United States, over 65, have arterial disease. And we know in the venous insufficiency population that easily 20% of these patients  have concurrent peripheral arterial disease.  Now, why aren't these people healing? Well, the first thing you have to understand is what's the difference between a chronic and acute care,  between an acute wound and a chronic wound anyway? Well, when we get an acute wound, we have suddenly disrupted the barrier of the skin  that protects us from this outside environment. We all of a sudden have bacteria, viruses, toxins, particles and everything getting into our system.  There are four stages of healing we typically talk about. Now, some people will put this as three stages of healing with stages one and two being put as one stage  basically because they occur around the same time. I prefer to look at them as four stages. It's the way I think, that always isn't necessarily the greatest.  Now, there are four stages. Initially, when you get a wound and disrupt that barrier, you suddenly get bleeding because the capillaries have been cut.  The first thing that has to happen in the first zero six days is that the platelets come in and they say, let's stop this bleeding.  They then send out cytokines and messengers to say, somebody better clean this mess up because we have the bleeding stopped. That calls in the inflammatory cells,  white blood cells, phagocytes, macrophages, et cetera, to go and clean up this mess. And I think of them as almost Pac-Man  cleaning up all the necrotic tissue and bacteria, et cetera. They then send out cytokines and further messengers to say, hey, we've got this area cleaned up.  Somebody better start getting this closed. And the fibroblasts are then called in. And the fibroblasts then start to deposit the fibrin  and the collagen to be able to start getting healing. The collagen that's first placed down, however, is very erratic. It's very fastly placed.  It's very erratic. It's not very strong. And it's really a collagen type three. And then that occurs again over the last about two weeks.  And FOD is followed by what we call the remodeling stage. So the collagen has been placed. The epithelialization has occurred across the epidermis.  And now we have to tighten this bond or strengthen this collagen tissue. And the fibroblasts then start switching from a collagen type three to a collagen type one,  which gives the cross-hatching with more of the parallel fibers that gives more strength to the wound. And we get the wound to start to heal and get strengthened.  This can take up to a year or two years. In addition, once we've gone through full thickness wounds, once we've gone into full thickness,  the most healing we can ever get as of today is about 75 to 80% strength. Again, am I not surprised that with trauma or continuing damage, wounds open up very easily.  So what is a chronic wound? Well, a chronic wound we described as something that's unresponsive to the best evidence-based practice. That includes debridement, controlling swelling,  controlling the infection, et cetera,  and controlling the inflammation. And when we do that, it still does not reduce in the area by at least 40% in three weeks. Now, this is for your venous wounds.  For the diabetic wounds, we tend to go a little bit longer because with the diabetics, that glucose tends to harden the small vessels. We get a lot of microvascular disease  and decreased oxygenation. And in addition, hemoglobin does not give up oxygen as well in a glucose-filled environment. So we get less oxygenation.  So in a diabetic wound, we tend to see slower healing. And we'd like to see within the first three months, at least 50% healing.  What is happening and why is this so slowed down with the chronic wounds? Well, it's that stage of inflammation. The inflammatory stage, we get stuck in it.  There is constant inflammation, constant eating up of all the good new tissue  starting to form, and we cannot get this wound closed. Why does that inflammation continue? There are a number of reasons. One of the main reasons we know is hypoxia.  There's lack of oxygen to that area. If I have arterial disease, for instance, and I can't get good oxygen to the wound, I can put on every fancy dressing and do everything,  but I will not get this healed. And that is a big piece of where exercise comes in because we will talk about how oxygenation and how exercise improves that oxygenation.  In addition, when we get swelling, it goes into the middle layer of the skin, pushing the top layer of the skin away from the bottom.  And below the bottom is where the main arteries are that supply oxygen with small capillaries up to the top layer of the skin. When swelling occurs in that middle layer of the skin,  it pushes the top layer away from the bottom, thereby decreasing capillary input to the top layer of the skin. We also get less oxygen and thereby also get nutrients  to the top layer of the skin. So we get a hypoxic injury along with the decreased nutrients, and that causes further damage to the skin  and further impairs healing. There are also, we see local infection and also biofilm formation in these chronic ulcers. In fact, anywhere from 80 to 100%. What are those biofilms?  Well, bacterias, and most commonly, though any bacteria colonization can do it, the most common are Staph aureus and Pseudomonas. And they form these wonderful communities  where they communicate with each other and they form a shield or a glycocalyx over them, also known as a mucopolysaccharide shell  or shield that is negatively charged that protects them from any oral antibiotics, IV antibiotics, local topical antibiotics. And they keep increasing in number, replicating,  and causing further and further growth along the wound and then cover themselves more with this biofilm and we get continued inflammation. I already alluded to what trauma can do  with continued inflammation. Foreign bodies, even a small suture can cause problems, but I've seen where we have these diabetic wounds and a diabetic comes in saying  their foot was leaking for two weeks. They didn't, they just noticed something. Should we check it? And I've taken pieces of glass out, which are a half centimeter diameter.  So foreign bodies can do it. I alluded already to the systemic issues that impair healing and cause continued inflammation. That includes the diabetes, malnutrition.  In somebody who has a significant wound, we know their increased need for protein, for instance, is 0.6 grams of increased protein per K-Cal per day. In a 180 pound person,  that would be about 65 grams of protein a day they would need to heal. K-Cals, calories themselves are increased significantly. They will need, they will need a 150 pound person  normally maybe needing 1,500, 1,700 calories a day. If they're thin and malnourished with a wound, they may need 2,500 calories a day to have a chance of healing.  Medications cause significant problems with swelling and can also impair healing. Actually, the opioids are noted to do this now. They impair healing.  We're not sure of the mechanism of that. We also know things like allopurinol, Losartan, a number of medications can impair healing. Immunodeficiencies obviously impair healing.  Now, wound care has been going on for a long time. Just a quick overview. We've known since 2,200 BC when we have found manuscripts from that time,  people were putting, washing these wounds, making plasters and bandaging, keeping them warm and moist. And in the last 60 years, in 1962, we came into the modern age of wound care  where George Winter did some wonderful studies on pigs, had, it basically caused wounds in them and actually some he covered, half he covered with warm, moist healing  and the others he didn't. Those with warm, moist healing healed much faster. I know people still do wet to dry dressings. You will not see me do them except in extremely rare cases.  Warm, moist healing is the best except in arterial wounds, which are basically a different class of wounds, but warm, moist healing makes a huge difference  in healing these chronic wounds. Other advances we've made with debridement dressings, a lot of energy-based modalities, which changed that negativity of the biofilm shield  and help us break that up. Edema control, autologous platelets, growth factors, we have a lot of bioengineered grafting materials now, and we also have hyperbaric oxygen.  But what's really is missing, and I think people have been not paying attention, is the value of exercise. I think it's actually the most under-prescribed thing  we do in all forms of medicine. Exercise is extremely beneficial. What we have seen today,  let me move this. I'm sorry, I got to back up there.  What we have seen in physical exercise is associated with decreased levels of inflammation. We know that, and I know Dr. Whiteson reviewed that. Pielock did studies in aged mice,  and what he did is he took aged mice and put them on a, half of them on a treadmill and half of them just in their cage.  When he measured, he did put little biopsies in them and sores. When he measured pro-inflammatory cytokines, such as tumor necrosis factor alpha and interleukin-1 beta,  which are very well known to be increased in chronic wounds, he showed that there was a decrease in these. And in addition, the exercised mice healed 25% faster.  Emery from Ohio State started looking at healthy adults, an average age of 61. And he started them on a program where he had 28 patients actually to start,  and he exercised them for three months aerobically, three days a week, one hour per session. And then about a month after he started this, he put small biopsy wounds in their,  in their arms and showed that those who were exercising healed 25% faster. Venous leg ulcers have been followed very closely. And we know when they've done standard of care  with the debridement, with treating the infections, inflammation, and doing compression,  versus doing the standard of care with heel pumps for 12 weeks.  O'Brien showed that, again, the exercise group healed faster, 53% healing rate without exercise and 77% with exercise.  What in the world is going on and why is this happening?  Well, we know media showed, you know, we had previously known that with a high level of intensity of exercise, something called nitric oxide increased.  And we know nitric oxide has extreme benefit for helping with the blood flow, especially to the skin. So we knew heavy exercise did that,  but what he did is Dr. Medea took 15 untrained women, ages 59 to 69, and 10 of them, he put on an exercise program of a moderate exercise program  with bicycle ergometry, with just a cycle of foot peddler. And he put them doing it five days a week  30 minutes per session for three months. And then he did it with five, tested them against five controls. And those with, who were doing the training,  and these people had previously not trained at all, any of them, nitrous oxide increased.  Kashiwagi showed that perivascular nitric oxide mediated angiogenesis and stabilized the blood vessels. In fact, we found nitrous oxide, which is produced by the macrophages,  produced causes cell proliferation,  regulates collagen formation, helps with wound contraction, causes vessel morphogenesis, and also angiogenesis with stabilization of the vessels and muscle vasodilatation.  Trinity actually said, well, is this only aerobic exercise or can other things do it? So Dr. Trinity checked isometric hand grips in 20 patients greater than 60 years old.  Now, 10 of them were controls, 10 of them were exercise. He just had them do the isometric exercise like that. And he noted increased vasodilatation  with increased nitric oxide in the exercised patients. Again, aerobic physical activity has been shown to reduce vascular resistance, improve autonomic response  and increase muscle vasodilatation.  Low-intensity exercise, and excuse me, and it's not just the nitric oxide. Again, low-intensity exercise, we know decreases the blood glucose levels.  As we said, we know in the diabetics, those high blood glucose levels decrease the ability of the hemoglobin to give up oxygen to the skin and also increases,  and also decreases the stiffening of those blood vessels.  So how do we get these patients to even exercise? And let me tell you, in my clinic,  it will be rare a day when I see a patient with a BMI less than 45 or 50. And these are the patients that I see. So how do you get these patients going?  And I'm just going to tell a couple of pearls that I've learned over the years.  Education.  We really talk about what exercise can do and how it can help. And I have to give them permission to exercise. I say, you know what? You have the right to take care of yourself  because if you can't take care of yourself, you can't take care of anybody else. And you can do it. To just tell them to exercise and go diet is not going to be effective.  I can't believe people say that because that's like, why are they paying you to say that? I give them a lot of resources. We talk first about how to exercise and how to get started.  You start very slowly. Start with reasonable goals.  We start with, people will say, well, how do I exercise? My knees hurt. My response to that tends to be, well, that means all those Paralympic athletes are a joke  because a lot of them don't even have knees. What I talk to them about is different activities they can be. They can do sitting exercises.  They can do standing exercises with a chair. They can work on a bicycle ergometer or a bicycle peddler like I show here. Those are 40, 50 bucks.  I'll put in a plug for amazon.com. They can use, in this day of COVID, when they have to work at  home, YouTube has awesome videos of all different types. They can do salsa dancing. They can do  anything. They can actually just do sitting exercises there. There's some wonderful exercises.  The internet is good. Cable TV libraries. If they don't have internet access, use bookstores and  videos. We talk about how to get weights. They don't have to buy weights if they can't afford  it. Cans, bottles, jugs, books. And again, start slow. And the real key is to make the time for  themselves. They have to put it in their schedule. If you don't put it in your schedule, it won't get  done. And I've been very effective in getting a lot of these people exercising. So that's what I recommend. And hopefully I've helped you out and have just a basic understanding of  some of these wounds and the importance of exercise. So that's that.  Dr. Rosenberg, thank you. That was a wonderful talk and very, very interesting and  challenging group of patients, no doubt about it. But we really appreciate your expertise.  So for the sake of time, we were going to go into a community discussion at this time. But just to  get us back a little bit on track, I'm going to jump forward. We will come back to our community  discussion. For Dr. Rosenberg, if you have questions, please do send them through the chat box. And Dr. Rosenberg, you can look there and see some questions that have been coming  through for you. I'm going to ask Dr. Prillick to start sharing her slides. And as she does that,  Jose, if we can also put up her polling question. And for all of you, Dr. Prillick is a clinical  instructor in the Department of Rehabilitation Medicine here at NYU Grossman School of Medicine.  She's the Clinical Director of Cardiac and Pulmonary Rehabilitation. She runs the Inpatient Cardiac and Pulmonary Rehab Program here at Rush Rehabilitation, treating patients with  complex cardiac and pulmonary disease, including those pre and post heart and lung transplantation.  Dr. Prillick is going to talk about exercise requirements to combat fatigue and sarcopenia in an aging population. Please do look at our polling question. It's up now.  And when that looks like it's answered, then Dr. Prillick will get on and present.  Hi, thank you for having me. The topic of my presentation is sarcopenia and specifically its exercise requirement to combat fatigue and sarcopenia in an aging population.  I have nothing to disclose. So what is sarcopenia? So the definition actually comes from Greek, sarco, which means flesh or muscle, and penia, which means deficiency. So altogether,  this is some sort of deficiency in muscle. And in fact, the definition is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength,  usually related to aging or an underlying condition. The sarcopenia term was first coined  by Dr. Irvin Rosenberg, who had an interest in the process of aging. And he actually noted that  the loss of muscle is far more dramatic than any other age-related physiological decline.  He defined the term sarcopenia in 1997. And the reason he did it is because the condition is  prevalent and it is important for doctors to recognize it and treat it.  So what are the factors contributing to sarcopenia? Well, first, it's important to know what  amount of muscle you start with and also at what rate the muscle mass declines. Under the microscope,  we see a few changes. Well, first of all, we see decrease in the number of muscle fibers, but even each individual muscle fiber is actually decreased in cross-sectional area.  Some of the factors that contribute to muscle loss include sex hormones, the process of apoptosis,  mitochondrial dysfunction, exogenous corticosteroids, the presence of growth hormone and insulin-like growth factor 1, thyroid dysfunction, insulin resistance, neurodegenerative  processes, suboptimal nutrition, disuse, such as an immobility and zero gravity, zero gravity, cachexia and muscle wasting, and presence of chronic diseases.  The mechanism of muscle loss is that type 1 or slow-twitch fibers are largely unaffected, but then when it comes to type 2, up to 40% of fibers are actually smaller fibers.  So sarcopenia is important to consider when evaluating our patients because it has a number of consequences. So it can lead to poor endurance, slow gait speed, decreased mobility,  decreased aerobic capacity, increased risk of falls, all-cause mortality risk, and it's  associated with higher healthcare costs. So the process or the syndrome of sarcopenia is important and it's an important contributor to cardiovascular disease risk factors as well.  So in essence, it's a vicious cycle, which starts with muscle wasting, as you can see  on this little diagram, which leads eventually to perception of increased effort, and that leads to avoidance of exercise altogether. And then of course the cycle repeats itself.  In terms of the frailty syndrome, so sarcopenia is one of the major factors contributing to frailty  syndrome, and frailty by definition is a clinical syndrome of physiological decline when a person's  not able to adapt to acute stressors such as illness or trauma. The criteria for frailty is the amount of time a person spends in the hospital, the amount of time they spend in the  hospital. The criteria for frailty are decreased grip strength, exhaustion, low activity, and slow  walking speed. Sarcopenia can be primary and related to aging alone without any other apparent  cause, and it can also be secondary where it's related to one or more causes, such as related  to activity or its absence, or for example, absence of gravity conditions. Disease-related,  such as an organ failure, inflammatory disease, malignancy, endocrine, and nutrition-related,  where there's either inadequate protein intake or some sort of malabsorption, or perhaps a GI  disorder and medication side effects. Sarcopenia can further be classified into acute, where it's  present for less than six months and usually related to acute illness or injury, and chronic  sarcopenia, which is present for six months or more. It's usually associated with chronic and  progressive conditions, and unfortunately, it increases overall mortality. One other term to  consider is called sarcopenic obesity. As the name suggests, it's a relationship or a coexistence of  sarcopenia or muscle wasting or loss and obesity, which leads to increased weight, of course.  As this diagram suggests, there are a number of factors that contribute to both, such as insulin resistance or inflammatory states or decreased physical activity, and of course,  the outcome or the resulting conditions from sarcopenic obesity could be increased or worsened  cardiovascular disease and cerebrovascular disease risk factors, such as high blood pressure,  diabetes, dyslipidemia, and so on. In sarcopenic obesity, there's reduced lean body mass,  there's excess fat tissue, and it's associated with 24% increase in the risk of all-cause mortality.  In order to diagnose sarcopenia, we have to make sure there's documentation or evidence of low muscle mass and either low muscle strength or low physical performance.  As far as stages of sarcopenia, you can have pre-sarcopenia, where there's just decrease  in the muscle mass. Then there's sarcopenia, where decrease in muscle mass is associated with  muscle strength issue or performance issue. And in severe sarcopenia, all three are present,  muscle mass decrease, muscle strength, deficit, and low performance. And this classification can  help select appropriate treatments. So what do we do with our patients when we see them? So if we  suspect a patient to have symptoms of or coexistence of symptoms of sarcopenia, maybe  wasting of muscles, atrophy, and so on, or just a little suspicion, we can go over a screening tool  just like this one. So there are several components that can be assessed, including strength,  need for assistance in walking, ability to rise from a chair, ability to climb stairs,  and history of falls. Then we score each of these factors from 0 to 2. And then a score of 4 or  above is considered positive. So as you can see, the threshold is pretty low to diagnose sarcopenia, which means we have to go straight to the next stage and implement treatment.  In terms of screening or evaluating the muscle strength, it can be pretty straightforward and simple, such as testing hand grip using one of the dynamometers, such as Jamar,  or check the ability to rise from a chair. Skeletal muscle quality and mass can be also  assessed by imaging studies, such as in DEXA scan, or using bioelectrical impedance analysis,  or checking CAT scan or MRI for cross-sectional area of the lumbar muscle. So all of these tests  are great, but they have limitations in that they're very costly usually. They're not portable.  They require trained personnel to administer and read the results. And unfortunately, there are no  well-determined cutoff points. So what do we do with the results? We really don't know.  So the use or the usability of these tests, I guess, is very limited.  All right. So in terms of checking the physical performance, we can check gait speed. We can also  check the gait as well as balance and ability to rise from a chair. Tests such as timed up and go,  can be checked as well, and just a simple walk test. So all of these can give us some degree of knowledge of the patient's functional performance. So this algorithm that's  illustrated here can be helpful. So we start with a clinical suspicion right at the top, and then if there's no clinical suspicion, obviously nothing needs to be done. But if  we suspect the person to have sarcopenia, we check their muscle strength either with grip strength testing or chair stand test. And if those turn out to be low, then we can  pretty much say that there is a sarcopenia present. And usually in clinical practice,  that's pretty much enough to start implementing treatment. But if we want to be more academic and  more thorough, and if there's availability of tests such as DEXA, CT, MRI, we can check the  muscle quality. And of course, at that point, we can confirm sarcopenia. And then we check physical  performance as well. So all of these tools that I just mentioned are listed in this algorithm, so it could be helpful. But the bottom line is that if we have clinical suspicion,  and it's backed up by some sort of evidence or objective evidence on physical exam, I think we can pretty much say start treatment and go from there.  In terms of treatment, so straightforward again, physical exercise is highly effective at counteracting the decline in muscle mass, and it helps increase muscle mass as well.  The higher the intensity, the greater the improvement. However, even with low intensity  training, it's still effective in increasing muscle mass. And anything is better than nothing.  And of course, our goal is exactly what Dr. Whiteson was describing, 300 minutes of  aerobic exercise per week, as well as resistance exercise, which we'll discuss in a little bit.  In terms of intensity, so that's really up to our clinical judgment. So of course, we have a whole range of intensity from low intensity to high. And we go by what's called  one repetition max. So essentially, it's one type of exercise, such as lifting a weight or pulling a,  let's say, exercise band, or any type of exercise that can be performed just for one repetition, that's one repetition max. And let's say less than 60% of that is low intensity, and  80% or more is high intensity, and everything else is in between. So I mean, just logically  speaking, we probably want to stay in the low moderate to moderate high area with our patients,  but also we have to use our clinical judgment and evaluate patients with their comorbidities and  risk factors and so on. But like I said, even low intensity training is still more effective  than no training at all. And it is important to use multimodal exercise training, which combines  resistance training, walking, aerobic balance, and other exercises, because it's not just that we  want to build the muscle, we also want to make sure that we reduce cardiovascular risk factors and also provide functional training to our patients. There are absolute and relative  contraindications to resistance training, just to name a few. So absolute contraindications would  be, for example, unstable angina or decompensated heart failure, uncontrolled arrhythmias, myocarditis,  uncontrolled hypertension, aortic dissection, and so on. And that said, we also have to realize  that resistance training, which is what's more effective for sarcopenia and building of muscle,  is safe, even in patients with cardiovascular disease, even in patients with multiple comorbidities.  But some of these patients require closer monitoring, they may need risk factor stratification, they may need a stress test, they may need telemetry. And we, again, have to use our  judgment as to what kind of intensity we prescribe. Again, it is safe, resistance training, that is.  It helps modify risk factors for cardiovascular disease as well as cerebrovascular disease.  So it does contribute to weight loss, hypertension control, insulin sensitivity, lipid control, and anti-inflammatory effect. It does improve quality of life and return to desired  daily activities. And as far as independent exercise, of course, aside from supervised exercise,  we also have to make sure patients are able to exercise independently. So education, education,  education. And patients need to know about their own risks, as well as precautions they need to  take. So this is just a version of the table that Dr. Whiteson presented. So I didn't highlight the  300 minute per week aerobic training, but you already know that. So minimal is 150 minutes per  week of aerobic training. But in addition to that, the last column essentially illustrates  that you need some resistance training as well. So anywhere from two to three times a week.  And strength training should include ideally exercises for all major muscle groups. So this could be done during each session, each of those two or three sessions a week,  or it could be distributed over the course of the week, whichever is better tolerated by patients.  Balance exercises, of course, will help patients with their functional abilities.  So just to differentiate between low intensity and high intensity strength training. So low intensity is less than 50% of one repetition max, but we do have to make sure there are,  there's a higher number of repetitions prescribed. And in terms of high intensity,  it's usually more than 70% of one repetition max, but low repetitions might be sufficient.  I also have to mention importance of diet and supplements, although I'm not a nutritionist, but I think we all can use common sense in order to build muscle. We need  plentiful nutrients. Protein is one of those, and it has to be supplemented sometimes. Our  absorption of proteins is not great as we age. And also the quality of proteins that we consume is  not the best either. So we have to make sure there is anywhere from one to 1.5 grams per kilogram per  day of protein consumed, if we want, per day, if we want to make sure that the muscle is built and there's enough substrate to build it. It can be through both food and supplements.  And there's some evidence that exists on benefits of vitamin D. And so I think we begin to  understand that more and more about its use and its nature. You know, some people say it's a  vitamin. Some people say it's actually a hormone and other supplementation such as testosterone and growth hormone and some other ones can be considered in order to  enhance building the muscle. And it can be based on individual cases.  In summary, sarcopenia is a syndrome of muscle loss as part of aging or underlying condition. It leads to devastating consequences, including adverse changes in body composition,  functional decline, disability, as well as worsening risk factor profile. Physicians need to be able to screen patients for sarcopenia and the treatment of sarcopenia has to  be implemented early on in order to counteract the effects of it and in order to attempt to modify  the risk factors such as insulin resistance, blood pressure, obesity, and inflammatory states.  Resistance training is safe to implement even in those with cardiovascular disease and other comorbidities. It just may require additional monitoring and supervision  or perhaps closer guidance by the physician. And it obviously can be determined on case-by-case basis. And not forgetting the nutrition aspect, addition of adequate amount of  protein is important and can help in rebuilding muscle mass. Okay, thank you.  Thank you, Dr. Prelik. That was a wonderful talk. And sarcopenia and the frailty syndrome is certainly something that we're all familiar with, whether it's primary or secondary,  inpatient or outpatient. It's certainly very prevalent and more so in an aging disabled  population as well, many patients we see with that. So it's so important that we address this.  Thank you so much. And you'll be happy to know there's lots of questions for you on the chat box  so you can spend a few moments answering those. We are catching up in time. We will have a  community discussion in a moment, but we're going to move on to the next talk. Dr. Francesca  Konig-Toro is going to present now and she'll start sharing her slides. And then after her,  I promise you, we'll get to a community discussion. And we really value your input on that.  Dr. Konig-Toro completed fellowship in cancer rehabilitation at Memorial Sloan-Kettering Cancer  Center. She's an assistant attending at Memorial Sloan-Kettering Cancer Center and works in inpatient and outpatient settings, involved in the training of the programs, fellows,  and residents. Jose, oh, you're sharing the polling question already, which is great. Thank you.  Dr. Konig-Toro will be talking about interval training in the rehabilitation environment, the experience in oncologic rehabilitation.  All right. Great. Thank you so much. Thank you so much, Dr. Whiteson, for the opportunity and the  experience here today. I'm going to really just jump into it. I know we're a little bit short on  time. So I'm going to be talking about interval training in the inpatients with cancer. And while  this talk could definitely be 60 minutes long, I've tried to condense it into 10 minutes here.  So I have, sorry, one second here. Wonderful. So I have no relevant financial disclosures.  Quickly, the objectives for today are going to be to understand the importance of exercise  in oncology and no current guidelines. I'm going to define HIT or high intensity interval training,  and then understand the benefits of HIT in oncology. So as we know, a cancer diagnosis is commonly accompanied by physiological, functional, and psychosocial deterioration  due to both disease manifestation and adverse effects of treatment. It is generally accepted  that exercise is a viable strategy of enhancing both physical and psychosocial outcomes in  individuals with cancer. And furthermore, evidence demonstrates that exercise reduces the risk of  cancer recurrence and mortality. The mechanistic properties of these relationships have been explored via in vitro models, indicating exercise-related inhibitory effects on tumor  growth and proliferation. These anti-neoplastic effects are multifactorial and include reduced bioavailability of tumor growth factors, increases in p53 tumor suppression protein,  as well as natural killer cell mobilization and infiltration induced by epinephrine.  So the current recommendations for exercise in cancer have been put forth by the American Cancer Society and the American College of Sports Medicine. The American Cancer Society,  as Dr. Whiteson mentioned already, has recognized that for most Americans who are nonsmokers,  the most important cancer risk factors that can be changed are body weight, diet, and physical  activity. Their current recommendation, like we've discussed, for adults is 150 to 300 minutes of  moderate intensity physical activity per week, or for added benefit, 75 to 150 minutes of vigorous  intensity physical activity. As for the American College of Sports Medicine, in 2019, a roundtable  of experts from 17 partner organizations reviewed the latest scientific evidence and offered  recommendations about the benefits of exercise for prevention, treatment, recovery, and improved  survival. And so now the new evidence-based guidance and recommendations include for all adults, exercise is important for cancer prevention and lowers risk of seven common  types of cancer, including colon, breast, endometrial, kidney, bladder, esophagus, and stomach.  For cancer survivors, they recommend incorporating exercise to help improve survival after a  diagnosis of breast, colon, and prostate cancer. And then exercising during and after cancer  treatment improves fatigue, anxiety, depression, physical function, quality of life, and does not  exacerbate lymphedema. So the recommendations we see here, depending on the outcome that you're  trying to achieve, is moderate to vigorous aerobic exercise, resistance exercises, or a combination of  both. So what is high intensity interval training? As you saw in the last slide, the  general recommendations are for exercise delivered via moderate intensity continuous training, a mode  of exercise that has been well established in both its safety and effectiveness. However, a growing  amount of research suggests that exercise at higher intensities may offer different and additional  benefits for people with chronic disease, including cancer. So HIT dates back to the 1930s, but it  really became popular for training athletes during the 1950s, when Emil Satopek, a Czech long  distance runner, won three gold medals at the 1952 Helsinki Olympics for the 5k, 10k, and then wait  for it, a last minute decision to compete in his first marathon of his life, all after having trained  using the HIT method. So HIT is defined as a series of repeated bursts of exercise, of high intensity  exercise, defined as 85 to 95 percent of peak heart rate, interspersed by periods of rest or active  recovery, meaning exercise at a lower intensity. Exercise duration ranges anywhere from 30 seconds  to several minutes. And the overall general premise underlying HIT is that a greater volume of higher intensity exercise is accumulated during a single exercise session compared to  energy expenditure matched steady state moderate intensity continuous exercise. And why does this  even matter? Evidence suggests that aerobic capacity, or your VO2 peak, is the strongest  predictor of future health, all cause mortality, and cardiovascular risk. And HIT has been shown  to increase VO2 peak more than, or at least comparable to, moderate intensity continuous exercise. The graph that you guys see here shows results of a randomized control trial  in which Rogmo et al. placed heart disease patients either into HIT or MCT groups for 10  weeks to evaluate VO2 peak. And so compared to baseline, within-group analyses showed that the  VO2 peak significantly increased in both groups, as expected, and furthermore, between-group  analyses indicated that the HIT group's 17.9 percent VO2 peak improvement was significantly  greater than the 7.9 improvement found for the MCT group. And moreover, none of these patients,  either in the HIT or the MCT groups, suffered cardiac events during the training program.  And so what about HIT in patients with cancer? The benefits of HIT are quite significant, and while no studies have directly compared the anti-inflammatory effects of HIT  versus MCT in cancer, such comparisons in other populations with chronic disease indicate that  HIT may be more effective. And so they've seen that interleukin-6, a pleiotropic cytokine with  growth properties promoting tumor progression, has been shown to be significantly suppressed  after 12 weeks of HIT compared to MCT in heart failure patients. HIT also appears to moderate  the overexpression of reactive oxygen species known to potentiate tumor growth and upregulation  of inflammation via increasing glutathione peroxidase, an enzyme with protective effects  against reactive oxygen species. And evidence also supports that insulin resistance is better regulated via HIT compared to MCT. This is important as chronic hyperinsulinemia is  associated with various types of cancer, including colorectal, pancreatic, endometrial, and breast.  And so apart from all of that, all these anti-inflammatory effects of HIT are also important for cardioprotection in patients at high risk of treatment-related cardiotoxicity.  And very importantly, HIT may also prove to be easier to adhere to. I saw a lot in the comment  box, how are we going to get, you know, our patients to do 150 minutes of exercise, 300  minutes of exercise? Imagine a patient with cancer. For individuals with cancer, the brevity of HIT  may be a preferred strategy for routine exercise to avoid some of these common time-related barriers,  including the numerous medical and treatment appointments, returning to work, and just daily  windows of adequate energy to expend. And is HIT safe in patients? And so evidence indicates that  it definitely is. In the eight studies on this slide, HIT was studied in patients with cancer,  and only one serious adverse event was reported. And Adamson and colleagues reported a grade three  seizure following a HIT session in a participant with brain cancer, and that participant was  discharged on the same day. And then the author suggested that in patients with brain tumors or  brain metastases, one should avoid high-intensity training. In the Devin et al. study, two non-severe  adverse events following HIT were reported in colorectal survivors in which they experienced  symptomatic hypotension. And despite these episodes, both participants completed the study.  Finally, the Midgard et al. found that six participants in a study with mixed malignancies  developed lymphedema over 12 months of HIT and resistance training versus no adverse events in  the control group. And so it's unclear if these symptoms were attributable to HIT or resistance  training. However, all six participants completed the intervention without additional symptoms.  It is important to note that as with any patient with cancer who's participating in any type of  exercise regimen, individualized precautions and safety measures must be taken into account.  And so we've seen so far that HIT may be beneficial in potential antineoplastic properties  and physiologically an aerobic capacity, again, the strongest predictor of future health and  all-cause mortality. It's also been shown to be a safe intervention for people with cancer.  But functionally, what does this look like? Oh, sorry. And so in this study out of Australia,  sedentary survivors of cancer within 12 months of their diagnosis were randomized into three groups  for 12 weeks of low-volume HIT, continuous low-to-moderate intensity exercise training,  or a control group. And the exercise intervention involved three sessions per week for a total of  36 sessions. The low-volume HIT group performed seven sets of 30 seconds on 60 seconds rest  intervals versus the continuous low-to-moderate intensity exercise group performed continuous  aerobic training for 20 minutes on a stationary bike. And significant improvements in cardiorespiratory  fitness levels were identified through the increased distance covered in the six-minute walking test with a larger effect observed in the low-volume HIT group, suggesting that more  comprehensive cardiovascular adaptations may occur with HIT. This study also demonstrated  that participants in the low-volume HIT group gained a larger effect in the sit-to-stand test  compared with the other groups, indicating improvements in lower limb strength. And as we  know, maintaining or improving lower limb strength in cancer survivors is essential as it enhances  the patient's ability to move around and carry out physical activities during and after treatment.  And so this takes me into, you know, what we do here at Sloan and the inpatient experience here.  We've implemented sit-to-stand interval training specifically for our patients with prolonged and  complicated hospitalizations who have had difficulty with functional progression and therapy.  And we've seen this oftentimes in patients admitted for bone marrow transplants who, again, due to the nature of the transplant, tend to have a prolonged hospitalization increasing  their risk for physical deconditioning. And the training is pretty basic, as the name implies. We start off with a brief warm-up, getting the patient to the edge of the bed,  performing some ankle pumps, some seated marches, and then followed this with sit-to-stand sets.  The goal, again, is not to use upper extremities. It should just be a lower extremity  exercise. And the most important factor here is modifying the work-to-rest ratio to make this exercise more feasible for these patients. Depending on the functional level of the  patient, we may start with a 10-50 set, meaning work for 10 seconds and rest for 50 seconds,  repeating this five times for a five-minute total workout time. And then we decrease that  rest time by five to 10 seconds intervals until a 30-30 set is achieved. And so I have to thank  my inpatient colleague, Dr. Grisha Serking, for sharing these data points. But this patient is  actually one of our great success stories. She's a 64-year-old female with history of myelofibrosis,  which is a rare type of bone marrow cancer, status post-stem cell transplant in December of 2018,  complicated by press, multiple UTIs, graft failure, GI, GVHD, with significant diarrhea, anorexia, ultimately requiring TPN via Dobhoff, ascites, peripheral neuropathy,  limedema, you name it. She was admitted in November of 2018, and during this time became quite deconditioned, as you can imagine, functionally only progressing to a two-person  modesis for sit-to-stands, at which time we were consulted for lack of progression in therapies.  We evaluated the patient, discussed with treating therapists, and ultimately instituted a modified  sit-to-stand interval training program, including sets from an elevated edge of bed. And we did start with that 10-50 model, progressing as tolerated. During this whole time,  we monitored heart rate via pulse-ox and telemetry, and ultimately...  Sorry, can everyone hear me? I thought I was unmuted there for a second.  But ultimately, what we found was that over a span of about six weeks of interval training,  there was overall improved endurance and physical fitness, as evidenced by a favorable trend in  sit-to-stand tolerance in the setting of a general downtrend in heart rate, and overall stability of  hemoglobin. There was no adverse offense related to therapy sessions. And you see here, again, we started with the 10-50, progressed to 15-45, 20-40, 25-35. And at the end here,  she was able to do 30 seconds on, 30 seconds off, and multiple sets of those.  So overall, take-home points, exercise reduces the risk of cancer recurrence and mortality,  HIT has antineoplastic effects, and it mitigates inflammation directly via these effects on  oxidative stress and insulin resistance. HIT may be an appropriate alternative to usual recommendation  of moderate continuous training. Again, it increases that VO2 peak, at least comparable to or even better than modified continuous training. And in these patients, again,  and in all of our patients, just improved adherence to an exercise plan. And ultimately,  HIT is safe in patients with cancer, although of course, usual precautions must be implemented.  So these are my references, and that's it for me.  Jonathan, you're muted.  Sorry, can you hear me now? I was speaking, I guess I was muted. Forgive me, can you hear me?  I hope so. That was wonderful, Francesca. Thank you so much. Very, very informative.  Actually, David, how come, I don't know why, oh, there's another slide that we just have a  photograph of David up on the screen right now. So at this point, we're going to have a community  discussion because we have just about caught up. We have a few moments.  Wow, COVID is, let's see if  I can get my screen up again.  Hopefully, you can all see my screen, and we're going to have a little discussion now. I think, Jose, that we can unmute the participants, but there's close to 300  participants, so what we can't do is have everyone speaking or talking at the same time.  But what I'd like to do is review, perhaps modify and approve the goals of this exercise of medicine community. But most importantly, establish what your goals are. You're the  participants. This is for you. What do you want from this community? So again, these were the  goals which I showed a little while before. We break them down into education, research, clinical  and admission goals. So we want to educate ourselves and each other. We want to share the information. We want to do perhaps collaborative research. We want to implement  what we learn and what we discover into our clinical practice. And then how do we want to grow? I have an idea of how I'd like to see exercise as a tool in PM&R grow, but  really it's what you're looking for. So I don't know if we're able to unmute everybody. If there's a way to get people to discuss  or give their thoughts or opinions on this community and what can it do for you? What do you wanna see from this?  Jonathan, just one comment. I think if you go maybe back a slide, I think you just have, it's limited to aerobic exercise. And I think you can expand beyond that.  Sorry, what was that?  So yeah, so again, I wrote these goals  and if I heard you correctly, yeah, it's been a bit of an aerobic exercise. So yeah, that maybe shows my bias,  but absolutely we should modify that, perhaps leave out the word aerobic and just leave in exercise. And for all that that means, aerobic resistance,  flexibility, balance, et cetera, because there's so many different, as I said in my talk, there's so many different modes of exercise. So certainly that's in terms of modifying  the education goal, leave out aerobic.  Thank you.  Hello, I have a question for Dr. Rosenberg regarding the wound care. I work in nursing homes and that is the first, her talk, the first time I'm hearing of exercise  related to wound care. Normally when there's a wound, they tell our therapist, the wound care doctor or nurses, they can't do therapy.  So I'm just wondering how I portray that change.  It really isn't a change. That has been, it depends on where the wound is. That's a common misconception that they can't keep moving and doing things.  Now, if the wound is a diabetic foot wound in the bottom of the foot, yes, we do want to keep all weight bearing up, but using a contact cast, et cetera, allows them to do that.  But they can do basic transfers, but often we don't want weight bearing.  We want that to heal up. If somebody has significant arterial disease, there is a problem because of the increased metabolic uptake required with exercise  and the arteries just can't supply that. So unless you get good revascularization or optimize your oxygen flow, you're gonna have trouble.  But in other wounds, no, exercise is extremely beneficial and it is helpful. That is a common misconception. I see that coming from so-called wound clinics or from doctors.  I've seen it from podiatrists. I've seen it from other doctors. Oh, just keep it elevated and don't move and then it'll heal better.  That actually is a myth that has not been shown up to be supported by the literature. Okay, thank you.  So thank you for that question. And again, I think the attendees, your mics are open. You're not muted anymore. And again, just thinking about this community,  a couple of things here. Your goals for the community, this is a didactic session. It happens once a year. We lecture, we talk. Is that what you're looking for?  Are you looking for further collaboration in terms of research? Are you research oriented?  Do you wanna know and wanna discuss, not just at this time, but maybe throughout the year, how do you implement exercise in your practice,  whether it's inpatient, outpatient, pediatric, geriatric,  or perhaps, and this is my perspective, I'd like access to the board. I'm not quite sure why I didn't learn more about exercise during my residency training.  Why wasn't I examined on it?  When I needed to pass my board exams, why have we not focused on exercise as medicine,  as sort of a mission of AAPMNR? My thoughts, hopefully maybe stimulating someone else's thoughts as well. Agree, disagree.  So I have some input. Hello, everybody. My name is Victor. I am not an attending, unfortunately, but I do have some requests. I'm a third year medical student,  and I definitely would like to hear some more about nutrition from PMNR. I find that in my experience at gyms and CrossFit,  although many people are super excited about exercise, nutrition is a hindrance to progression to goals.  Excuse me. I definitely think that proper nutrition goes hand in hand with progression of goals in any sort of situation,  especially these situations where we've talked about. So my question to you all is, how can we integrate nutrition more into the curriculum?  I will tell you, one of the things we're doing here is looking at the development. I'm at the University of Minnesota piece, and we are looking at the development  of a wound care fellowship, which nutrition actually is an integral part of that, because you're absolutely right. You cannot heal wounds without adequate nutrition.  It does not work. And again, the time in this lecture did not allow us to do that, and this is concentrated on the exercise piece. But if people aren't eating properly,  and their protein stores are low, and their caloric needs are low, and their numerous vitamins, for instance, I see in wound care are not adequate, we can't get a meal.  I'll share with you a little story briefly from when I was a resident in PM&R here at Rusk Rehabilitation 24, 25 years ago.  I did a study looking at prealbumin and length of stay and disposition from our inpatient rehab, and those people that had the higher prealbumin  had the shorter length of stay and the greater disposition to home. So there's no doubt across the board, inpatient, outpatient, that nutrition plays a huge role.  I tend to agree with you, there are gaps in our education curriculum,  and it's up to us if we feel it's a value to try to influence our residency training and our faculty training.  And I'll take your point, and I will happily go to the powers that be and say, why isn't there more emphasis on exercise? Why isn't there more emphasis on nutrition?  And then there was some conversation in the chat box about motivation as well.  So I think there's many areas, and it all does, I think, from my perspective, feed into exercise and medicine. And we can look at it from primary prevention,  secondary prevention, individuals with disability, individuals without disability.  There's a lot of power there. And of course, Dr. Rosenberg, Francesca, Sophia,  everyone's talking, they cannot get their patients to exercise and recover without good nutrition.  So it is vital. Thank you for bringing that up.  Just to- Yes, anyone? Sorry, go ahead. Yeah, I'm on the board of the academy, and since you brought up the slide with the question about emphasis of exercise on the board,  I can tell you that as a part of the mission and vision  of the BOLD initiative,  anything like exercise and nutrition that emphasizes the value that PM&R brings to the field and its patients is something that the board is focused on as well.  So in that general sense, absolutely.  We are, as a part of the board,  emphasizing elements of exercise as a essential, indispensable, vital element of what PM&R does.  I would point out, if I might, that the AAPM&R, of course, does not set requirements for residency training.  And that's done through different organizations. And the board of PM&R is a different organization as well. Sometimes that gets confusing to people.  But I do wanna say that in terms of nutrition, we're seeing a lot more interest in things like culinary medicine. So I think that we're probably going to see  some natural evolution of interest in nutrition in our residents over the coming years, and a demand for more information. But I do have to say that I have found that,  really, that the emphasis on exercise and understanding exercise and understanding how to prescribe exercise is really lacking in our residency training.  So I absolutely agree with you, Jonathan, that this is something that we really need to get back to. I think I kind of got educated back in sort of the old days  when exercise was really something that we studied.  But I'm not sure that we have that emphasis on it now. And I agree that this is so crucial to not just musculoskeletal or sports medicine, but also to cancer.  To my field of traumatic brain injury and stroke, very important. Looking at cognition, looking at motor neuro-recovery, extraordinarily important.  So I really applaud you for pushing ahead on this.  Yeah, Dr. Bell, I so agree with you. Actually, at last year's community meeting, we did talk about fatigue. We talked about exercise in neurologic injury,  brain injury, stroke, dementia, et cetera. And the value is tremendous. And I'm a cardiac and pulmonary rehabilitation guy. But when I think about exercise  and I start to look at all these other fields, that really excites me. And so as a physician, as a physiatrist, if I was going to do brain injury rehab,  but I use exercise as a modality, I would love that. And I think that's the way that we appeal to junior doctors and appeal to residents and et cetera,  by telling them that focus on exercise and it will lead you to a career in anywhere in rehabilitation medicine. Every element of rehabilitation medicine needs exercise.  So forgive me, but we're going to move on. We're going to have more community discussions. This is very stimulating and I hope lots of you are thinking about this.  And anyone can email me with thoughts and ideas, et cetera. I really would appreciate that.  Jonathan.Whiteson at nyulangone.org.  And I'll put that up again at the end. But we're going to move on right now. I am going to stop sharing my screen  and I'm going to ask Patrick. Patrick Corderbine is going to start sharing and Jose, you can put up Patrick's polling question. Dr. Corderbine is a clinical professor  of physical medicine rehabilitation at the University of California, Davis and acting chief of the PMR service at the VA in Sacramento.  And he's going to be talking to us about exercise during inpatient rehabilitation challenges and opportunities. Patrick, it's all yours. Great. Thank you.  So I'm seeing people responding. I was hoping for a hundred percent since Dr. Whiteson's already giving you the answer to this one, but we'll give you a few more seconds here.  We're going furiously.  Okay. Why don't we go ahead and stop? That's very good. I think most everybody got that right. Well, I'll hit the answer a little bit later on, but as Dr. Whiteson mentioned,  I'm going to be talking about exercise during inpatient rehab and the challenges and opportunities. So no financial disclosures, nothing I present is a view of the VA  or the United States government. So briefly, given the time constraints, I'm going to talk about the current state of exercise during inpatient rehab,  talk about the challenges associated with implementing exercise training during inpatient rehab and then discuss opportunities for exercise training during and after inpatient rehab  because I think that's a definite goal as well. So hopefully everyone agrees this is kind of maybe a typical paradigm of a patient coming from an acute hospital admission,  had a function decline, goes to rehab, and I hope we would all agree that rehab is better than no rehab as far as inpatient for sure.  And that rehabilitation, when you break it down, does include some element of therapeutic exercise. Of course, there's many other components, but I think virtually every patient,  there's some component of therapeutic exercise. And the therapeutic exercise, when you break it down, is aerobic and resistance exercise. There's some elements of that  for patients receiving therapeutic exercise during inpatient rehab. And Dr. Watson already went over this, but just a reminder. So exercise is a subtype of physical activity  in that it's planned, structured, repetitive with the goal to maintain or improve physical fitness in contrast to just movement, which is physical activity basically.  So therapeutic exercise during inpatient rehab should be functionally specific, right? We're trying to, according to the specificity of exercise, we want to work on those activities  we want to get better at. And it needs to be of minimum intensity. So regardless of whether it's aerobic or resistance exercise, the lower limit of about 40% max  is what's needed to derive some benefit. And as you heard, as was your polling question, everybody should have gotten this. So the exercise prescription or the dose of exercise,  whether it's the formal exercise training out in the community or in the inpatient setting and with a guy's sort of a therapeutic exercise, the same prescription would apply.  So frequency and density, time or duration and the type, and then as progressive. So what about exercise during inpatient rehab? What do we know about it?  Unfortunately, very little. I mean, in the field of PM&R, this is something that's an all too common statement that, quote unquote, more research is needed, definitely in this case.  So this is the only study, frankly, I've found looking at sort of exercise and objectively measuring really its intensity here using heart rate. It's been done in the United States.  There's some other studies. I'm going to talk about one other. In Canada, there's actually been a fair bit in Canada and some in Europe,  but really limited to none in the United States. So this was a group out of Spokane, Washington, inpatient subjects. Typical, I put their inpatient numbers. They had 15.  I didn't include all of them, but in the box there that I've highlighted in red or encircled in red, you can see the mean age was 61. You see stroke, medically complex,  stability, cardiac, pulmonary, ortho. And what they did was they gave, put a wrist accelerometer with a heart rate monitor, so basically a Fitbit on all these patients,  and they monitored them 24-7 during their stay. And then they looked at, okay, what was the time period that they were in the target heart rate range of 50 to 80%  of their predictive heart rate max, which is about appropriate for an aerobic benefit. And it had to be a minimum of 20 minutes per day during their stay.  And so in the green box there, you got the percent of days meeting that recommended minimum amount in the target heart rate, with the goal being 42% of hospital days,  which would be three of seven days a week. And you see the mean was 61, but you've got a couple of people at 100, a couple of people at zero, some at 30,  and one at 67, so a pretty significant range. So an interesting study, but again, this is the only one I found looking at really exercised  formally in the U.S. inpatient rehab setting.  So this next study was a randomized trial. The spinal cord injury patients, as I mentioned, in Canada, and these were, if you look at, sorry, it's a little bit blurry there,  but they were mean age of 45, rather. Time since injury was about two months and 20 patients. So we're going to split into two groups here. Majority of them were aged C or D,  and they had standard of care rehab plus upper extremity ergometry training. So a specific formal exercise intervention. And they did an interval training.  So sprint interval training is the SIT, and that was a total of 10 minutes. So they did three intervals, 20 seconds at an RP greater than 16, so high intensity,  the rating of perceived exertion, followed by two minutes of low intensity. So that was about 10%. They did three of those, and there was a little brief warm up  and cool down to get to the 10 minutes. And then the other group did continuous  moderate intensity exercise. So 20 minutes at an RP of 12 and a total of 25 minutes, including again, a brief warm up and cool down.  And they did this three times a week for five weeks. So again, length of stay, inpatient rehab, but longer in Canada.  So what did they find here? So the training heart rate, the interval training group, the training heart rate, the mean heart rate was 135. And then the continuous intensity,  moderate intensity group was 119. So kind of about what you would anticipate. So it looks like they were accomplishing what was intended as far as intensity.  And surprisingly, or maybe not, what they found was that the peak power change was very comparable. In fact, it was a little bit higher in the sprint interval group.  And you see that they did one minute, so 20 seconds times three, one minute of total high intensity exercise, three times for a week for five weeks,  and got very comparable improvements to doing, in fact, even a little bit better than doing 20 minutes three times a week.  So very interesting study. So moving on, so who are the patients in the US and who are the ones that might benefit from an exercise intervention?  I think for sure the debility group, spinal cord injury, pretty for sure. Stroke, you could question, but I think they probably can as well. And then there's some others there.  But there's different groups might benefit to different degrees of a formal exercise intervention.  What is the optimal exercise prescription for these patients to reach any one of those individual groups? And I think, unfortunately,  we don't have any data to say what it should be. I think we have some thoughts on what it could be, but not specifically what it should be because we don't have the data  to make that recommendation. So what are the challenges? So of course, the purpose of inpatient rehab is functional recovery, get patients home.  And that's largely therapy, but then again, exercise. How much, what component of what the rehab program that someone's doing in an inpatient setting,  how much of it should be somewhat or more formally considered exercise? The other thing that has to be considered is the therapist. They're the ones who are doing the therapy.  What's their training and philosophy regarding exercise?  Another item, medical management. I don't have to tell anybody who's working in an inpatient setting. Oftentimes, you're doing all you can  just to get the patient well enough or safe enough, medically stable enough to go to therapy, much less think about, well, what are we going to do as far as exercise?  And then safety. And I'm going to hit on a couple of these things that others have touched on as well, but the patient's past history, their co-morbid medical conditions,  and unfortunately right now, have to deal with the COVID-19 situation.  The other issue is, or one of the others is length of stay. So the average length of stay has been about two weeks, and it's been that way since around 2010.  Of course, there's a large standard deviation depending upon certain outlying patients, but by and large, it's about two weeks. So question then becomes,  well, what are you going to accomplish in two weeks with an exercise program? If you can argue you can make improvements, you can accomplish things,  but two weeks is not a long time.  Now, lastly, continuity of exercise training after discharge. So patients leave very frequently. Patients don't follow up with their PM&R doctor when they leave.  So who is taking this over if a patient is encouraged to continue and being engaged in an exercise or physical activity program? Who's going to sort of help them along that path?  And you saw this before, so I don't think anybody here is going to be surprised if we don't have the data again, but inpatient rehab patients are probably not much different  than those out in the community, and you saw this before. So men, women, somewhere in the 20% are actually doing the minimum amounts of physical activity that I recommended.  And then as far as the safety of exercise, so one of the key questions and one of the key risks, and this is based on the, this is the American College of Sports Medicine  pre-participation screening that came out in 2016, and this is for community dwellers, so it's not really applicable to our population, but if we were to use this,  so the first question is, is someone participating in regular exercise? Probably, unfortunately, a majority of them, just according to the last slide, probably the answer is no.  And then what I've highlighted there, or in case there is that they probably have some known cardiovascular, metabolic, or renal disease, hopefully they're asymptomatic,  but if they're symptomatic, you know, they really shouldn't be coming to rehab. But then for all these people, if somebody says no, I don't participate in regular exercise  for all these populations, recommendation is to start with light to moderate intensity exercise. Then the question becomes, okay, is inpatient rehab,  is that light to moderate intensity exercise? Maybe it is, maybe it's not, maybe it varies from place to place, but I think that's certainly something to be considered.  And then as far as COVID, I think this was published recently about, well-known that the COVID infection has an impact on myocardium. And for all of these,  whether you're asymptomatic, mild symptoms, significant symptoms, the box here, all of them say rest, no exercise for two weeks, status post, a positive test.  So question, should these people be coming to inpatient rehab if they've had a positive test? And this again was, I'm adapting it from an article  that was on athletes and highly active people and whether you lump inpatient rehab patients into that grouping is debatable.  Something to consider though.  So as far as opportunities, what can we do? I think so functional recovery and exercise. I think unfortunately the question is more research is needed. What is the most appropriate  therapeutic exercise regimen, either as a primary or adjunctive component of rehab for a particular patient or a group of patients?  We really should be doing this. This is really is, inpatient rehab is really our area of expertise and we should be focused on exercise and what component of exercise  is relevant and important for functional recovery.  Next would be secondary prevention. And I was hoping Dr. Roth would cover this, but maybe Dr. Gator's gonna cover it for his spinal cord injury. And then lifelong physical activity.  I'm gonna reiterate some of what others have said, but we certainly know that physical activity has positive impact on mortality and lots of other, basically every organ system.  So if you have stroke patients in the inpatient setting, this is a checklist from the Stroke Association and you'll see highlighted there that question,  is the patient physically inactive? The answer is yes, then they should be encouraged to initiate an exercise program along with doing all these other things,  controlling their blood pressure, controlling their diabetes, et cetera.  And then again, just to finish up here, again, positive aspects of physical activity and basically every organ system. We've all highlighted this, but a big one there,  all cause mortality decreased by 20 to 30%. So unfortunately we don't have a big portion of our population doing it and that should certainly be one of our goals.  And I'm gonna leave you there. So thank you for your attention. Thanks to all the other presenters.  Patrick, that was great. Hopefully my unmute button worked. Hopefully you guys can hear me, but that was wonderful.  And certainly the inpatient setting is a great place to start considering exercise or to reinforce exercise, you know, it's a captive audience.  And so, and the outcomes as you indicated of implementing exercise are there for all to see.  So unfortunately, as I mentioned, and some of you may have joined since I mentioned it, unfortunately, Dr. Roth is not able to join us today. I don't know, perhaps afterwards,  we'll see if we can get a recording of his talk and add it in and to the recording of this. I don't know if that's going to be possible. He was going to be talking on high intensity  gait training in stroke rehabilitation in the inpatient setting.  And if any of you have had the opportunity to visit the Shirley Ryan Ability Lab, formerly known as RIC, where Dr. Roth works, and it's a pleasure to see what he's doing  with his patients. And as far as I understand, the preliminary or the outcomes of his work in terms of doing high intensity gait training  in his patients who've had stroke in the acute setting is very, very encouraging. So not to steal his thunder or speak for him or misquote him, we will try and get his presentation  recorded and added to this. But it is just further evidence of the value of exercise in the inpatient setting and in acute stroke  and how it might positively influence the outcomes.  Let me see what I can do to share my screen again, because we do have, with Dr. Roth's absence, a few more minutes to continue our community discussion.  And again, this is really a question to all of you. And again, we'll unmute your mic so you can speak up.  But what is your commitment to support the exercises medicine community?  You want updates? You want information, but that's it? That's okay. Let us know.  You want to collaborate with people who have similar thoughts in terms of how to use and learn about exercises medicine throughout the year?  How do we set up chat groups or shared drives  or whatever it might be to share information, to collaborate, et cetera, throughout the year? Perhaps you want to participate in this community  in terms of helping it grow and take it to the next level.  That would be great. Perhaps you want to be involved in the leadership  of this exercise as medicine community. So, I'm the chair of the exercises medicine community  because I ran unopposed, because nobody else stood up to do it.  But that's not the best way to run a democracy. And it would be great if, and it's a two-year commitment, which I think ends next fall,  but it would be great to perhaps have two co-chairs. And I believe it's a two-year commitment. That's what it was. And maybe that will change, I don't know,  but it'd be great to have two co-chairs. It'd be great to have someone representing research, someone representing education, someone representing the clinical implementation.  So, three champions along those lines. It'd be wonderful to have an AAB PM&R board representative. We don't have to have them at each meeting if we have regular meetings,  but it'd be just wonderful to have a champion on the board  and some support staff in terms of someone to help us schedule meetings and take minutes and follow up and keep us on track. So, what are your thoughts?  I'm not expecting anyone to commit at this minute. Again, you can always email me, but does anyone have any other thoughts or comments  or questions about the structure of this community, how it might function?  I'll put it open to you.  Dr. Whiteson, Bruce Becker. I am really enjoying this session and I appreciate the emphasis on exercise. As I had spoken in my Zatter lecture of a couple of years ago,  exercise was really one of the most important elements in the development of our field as a whole. It sort of went into a dark period of time,  probably beginning in the late fifties after polio went away and after there were powerful medications to manage arthritis and things like that.  It's so exciting to see it coming back and I think it's really critical to move it forward. The development of a community committee,  I think is a really important thing to help move forward  the recognition of the importance to the field. And as has been discussed by virtually every lecture to this point, its value is ubiquitous  in the populations that we treat and certainly in the populations that we don't ever get to treat.  But I think that it is really important and I just applaud the efforts in moving this forward. Thank you.  You're welcome, Dr. Becker. Thank you so much for your comments. And I'm one of, I think, close to a thousand people  in this community. So I know there's lots of people who have an interest and I know also that other communities, we branch, I mean, we fit the exercise medicine branches  out into other communities. We touch this concept of exercise as medicine and exercise as a PM&R modality, I think touches all areas.  You know, in the eight speakers today or seven today, it should have been eight, can't encompass everything. There's so much more to talk about.  But yes, I think exercise is free, isn't it?  You can't patent it, you can't put it in a bottle and inject it, you can't charge a lot of money for it. So in terms of a lifestyle, in terms of a remedy,  it gets overlooked from all the other sexy things that cost a lot of money that people can make money from.  Vendors, I mean, no insult by that, but it's something that,  because you can't sell it so much, it doesn't seem to get a lot of airtime, but the value of it, it's important.  In rehabilitation, I think cannot be understated. And of course, all the literature that's coming out that's supporting it. And the literature is so exciting in the neurology world  and the cancer world,  down to biomarkers and inflammatory markers and neuronal pathways, and the work I know Dr. Bell is familiar with it, the work that started on animal models.  I mean, it's just incredible. Very, very stimulating. So yes, we need this community to live. We need it to thrive. We need people to be involved. And again, I'm not asking people  to jump on the bandwagon at this minute, but certainly do message me, be in touch with me. I'd love your commitment because I'm not gonna,  I can't do this on my own and I'm not gonna be doing it forever. And then we need to pass the baton on and we need fresh thoughts. So thank you, Dr. Becker.  Anyone else, any comments or questions before we move on with our discussions? I have a comment, if it's okay.  I think we're a specialty of the team approach and I think we should start with ourselves as well as our staff, in addition to educating our patients,  just because I think we need to set by example,  but also we need to have the help. Like you said, we can't be the one person that needs to change.  We don't have that team approach and we learn here and we try to implement it.  It may not go well if not everybody is also educated and on board. So that goes with the wellness as well, that we're also starting to realize  that it is important to be well as clinicians  and as healthcare workers in order for us to take care of our patients. So I think when we make a plan or implement something to kind of put forth later on,  it should incorporate everybody on the team.  I completely agree with you. I don't think there would be anyone on this call that would not agree with you, but we can't forget it and it should be emphasized.  And we know that the more that the team's on board, the more repetition there is to the patient and the family members. I know in the chats,  we've been talking about engaging families as well, the better it is. And then somebody also mentioned about,  we can lead by example. And again, absolutely right.  I'm not going to the gym right now because I'm concerned about the gyms in the time of COVID, but I was getting up at a quarter to five  every single morning to go to the gym for an hour and a half. I would exercise from five till 6.30, an hour of aerobic, 20 minutes of resistance, four days a week.  I took Monday off, Saturday off and played an hour and a half of soccer at the weekend. And it's true, you've got to live by example and then you can really relate to your patients.  And we've got to get the team involved as well. So I know we all have our own stories about what we're doing. We've got to live it. We've got to breathe it. We've got to discuss it.  We've got to engage. I agree completely. For those of you who may want my email, I'll show it up again later, but it's jonathan.whiteson.nyulangone.org.  jonathan.whiteson.nyulangone.org. Please, if you're interested, please reach out to me. I'd be so happy to discuss with you. Any other questions?  We do have a few minutes if there's other comments or questions. Comments about the community, questions about the lectures so far. I have one quick question, Dr. Whiteson.  If there's any opportunity for medical student involvement in your structure, that could be an additional way to garner more members.  I do see that you have two co-chairs, but I'm not sure that a medical student would have enough experience to be a co-chair.  If there's any other opportunity for involvement, such as a med student representative, that could be nice. So please do email me.  The downside of having someone who's so pinpoint focused is they can't see outside of their own world. They become myopic.  The value of a medical student is they have plural potential. Pluripotential? They see everything, and they have no qualms about offering comments and fair enough criticism.  So, yes, if you want to be involved, then PM&R is your field, even if it's not your field. We'd still love to have you involved. Absolutely. Why not? So, yes, be in touch with me.  Same for anyone else who wants to be involved. Those are great thoughts. I'm going to stop sharing. I'm going to ask Dr. O'Park to share her slides. We're going to move on.  Dr. O'Park is going to give our next lecture. She is board certified in physical medicine and rehabilitation, electrodiagnostic neuromuscular medicine, and sports medicine.  She's a professor in the Department of Rehabilitation Medicine at Albert Einstein College of Medicine  and Senior Vice President and Chief Medical Officer for Burke Rehabilitation Hospital, overseeing the clinical graduate medical education and research operation.  Dr. O'Park is also engaged in strategic planning and expansion of Burke's rehabilitation services within the Montefiore Health System.  And as an educator, Dr. O'Park has received 16 teaching awards, and as an academic, has 50 peer-reviewed publications.  Dr. O'Park is going to be talking on prescribing aerobic exercise for individuals with disabilities focusing on lower limb loss.  And I see that the polling question is up, and please do answer. And Dr. O'Park, I'm going to leave it with you. Thank you, Dr. Weiss. Can you hear me?  Dr. O'Park, can you swap your displays, please? Okay. Thank you. So thank you for inviting me to this prestigious panel.  And today I'm going to talk about exercise for 10 minutes with individuals with a PAD or lower limb loss. I have nothing to disclose in terms of this topic.  So this is a brief outline of what I'm going to go over.  So the first thing is when we are talking about especially aerobic exercises, we need to define the etiology of the lower limb loss, and also brief epidemiology of a peripheral arterial disease, and how exercise breaking the cycle of the disability and general considerations in exercise prescription in this population.  And lastly, the same topic for the people with lower limb loss. So the first thing when we see patients who have lower limb loss, think about the etiology is very important.  So many people lose the limb because of poor circulation.  And also large proportion of the people, they lose the limb, although they have a good circulation, they have diabetic neuropathy, and then that limb is infected.  And in this latter cases, the patient may not actually have a coronary artery disease. Instead, they may have arrhythmia because of the severe neuropathy, autonomic neuropathy.  So those are the things we have to think about. PAD is underdiagnosed and undertreated. So almost 10% of the population over age 50 have some degree of PAD.  And also this is a global marker for general cardiovascular health. This is more prevalent in men. However, as we age, prevalence among female also increases.  And these are well-known risk factors for peripheral arterial disease.  And as I said before, the PAD is a global marker for cardiovascular health, and then that includes ischemic stroke and myocardial infarction risk.  So this is a slide showing in men and women who has PAD versus who does not. And then compare the percentage of the people who has concurrent cardiovascular disease.  And you can see that the people with PAD has more than 2.5 times more concurrent cardiovascular disease in this population. And this is five-year natural history of the PAD.  So when you are following up 100 patients, actually 30 of them will unfortunately pass away from the cardiovascular event or other diseases.  And then 10 to 20 of them will have nonfatal MI or stroke. There are 25 people will have worsening claudication. And among 100 people, two patients will end up with amputation.  This is the questionnaire we are using to screen our patients.  And for example, if you ask the question, do you develop discomfort in the leg when you're walking? Then the answer is yes.  Then we think about the claudication or pseudoclaudication, spinal stenosis or any other conditions.  And then going to the next question, the same pain occurs when you're not moving. Then if this answer is yes, that could be something else. So it has to be no.  And we are going through the rest of the questions. And this is a pretty good screening questions. It has been serving a purpose.  So the major goals of the exercise or any intervention for the patient with the PAD will be looking at the limb outcome that will be improving the ability to walk and also prevent the progression to the critical illness ischemia or amputation.  And the cardiovascular mortality and morbidity outcomes, you want to decrease the morbidity from a non-fatal MI and stroke and of course the fatality.  So there are two different approaches for the PAD patient. One is lifestyle modification, which is the topic today.  And then the regular exercise in addition to smoking cessation and diet change. So let's talk about the exercise part.  So this is a slide showing that Medicare finer coverage policy published 2017.  So basically this is going to be for the supervised exercise therapy for the patient who is symptomatic and up to 36 sessions over 12 weeks.  And one session will be 30 to 60 minutes.  And it has to be hospital outpatient setting and by qualified auxiliary person who are trained in exercise therapy for the PAD, and it doesn't have to be a physician.  So this program can be under the direct supervision of a physician or PA or a nurse practitioner or a clinical nurse specialist who is trained in this area.  So to start this program beneficiaries must have a face to face visit with a physician responsible for the PAD treatment and obtain the referral.  So when you look at the response to the exercises, the outcomes generally we measure is the change in pain-free walking distance and also the change in peak walking distance.  As you can see that this is a study with a very small sample, but generally the response rate is very similar.  So the people who are exercising 12 weeks and there was great improvement of 100%, and then if you are exercising longer, you can accomplish even higher percentage of increase in pain-free walking distance.  And this similar pattern was shown also in the peak walking distance.  What about the type of exercises?  Instead of a treadmill exercise, what about using the arm ergometer?  So this is somewhat in contra, it's not very intuitive, but when you think about you have a problem in your leg circulation, maybe treadmill exercise is better.  But actually in this study, which was quite a long time ago, but still holds the truth, comparing the treadmill exercise and then arm ergometry and the combination, and actually the one showed the highest efficacy, effectiveness, I should say, was actually arm ergometry treatment.  So the conclusion of the study was dynamic arm exercise training can improve walking capability in people with PAD-induced claudication compared to the participant who had the usual care.  And this improvement was not different from the treadmill walking exercise.  So the hypothesis of how this arm ergometry exercise could help the claudication is that this arm ergometry exercise is helping the general cardiovascular health, the vascular bed health, that was the author's hypothesis.  What about comparing this strengthening exercise versus aerobic exercises?  So this study actually compared the treadmill exercise to the strengthening exercise of the body, whole body.  And when you look at the pre and post training effect, the distance they walk, and it was actually very comparable, slightly better when you were doing the strengthening exercise versus walking training.  When you compare the body, the pain they experienced, actually the pain level was much lower in strengthening exercises compared to the walking exercises.  So this suggested that if patient has more difficulty due to pain, maybe these are the very nice alternative we can introduce to improve their ability to walk.  So the exercise principle for the individuals with the PAD is basically progressive overload principle.  So gradually you increase the person can do the exercise, not only the amount of the exercise, but you can also increase the frequency of the exercises.  So this is an example of exercise prescription and protocol using claudication pain scale.  So one is no pain, and then level two is onset of the pain, level three is mild pain, and four is moderate, and five is severe.  So when the person can walk about eight minutes, and then to the point of onset of the pain, then you can rest, and you restart the whole cycle again, and continue this algorithm is the most frequently used exercise protocol.  So again, the progressive overload is the principle.  This is a table showing the exercise recommendation from the American Heart Association and American College of Cardiology.  The supervised setting exercise is the only one actually have a level one A evidence. And if you're doing it in a community level, this is not level one yet.  It holds the evidence to level two A level.  So talking about the patients who already lost their lower limb, and the benefit of aerobic exercise in this population was already published more than 20 years ago by Dr. Elliot Roth, who is one of the, you know, speaker, who couldn't come actually, but he already published this paper.  So it's very well known.  And the relationship between the aerobic capacity and walking ability in patients with limb loss, it's not just about the cardiovascular fitness, but also it increased the economy of walking.  So this graph is showing that the improvement in walking speed, cost of walking, or relative aerobic oxygen consumption also is improving.  So it's not just about the cardiovascular, but also the way they can walk is improving by aerobic exercises.  The challenges in aerobic exercise in any population, including these individuals with a PAD or limb loss is really compliance.  And there are many tools which can help to modify their behavior and how to engage to improve the exercise compliance.  So this is one of the example actually used in the UK, and we often refer to this method of doing it.  And also there is a supervised versus unsupervised setting differences.  And although there is the level of evidence for the unsupervised, as of now is level two, it still does benefit many, many patients, at least in our institutional setting.  And establishing a program from hospital, clinic, and also to the community, led by the physician, is the key to the success of increasing the compliance of the exercise program and dissemination of this program, or the individuals with a PAD and other patients who lost their limb.  Thank you so much, and I would like to thank Dr. Loh, the Director of Cardiovascular Rehabilitation at Berk Rehabilitation Hospital, and thank you very much for listening.  Dr. Whiting, I don't think we're able to hear you.  Now you can hear me. I have a double mute. Sorry.  I was saying that Dr. Loh is a hero to many people and has certainly influenced my career in cardiac and pulmonary rehabilitation.  We actually have spent some time down in Washington together in terms of lobbying for coverage for cardiac and pulmonary rehab.  And what Dr. O'Park was talking about in terms of supervised exercise therapy for peripheral arterial disease, you know, it is an approved program by Medicare.  It covers 36 sessions, just like cardiac rehabilitation. 36 sessions of rehabilitation.  You wonder why more rehabilitation centers are not doing it, because it's a great business venture from the financial perspective.  That's a little cynical, but it's great for the patients, as Dr. O'Park was saying.  So it's such a wonderful opportunity to treat people with peripheral arterial disease and claudication with supervised exercise therapy.  Again, it's evidence-based, and it's covered by insurance. So a wonderful presentation. Thank you so much.  We're going to move on now to Dr. David Gaider, who is already sharing his slides.  Dr. Gaider is a professor and chair of physical medicine rehabilitation at the University of Miami Miller School of Medicine.  He is the Spinal Cord Injury Fellowship Program Director and the Medical Director of Rehabilitation at Christine E. Lynn Rehabilitation Center for Miami Project to Cure Paralysis.  He's president of the American Paraplegia Society, president-elect of the Academy of Spinal Cord Injury Professionals,  both certified in physical medicine rehabilitation, electrodiagnostic medicine, spinal cord injury medicine.  Again, widely published, research emphasizing the effects of diet and exercise training on energy metabolism, glucose, lipid metabolism, obesity, and body composition, cardiovascular fitness, et cetera, and functional outcomes in spinal cord injury.  Dr. Gaider has been funded by the NIH, NIDRR, American Heart Association, et cetera, and the foundation, excuse me, the C.H. Nielsen Foundation and the VHA.  Dr. Gaider is going to talk on spinal cord injury rehabilitation, the essential impact of aerobic exercise. Thank you so much, Dr. Gaider.  Thank you for allowing me to speak, and all of the previous speakers, thank you for setting me up so well. I am actually not going to talk about aerobic exercise. What?  I'm going to talk about sci-fi, spinal cord injury fat intervention.  Hopefully, as I go through my talk, that will become a little bit more clear why I'm focusing on this. Now I'm stuck. Let's see if I can go forward. I have no financial conflicts.  I have several grants that are allowing us to move forward with this type of research.  What I'd like you to understand through my talk is the neurogenic consequences of spinal cord injury on metabolism and body composition.  I'd like to talk a little bit about energy balance and exercise components required to promote fat loss, and then talk about an exercise prescription specific to spinal cord injury for the intervention of neurogenic obesity.  I'm trying to admit folks as they're coming on board.  You all know spinal cord injury influences the somatic nervous system at a particular level of injury, and therefore disrupts a person's ability to voluntarily control certain muscle groups.  You should also know that the autonomic nervous system is disrupted significantly following a spinal cord injury, and particularly the sympathetic nervous system that arises from the thoracolumbar regions of the cord.  We, all of us, are in a constant tug-of-war between our sympathetic nervous system and parasympathetic nervous system.  For all of us, neither one of those systems turn off completely, but following a spinal cord injury, when you have disruption of the sympathetic nervous system and significant blunting associated with it,  you're going to have a number of comorbidities that are not associated just with the somatic nervous system disruption.  All of these are comorbidities that I would be listing on an exercise prescription for somebody with spinal cord injury.  Significant cardiopulmonary dysfunction, significant sarcopenia, significant upper extremity overuse issues, and significant obesity and metabolic syndrome.  I'm going to jump ahead a little bit on this, and just to talk about a new definition, neurogenic obesity after spinal cord injury.  This reflects excess body fat that is more than 22% body fat for men or 35% body fat for women due to the resulting components of spinal cord injury.  Motor paralysis and obligatory sarcopenia, sympathetic blunting, anabolic sufficiency, and blunted satiety, the ability to understand when you're full, when you're eating.  Energy intake significantly exceeds energy expenditure.  I was asked to speak on the good, the bad, and the ugly of listing weight after spinal cord injury, and it's important because it was only in 2006 that the model systems programs began to include body weight as part of their data set.  Subsequently, we were able to report at least body mass index, which is not a great indicator for percent body fat in persons with spinal cord injury.  The other thing that I'd want you to know about neurogenic obesity is that it mediates the metabolic syndrome.  It actually contributes to insulin resistance, hypertension, dyslipidemia, thromboembolism, and coronary artery disease in our folks with spinal cord injury.  Is it present in persons with spinal cord injury? We reported last year on 473 veterans with spinal cord injury.  About half of them had tetraplegia, and three-quarters of them actually were considered obese by the spinal cord injury definition of 22 kilograms per meter squared as a BMI.  And I know you all are putting your hands up in the air and saying, what? 22 kilograms per meter squared? That's pretty lean, but it's not.  It's actually obese in persons with spinal cord injury. Anyway, more than two-thirds of these individuals had dyslipidemia with HDL cholesterol less than 70%.  50% had fasting blood sugars greater than 100 milligrams per cent, and 57.5% had metabolic syndrome by the International Diabetes Federation definitions.  So we recently completed the cardiometabolic risk guidelines for persons with spinal cord injury, noting that there is significant cardiometabolic risk due to neurogenic obesity, prediabetes, and diabetes, hypertension, and dyslipidemia.  And our recommendations are those hated nutritional and physical activity interventions, as well as some degree of pharmacotherapy.  Essential clinical measurements for obesity intervention include actual assessment of body composition.  A person's total daily energy expenditure needs to be known, and their total energy intake needs to be known as well. So all of us are burning calories, even now.  Our liver burns about 30%, heart 10%, kidney 7% of our total daily energy expenditure. The brain, for most individuals, somewhere around 19%, 20%.  For the individuals in this room, obviously 25%, 30%. And then skeletal muscle is the most variable of all of the utilizers of energy.  Resting metabolic rate for all of us represents somewhere between 60% and 75% of our total daily energy expenditure.  Thermic effective activity, 15% to 30%, depending upon how much activity and the degree of muscle mass that we're using.  Even the thermic effective food, yes, digesting food burns calories, but only on the order of about 7% to 10%.  I bring this up because I want you to recognize that a person like me, my age, my size, typically, you know, my total daily energy expenditure is about 2,800 kilocalories per day.  If I was to sustain a spinal cord injury, and let's be generous and say paraplegia, my total daily energy expenditure would drop by about 25%.  But if we weren't being nice, and I developed tetraplegia instead, my total daily energy expenditure would drop by more than 50% of what it is prior to a spinal cord injury.  Now direct calorimetry is the best way to be able to determine total daily energy expenditure.  It's measurement within a contained structure, but there's only a few of these metabolic chambers in the United States. And so instead, we should turn to indirect calorimetry.  That is estimating energy expenditure through oxygen consumption. And we can do this using the type of system that we have shown on the lower part of that slide.  We did a systematic review recently reported out last year.  And the bottom line is we need to use indirect calorimetry to determine resting metabolic rate or basal metabolic rate for persons with spinal cord injury.  The equations simply are not adequate. So how do we predict energy expenditure in spinal cord injury now that I said that equations aren't adequate?  If we know basal metabolic rate, we can actually determine the approximate total daily energy expenditure by taking a ratio of what we know is one met for persons with spinal cord injury.  That is 2.7 milliliters of oxygen per kg per minute, as opposed to the one met for an able bodied individual, three and a half milliliters of oxygen per kg per minute.  We also reported out recently with regard to nutritional status in persons with spinal cord injury.  And what we found that is in what was reported, individuals had a significant mismatch of 160 calories per day.  That would lead to approximately 16 and a half pounds of adipose tissue gained per year.  Now, I want to jump back to what we started off with exercise prescription.  And I think that it's really important that those of us in physical medicine and rehabilitation really stick to our guidelines for exercise prescriptions.  That is, including the diagnosis and all of those comorbidities that I had listed on a previous slide.  And most importantly, the goals and the goals are going to require specificity of testing and training, recognizing the limitations, the environment that you have available to you.  And then, as has been discussed, the mode, frequency, intensity, duration and progression of an exercise prescription.  So I've put together exercise prescriptions in a couple of different formats over the years. We can look at aerobic or cardiovascular exercise. We can look at resistance training.  We can look at flexibility exercise.  One thing that I would note that maybe hasn't been brought up yet is all of these are good ways to prescribe exercise intensity, but may not be valid for persons with spinal cord injury because of the blunted sympathetic nervous system, circulatory hypokinesis that goes along with this.  And in fact, three to five word sentences.  If a person can speak in three to five word sentences while exercising, it's been demonstrated that their rate of perceived exertion on the board scale is approximately eight to 13, as had been discussed by Dr. Whiteson earlier.  We had put together a physical activity compendium for persons with spinal cord injury. Barb Ainsworth put this together for able-bodied individuals back in the 70s and 80s.  Hadn't been done for persons with spinal cord injury until we reported out in 2010.  And again, what I'm showing here is that one metabolic equivalent for a person with spinal cord injury isn't three and a half milliliters of oxygen per kg per minute.  But for persons with spinal cord injury is 2.7 milliliters of oxygen per kg per minute.  Now, cardiovascular health and exercise has been reported, recently updated, a wonderful review by Warburton in the spinal cord injury rehabilitation evidence that's available online.  This is a group out of Canada, 68 pages, basically saying that aerobic exercise and functional electrical stimulation exercise can lead to significant improvements in glucose homeostasis and lipid lipoproteins.  It's not to say that you can't improve these components, muscular endurance, oxidative metabolism, exercise tolerance, and cardiovascular fitness in persons with spinal cord injury.  But recognize that these folks are at the lowest end of the fitness continuum or the fitness spectrum.  And while there may be statistical differences, these are probably not clinically significant differences.  And then they have also reported out on body weight supported treadmill training. Again, this is for persons with incomplete spinal cord injury.  And we could take a look, recognize that this is peak, VO2 peak. This is maximal. No, this is beyond. This is peak exercise capacity for persons with spinal cord injury.  And you'll see that at levels of tetraplegia, we wouldn't even be able to exercise them at what we call moderate intensity.  Moderate intensity is three to five METs in an able-bodied population.  And so that translates out to very, very low levels. So, again, to be able to change this capacity may not be our best way to prescribe exercise for people with spinal cord injury.  And so maybe over the first 15, 20 years of my career, I was asking the wrong questions.  Maybe the questions I should have been asking, is it possible to achieve negative energy balance after spinal cord injury?  And so when I look at it from that direction, then I wanted to see, could we actually use exercise to reduce obesity and paraplegia?  And so we compared arm crank ergometry with functional electrical stimulation leg cycle ergometry in individuals over a four-month period.  And we looked at folks with paraplegia, T4 to L2, motor complete, looking at outcome metrics, including percent body fat, insulin sensitivity, and glucose effectiveness by intravenous glucose tolerance testing, and then several secondary variables.  And the bottom line was exercise 60 minutes a day in this group, five days a week, resulted in a reduction in percent body fat, improved in systolic and diastolic blood pressure, increased fat-free mass and improved HDL cholesterol, increased energy expenditure per session, but body weight increased.  And so their overall mobility wasn't necessarily enhanced because they were wheeling more weight around with them. And this is one thing that I took away from this study of note.  As we started out, the ability to perform functional electrical stimulation leg cycle ergometry was limited. And we ended up doing multiple bouts.  It's kind of like the high intensity interval training that had been discussed earlier in order to get them through that first hour.  And so the first four weeks, it was really, really difficult to see an improvement there. We did reassess energy expenditure halfway through the study.  So at eight weeks, what we saw was that those folks using functional electrical stimulation leg cycle ergometry finally exceeded the energy expenditure per session compared to arm crank ergometry.  And then that continued as we went through the study. And at 16 weeks, they actually expended significantly more so.  But recognize this is still under 250 calories per exercise session.  And so our newest endeavor is to look at folks with high paraplegia and tetraplegia in NIH R01 study called Spinal Cord Injury Exercise and Nutrition Conceptual Engagement or Science.  Yes, this is my science project.  And we are looking at folks with higher levels of spinal cord injury using home-based functional electrical stimulation leg cycle ergometry and diet with diet alone.  Again, over 16 weeks looking at percent body fat changes in fat mass, fat free mass, and glucose effectiveness and insulin sensitivity.  So I think that I've just about run out of time. And I certainly haven't answered your questions with regard to exercise.  However, I would say that over my 25 plus years doing exercise physiology, I am now convinced that we really need to focus on the exercise to reduce obesity.  And so I'll leave you with these references. And certainly am open to answering any questions if I have any time left. We certainly have time left, Dr. Gator.  And that was a really fascinating talk.  And again, just helps us all see not just the value of exercise, but the value of nutrition, the value of understanding exercise physiology and exercise science.  And where exercise plays a role throughout our specialty, inpatient, outpatient, spinal cord injury, wound, peripheral vascular disease, I mean, stroke.  We're talking about everything, cancer, heart and lung disease. So again, that was great. Thank you so much.  Maybe to the chat. Isn't this called adiposity? Yes, it is.  And again, some folks would characterize this as sarcopenic obesity, but because of the sympathetic nervous system blunting, because of the anabolic blunting, because of the blunted satiety, this is a different beast and it doesn't occur just in the elderly.  This occurs in an 18 year old young man, and you wouldn't necessarily call that sarcopenic obesity.  So, thank you, David. I'm going to share my screen again, but of course, all the panelists are still here if there are specific questions for the panelists.  And we will unmute people's microphones or speakers and invite anyone to ask questions. So, we have a few more community discussions or just thoughts.  Some of this we've discussed already. How should we structure our perspective on exercise as medicine? By age, by diagnosis or organ system,  by exercise type, by setting, primary, secondary prevention, on its own or in combination with other lifestyle practices like nutrition, like psychology and motivation.  We're just looking at individuals with disabilities because we're physiatrists, so we're looking at healthy individuals and the able-bodied.  So, again, I mean, I think this is up to you guys where this community goes, but I think hopefully this throws a very wide net.  Any thoughts, any questions, any comments or statements? So, there was one question about testosterone replacement. I just wanted to address that.  Yes, our folks with spinal cord injury, the men, definitely have reduced testosterone levels. Testosterone replacement can be helpful, especially with resistance training.  We haven't actually looked at it with regards to aerobic types of exercise, but we did report out it was called Terex testosterone replacement with exercise.  My colleague, Dr. Gorgi, who's at the Richmond VA, put this out, I think, one or two years ago. But I think in order to get optimal responses, to be able to increase muscle mass  and thereby increase resting energy expenditure throughout the 23 hours a day a person isn't exercising, that this is probably going to be necessary as we move forward.  The question about estrogen levels in females. Surprising or not, women generally resume menses within three to six months after a spinal cord injury,  and they will continue, they remain fertile. They typically will continue with normal estrogen levels until that point where they have a pause. What is that? Menopause.  And that said, they are still at significantly increased risk for osteoporosis in the lower extremities. Most people with at least motor-complete  spinal cord injury will develop osteoporosis, men or women, in the lower extremities, where they will typically, bone mineral density plateaus  at about two thirds normal in the lower extremities after spinal cord injury, somewhere one and a half to two years after the injury. And that's because of multiple factors.  Certainly we are no longer mechanically loading, but there's also a reduction in anabolic hormones. There's a reduction in the neural influences  and increased obesity, which I didn't really mention, but I will say this. In general, most of our folks will develop obesity to the tune of about 45 to 50% body fat.  But what? 50% body fat. And they are throwing out all these pro-inflammatory cytokines, which are also activating osteoplasts in the bones. So I never really appreciated it.  I mean, way back in the day, in the eighties, when I took my first obesity class, we knew there were associations, but I had no idea that adipose tissue  could mediate such responses. And until I really started working with spinal cord injury, I didn't recognize, I mean, this is a pop, there is no other population that I'm aware of  that has developed obesity levels to this extent.  The able-bodied individuals who are obese generally can stand. And so they still have large muscle mass and bone mass, which is metabolically active tissue.  So cardiovascular conditioning can be helpful. Again, there are statistical differences when you look at studies, however, because of several different aspects.  So recognize typically after spinal cord injury, you have a reduced afterload and a preload, you have circulatory hypokinesis, particularly if you're doing upper extremity work  where you don't have much blood flow, it's essentially been a stasis during the exercise itself.  And so while there are statistical differences between aerobic exercise intervention, I don't know that it's actually translated to clinical effectiveness.  And so I hate to be the bearer of bad news. And again, I mean, I've reviewed over 400 studies looking at exercise and spinal cord injury, and most of them show some improvement,  but it's just not clinically significant would be my perspective. I think that the obesity is overwhelming in our folks with spinal cord injury.  Even those folks, again, with a BMI of 23 are obese.  That is they have a high percentage of body fat. And so that's why it's so important. They are about to put out one of the consortium clinical practice guidelines  looking at osteoporosis and spinal cord injury.  Isn't there anything to do? Well, I think that doing things separately, using bisphosphonates, doing mechanical loading vibration therapy,  looking at other hormonal milieu and changing body comps,  in and of themselves, none of those have been demonstrated to be effective. However, some combination of those things probably would be helpful to reduce osteoporosis.  Another question about obesity due to the development of diabetes, not just diabetes. Actually, the obesity mediates hypertension through four different mechanisms.  I didn't have time to go into. It does mediate insulin resistance through nine different mechanisms. I didn't have time to go into. It changes the lipid profiles significantly,  increasing LDL cholesterol and decreasing HDL cholesterol as you expose the liver to more and more non-esterified fatty acids. So all of those results of this excess adiposity.  Use of blood flow restriction, resistance training and spinal cord injury. To the limbs where there were restrictions, yes, there is some improvement in terms of strength,  but is there overall improvement in muscle mass?  Not probably significant enough to change energy expenditure. And now I'll be quiet and let some of my colleagues jump in.  David, it's great to hear you talk. So you don't have to be quiet, but any other comments or questions? Again, this is the fourth sort of community discussion and question.  Are there communities or organizations we can collaborate with? As I said, I reached out to the spinal cord injury community, the wound community, the cancer community,  the inpatient community. Again, I think this spans the gamut of other organizations.  Again, I know them in my area, in my field in heart and lung rehabilitation, and they're very interested in collaborating on exercise discussions and research  and implementation.  I imagine also in other national organizations as well, but that's another way that we can take this community, not just to spread the word, but to learn and to collaborate.  And that's good for AAPMNR as well.  And does anyone want to share their own success stories in implementing exercise medicine in your area of practice? Anyone want to share their own stories?  So, there's still some chats coming through, some chat questions. I certainly understand, and many of you have been on, and we've certainly been on for coming up to three hours.  And I want to thank all the presenters, and our hearts go out to Dr. Roth. And I want to thank, behind the scenes, Jose and Elisa,  who have worked with all of us as presenters and myself to get this community session up and in front of you, our attendees today. I want to thank you all for coming.  And I do see there's still some questions coming through on the chat. I don't know if anyone else is reading them or wants to give some comments.  Do you suggest PM&R direct management of metabolic syndrome versus education of primary care providers? So, it's interesting, just a quick word  from my perspective, is the podiatrist the specialist or the primary care provider, and can we play both roles? Or do we collaborate with the primary care provider  as a co-primary care provider of individuals with disability and recommendations in terms of exercise and lifestyle with regards to secondary prevention,  but more than that, health promotion, quality of life, et cetera. I think we play a great role. I'm often on the phone with primary care physicians  working with them or them in touch with me and them asking me and me answering their questions with regards to lifestyle management.  So, I do think we as podiatrists can take that role. And certainly, I don't think there's anyone better for the care of individuals with disabilities than a podiatrist,  both from the specific pediatric management, but also primary care.  I welcome the other panelists to comment on that or anyone else to add.  Jonathan, Bruce Becker again.  One of the issues that has been consistently dealt with on here is the concept of exercise, but adherence becomes the really critical issue. In my clinical practice,  in all of the places that I've practiced, I have used regularly an exercise diary in the clinical practice that I've started with. We actually produced it for our practice  with some marketing literature included in it, but also basic principles of exercise, some biologic interests or points to make.  And I expected my patients to complete that exercise diary when each visit, when I saw them, and I would reinforce to them that if they don't show up with the diary,  I won't see them.  Sometimes that was effective, and other times they just weren't that motivated, but it is really critical. And it included all of the basic principles  of dose, intensity, regularity, duration,  all of those kinds of things. And I expected them to complete it essentially on a diary-based issue by the day.  And I think it really helped. And the patients that did it really liked it. And it became really quite an effective marketing strategy for our practice.  Primary care physicians in the community liked to see it. They talked with the patients about it. And I think it was a useful way of motivational strategy.  Does anybody else have experience with that?  So I think many must have experience with patients lacking motivation and lacking follow-through, and it's all well and good sticking with  any kind of lifestyle change for days, weeks, months, but how do you turn that into a lifelong perspective?  And it is challenging. I mean, I do, I commit to my patients and I follow them four times a year on an ongoing basis. And those who are doing well,  then it becomes twice and maybe once a year, but I don't drop anyone.  And that continued follow-up. And patients say when they come to see me, the value of knowing that they've got an appointment with me is that they think of me on their shoulder  talking to them about keeping up with their lifestyle. So it is a challenge.  You know, obviously engaging the family as well. I think there's lots of different approaches to maintaining motivation or helping people stay motivated, but it is a challenge.  It's a great point, Dr. Becker. Anyone else have any thoughts in terms of the issue of motivation, compliance, not just over the short term, but the long term?  I would just like to ditto. I think the idea of the diary is actually can be helpful depending on the patient. That's very specific to the patient.  I've had some fascinating diaries come back to me.  The other thing is, yes, engaging the family. And I think the regular follow-up, I do have the advantage that I'm actually seeing my patients fairly frequently  because a lot of them have significant chronic wounds that have to be seen and cleaned up, and we have to do, they get infected, we get issues. So I'm seeing them,  but that is always a part of our discussion is what are you doing? I also work very closely with our bariatric medicine doctors and working with that and outlining good programs  because a lot of my patients have significantly, we're talking supermorbid obesity. So to get these people going at all is very, very difficult, but we do.  And again, it's such a multidisciplinary challenge  to be able to get them going. It might be incorporating therapy. It might be incorporating counseling, psychology, psychiatry. It might be incorporating the bariatric medicine,  the primary care, et cetera, but it does become an important piece. And I do agree, Dr. Becker, when you talked about the multidisciplination of rehab,  that is absolutely the core of rehab. I trained under Ernie Johnson. I was one of his last, last kids and felt very strongly about, and then actually my mother was the one  who started all of group rehab for Rosenbrook. She started all group psychotherapy, group therapy, and it was all actually started with Abrams out at Albert Einstein.  Way back in the 1950s.  So, but that group team is something that we do far better than anybody else and how to incorporate that. And exercise has always movement.  Mobility is the core of rehabilitation and PM&R. And I think we've unfortunately moved away from that,  which is definitely not healthy. I very much appreciate that. There are gender biased differences in motivational behaviors. And for females, a social construct to exercise  is significantly more important, apparently, than it is to males.  And so I would approach them somewhat differently. And particularly for my female patients, try and find an exercise partner.  And talk with them together. Yeah.  So I have to be very sensitive of the time. And we are one minute from the end of our three hours. Again, I wanna thank our panelists and all our attendees.  I will say one last thing. I'm gonna give a little plug. If you listen between six and 8 a.m. Eastern Standard Time, Monday, this coming Monday,  to Sirius XM channel 110, it's called Dr. Radio. I will be interviewing Dr. Rosenberg,  Dr. Michelle Gitler, Dr. Sophia Prillick, and Dr. Jonas Sokoloff on the value of exercise in wound, in sarcopenia, and cardiac and pulmonary rehab in cancer.  And Dr. Gitler, our outgoing president, will also be talking about the value of rehabilitation medicine, PM&R, and the role of rehabilitation during the COVID pandemic.  And with that, I'm gonna call a close to this community session. Please be in touch with me. Thank you for participating. Look forward to communicating through the air  and seeing you again, hopefully in person, at next year's Academy. And with that, we'll say goodnight.  Thank you. Thank you, too.

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