Hello, and welcome to the Exercises Medicine Community Session. This is part of the 2021 AAPMNR Annual Assembly. This is, as I said, the Exercises Medicine Community Session, from lab to practice, translating science into programmatic enhancements. And we're really pleased to welcome you and glad you've joined us, and hopefully will stay with us for the three hours of this community session. We have a very busy program and a very interesting program, and we're going to start off in a few moments. I'm going to be giving a talk on activity and exercise for post-COVID-19 fatigue. And then we'll go on through our series of talks, as you see here. We'll be taking a brief break in an hour or so for a glass of water, a bathroom break, and coming back and having three more talks before we go into a general question and answer session. And then of significant importance for us and for the future of this community, we're going to go into a business meeting slash networking session where we have some questions for you. And we really welcome your participation and engagement with that as to how we define the future of this Exercises Medicine Community. I want to start by thanking the AAPMNR. I want to thank you for attending. I want to thank our speakers. I will go through more formal thanks later on. Jose Lopez and Emma and Sean, who are behind the scenes, who've helped us get to this point. So I'm going to be talking now about activity and exercise for post-COVID-19 fatigue. I'm Jonathan Whiteson. I'm an Associate Professor of Rehabilitation Medicine and Medicine. I'm the Vice Chair for Clinical Operations, and I'm the Medical Director of Cardiac and Pulmonary Rehabilitation at Rusk Rehabilitation here in New York City at NYU Langone Health. I'm also the Chair of the Exercises Medicine Community. I served two years. I managed to find myself elected for another two years. That's what happens when you stand unopposed. But hopefully the future is bright with getting other people more engaged. For each of the speakers today, we're going to give you just a little fun fact, a personal fun fact. I'm an avid soccer player. Despite my nearly 57 years, I have played since I was just about able to walk. I've had multiple injuries. And my wife introduced me to Miranda Resmond White. I don't know if any of you have heard of her. She's Canadian. She must be in her 70s herself. And she talks about classical stretch, or this is her program. It's a form of dynamic stretching. And since I've been doing classical stretching or eccentric stretching, I've not had injuries. So if you're interested in protecting yourself as you grow a little older, check out Miranda Resmond White. Her program's called Classical Stretch. You can find it on YouTube, and you can also find it on PBS. It's fun. I have nothing to disclose. And we're going to put up a polling question now. Which of the following is correct in relation to fatigue in PASC, or post-acute sequelae of COVID? Is it reported in up to 35% of individuals? It rarely persists past three months. It responds well to pharmacologic therapy. It should be differentiated from ME-CFS. If you could place your answers by clicking on the circle or the box that you think is correct. And I appreciate the responses, and as we go through the body of the talk, we'll see who was right and who was not right. Okay, so this is what I'm going to be doing today. I'm going to talk about what is fatigue. I'll briefly talk about fatigue and other disease states, and then I'm going to review with you the AAPMNR Multidisciplinary Collaborative Consensus Guidance Statement on the Management of Fatigue in PASC, and we'll see where exercise fits into that. And we'll talk more about that in a few moments. So I guess the first place to start is what is fatigue? It's a symptom. It's a feeling of weariness, of tiredness, of lack of energy. It's been described as physical, cognitive, even emotional. And in terms of nature, it can be mild all the way to severe. It can be intermittent, completely remitting and then relapsing again, or it can be persistent in a very variable pattern over days or even weeks. And certainly it affects a person's energy, motivation, and concentration, and can negatively impact the sense of well-being and quality of life. Fatigue lacks objective markers, and that's a challenge for all of us as we're trying to quantify fatigue and really understand it. And when we think about PASC, post-acute sequelae of COVID, we recognize that fatigue is part of acute viral illnesses, but it's not that common that it persists months after a viral illness has settled and is now past history. That's certainly what we're seeing in those people with PASC. So if we want to know what is fatigue, we also have to understand what is not fatigue, and it's important in this field, and certainly in terms of fatigue and PASC, to distinguish fatigue from other conditions, one of which is diminished activity tolerance. And that's defined as the inability or the reduced ability to perform physical activity, as what is expected of us in terms of frequency and intensity and duration for our age, our gender, our size, our muscle mass. And if you've ever experienced diminished activity tolerance yourself, if you've gone out and tried to do too much compared to your fitness level, then you may have experienced some of these symptoms of pain and fatigue, even nausea and vomiting. Diminished activity tolerance can be improved through activity training. We also have to understand the difference between fatigue and post-exertional malaise, and this is very important in the post-COVID long-hauler syndrome or PASC. And the post-exertional malaise is defined as a significant worsening of symptoms following and out of proportion to even minor physical or mental exertion, with symptoms typically worsening over days after any activity, both physical or mental, and can last. This malaise can last for days or even weeks. And we can minimize post-exertional malaise by activity management or pacing, and we'll talk more about that. So there are ways of looking at fatigue. There's a pathophysiologic classification. Physical fatigue is a sort of physiologic deconditioning. It's associated with muscular effort, and we call that peripheral fatigue. Traumatic fatigue is associated with disease states and is part of the hypothesis or theory of central or primary fatigue. And mental fatigue is something that we notice when we are doing continuous or repetitive cognitive tasks. And then there's the psychological fatigue, where there's perhaps a lack of interest or motivation, which leads to tiredness. This peripheral fatigue or physiologic deconditioning, this fatigue from exertion, is related to, as I said, deconditioning physiologically related to impaired either cardiac output or reduced muscle perfusion or oxidative capacity. We also see physiologic fatigue in those with reduced muscle mass or impaired muscle function, as in the syndrome of sarcopenia. We also see it in anemia, where there's poor oxygen carrying capacity despite a good cardiac output. If there's not enough red blood cells to transport blood around the body or oxygen around the body, then you get poor peripheral perfusion. And obviously poor nutrition and malnutrition, and we'll come back to that again in a few moments. So physiologic fatigue is something that we need to understand and actually something that can be measured, and we measure it physiologically speaking by doing a cardiopulmonary exercise test. And we can understand physiologic fatigue or conditioning or perhaps fitness level by thinking of oxygen carrying capacity or oxygen utilization, the VO2 max. And the Fick equation, if you're familiar with exercise physiology, really helps us understand that our oxygen utilization or fitness level is related to the cardiac output and the extraction of oxygen in the periphery, the arteriovenous oxygen difference. So the central factors are key, as in lung function and cardiac function, and the peripheral factors are also important in terms of the activity of the skeletal muscle and its ability to not only extract oxygen, but make ATP, which is our energy molecule. We also recognize fatigue in depletion states, and certainly if people haven't eaten or they're depleted of glycogen, we see fatigue and high-carbohydrate diets has been associated with the reversal of that fatigue. Mechanism is not 100% clear, but probably related to enhanced sarcoplasmic reticulum reuptake of calcium. Fatigue is also seen in dehydration. We see people who are lacking in body fluid have impaired endurance. And we also see it, as I mentioned, in decreased food and calorie intake, certainly in people who have had weight loss. That's the syndrome of sarcopenia and frailty. And also vitamin D probably plays a role as well, vitamin D deficiency. And conversely, vitamin D supplementation has been associated with reversal of fatigue. On a central level as well, dopamine also plays a role. And in those people, individuals with cancer-related fatigue, methylphenylate and pemylene have been associated with increased dopamine concentrations and improvement of fatigue. And we also know that dopamine metabolism is enhanced centrally following either acute or even chronic aerobic exercise. Fatigue is associated with many different clinical conditions. We're going to talk about some of these now just briefly. Fatigue we've seen, or we do see, in stroke and traumatic brain injury. And it's quite common. From a third to close to three-quarters of patients who have had stroke and traumatic brain injury can experience fatigue. Multiple different risk factors. Interestingly, sleep and sleep disorder, probably underappreciated, but significantly associated with fatigue in stroke and brain injury. This is sort of a theoretic model of fatigue in traumatic brain injury. And you can see this interplay between neuropsychological issues, inflammation and oxidative issues, neuroendocrine issues, leading to central and peripheral fatigue through mitochondrial dysfunction and cardiorespiratory dysfunction. Sort of gives you a window or a picture on how you might manage fatigue. We also see fatigue in cancer. A significant number of patients, up to three-quarters of patients, will experience fatigue during a cancer and cancer treatment. And a third of them will have fatigue on a daily basis. And close to a third will also have fatigue that persists for many years post-treatment. So, again, very significant. And what are the causes or the proposed causes of fatigue in cancer? Well, it could be a relation of the direct toxicity of chemotherapeutic agents or radiation therapy, anemia, loss of muscle mass and impaired muscle function, persistent systemic inflammatory response and immune activation, disordered sleep and hormonal issues. So, probably multifactorial etiology of fatigue in cancer. What about fatigue in cardiac disease? Well, we see patients with heart disease, nearly all of them have fatigue. Heart failure is probably the most common. But up to 80 percent of patients with heart disease will complain of fatigue. This kind of fatigue is what we consider to be that sort of peripheral or physiologic fatigue. It gets worse with rest, and that's very important to stress to our patients that despite fatigue, and they think they should rest, we need to get them more active. And physical fatigue is associated, as I've talked about before, with low cardiac output, et cetera. What about fatigue in PASC? So, I do want to point out that what I'm going to talk about now is the result of a multidisciplinary collaborative. This is a consensus guidance statement on the assessment and treatment of fatigue in PASC. And as well as these authors here, there was a large group of people and many clinics that were involved in these consensus statements. And as well and very, very important was the input of patient representatives and patient groups who really helped educate us and guide us with regards to the guidance of the management of fatigue in PASC. It's very common fatigue in PASC, we're seeing it up to two-thirds of individuals. Paradoxically and quite interestingly, we're seeing it more in those who were not hospitalized versus those who were hospitalized. Maybe that's because those who were hospitalized are really focusing on other issues or have not pushed themselves during their recovery to the point where they're experiencing fatigue. It also depends on the time that you're seeing the patient since they were infected. More commonly, if we're seeing patients sooner, they're more likely to have fatigue, and later on that fatigue tends to improve. Although fatigue can persist, and we talk about at least six months, but we're now seeing patients who were infected 20-plus months ago who are still complaining of fatigue. And this fatigue can significantly impact their function. So who should we assess? Well, we shouldn't be assessing everyone who's got post-COVID fatigue. If it's not continuing to improve after the initial four weeks or so beyond symptom onset, we felt that fatigue should be evaluated. If the symptoms are moderate to severe as well, and if it's negatively impacting quality of life. But otherwise, if the fatigue is mild and not functionally limiting, then perhaps just monitor it to begin with. The etiology of fatigue in PASC is probably similar to the etiology of fatigue in other conditions, as in multifactorial, and we've listed a number of different contributing factors, whether they were preexisting or whether they're secondary to the acute infection. But probably there's a lot of input, a lot of different etiologies. And we're still learning, and we don't have the final common pathway yet. But the differential diagnosis, what's causing the fatigue, perhaps is affected by the severity of illness. And those people who had critical illness and were in the ICUs may have, for instance, like post-intensive care syndrome, which is contributing to their fatigue. And I think it's very important, and I wanted to get it in here in terms of health equity and health inequality. And Talia Fleming, who's going to be talking with us today, has been very central to not just educating, but really making sure that all of our guidance statements include consideration of health equity and health inequalities. But pregnant women, racial, ethnic, minority individuals, and other vulnerable populations may be at greater risk for serious COVID-19-related illness, subsequent post-intensive care syndrome, and many other symptoms too. So definitely do please consider health equity and health inequalities when it comes to how patients are presenting. This table, I'm not going to go through it in detail. You can see it in the guidance statement, but it really goes through if you're looking at other conditions or other systems that may be contributing to fatigue and what you should be evaluating for. And also it's very important that we make sure that we understand if patients have myalgic encephalomyelitis or chronic fatigue syndrome. The jury is still out. While some patients who have PASC fatigue may have ME-CFS, we're still learning. And, you know, we don't want to throw the baby out with the bathwater. The patient representative groups are very concerned that we were recommending activity and exercise to individuals with fatigue following infection because they are once bitten twice scarred by the ME-CFS issues. You see the National Academy of Science proposed diagnostic criteria for ME-CFS on the right-hand side. You do have to take care when you're evaluating patients for fatigue that if they give a picture or a pattern or a history of exacerbation of fatigue significant that sounds like ME-CFS. You have to be very cautious in your recommendations for exercise. But I would say many, I'm not going to say the majority, but many patients who have fatigue do not have ME-CFS as far as our experience is concerned. So how do we measure the severity of fatigue? There are scales that you can use. We tended towards this numeric 10-point scale, 1 through 10, to clarify mild, moderate, or severe fatigue. And the National Institute for Health and Care Excellence in 2007 did publish guidelines to define the severity of fatigue in ME-CFS if you want to look that up. So what did our collaborative feel? So mild fatigue, this was sort of defined as intact community mobility, performing activities of daily living, needing time to recover, so feeling fatigued but still able to do community activities and household activities, as opposed to moderate fatigue where there was really significant decreased community mobility, may have stopped work or stopped school and limited IADLs as well and requiring frequent rest stops. And severe fatigue, these are people who are really confined to the home. They can't get out. They can't work. They can't walk outside because they have significant fatigue and they're significantly impacted. So this is how the collaborative defines fatigue. And this is how we discussed its treatment and its management. So a four-step process in terms of initiating a return to activity program that's titrated according to symptoms and response to activity, energy conservation strategies, healthy diet and hydration, and then collaboration with other specialists, and also considerations of other issues including sleep. So in terms of initiating and progressing an activity, an exercise program, it depends on the severity of the fatigue. So mild fatigue, which we considered, as I said, on the scale, the numeric scale of one to three, patients were recommended or individuals were recommended to continue all household activities and try to return to higher levels of activity. The rule of tens we found was a useful rule in terms of increasing the duration, the intensity, and the frequency of activity by 10% every 10 days and starting with a rate of perceived exertion at light activity or 11 on the RPE scale and slowly progressing up. In terms of moderate fatigue, we start at a lower level of intensity when people are starting their activity level at a rate maybe of nine or very light activity. And again, slowly advancing their activity in terms of the frequency and the duration and the intensity, encouraging individuals to recognize when or if they're getting exacerbations of symptoms and pulling back. Perhaps also referring through to a rehabilitation therapist with knowledge of post-COVID care to help guide them through this slowly progressive and symptom monitored or limited activity progression. And those people who have severe fatigue or significant post-exertional malaise, then this is where we have to be very careful and cautious in our recommendations, starting at extremely light in terms of the RPE scale at a rating of seven on the scale and very, very slowly progressing activity. It could be just simple household activities. If there's exacerbation, then patients should be encouraged to rest. Stretching perhaps is the first activity people should be trying, some light strengthening activities, but really holding back on progression to aerobic or more significant activities to try to avoid this post-exertional malaise. And certainly someone with severe fatigue should be referred through to a physician like a physiatrist with knowledge and skill in managing PASC. Energy conservation strategies, which I'm sure you're familiar with, including pacing, prioritizing, positioning, and planning are really important for individuals with more significant, actually moderate or severe fatigue in order for them to get through their day and achieve all the things they need to do. And in terms of healthy diet and hydration, there was no data to support the prescription of any one specific diet with regards to PASC fatigue. We do recommend people eat a healthy diet that's rich in antioxidants, fruits and vegetables and whole grains, et cetera, and to avoid red meats and alcohol. And certainly, if we think of post-COVID as an ongoing immune response, then eating anti-inflammatory nutrients, whether it's single nutrients or specific diets, may be helpful in terms of improving the symptoms of PASC, especially fatigue. There was discussion, and this was certainly brought up by patient groups, of mast cell activation syndrome, where there's a breakdown in the metabolism of histamine, leading to increased amounts of histamine and histamine intolerance with symptoms. But again, we found no evidence and no supporting data to recommend a low histamine diet. Some patients do follow along this, and they do an exclusion diet to see if they can improve their symptoms. And there have been some anecdotal reports of elimination of certain foods, improving fatigue and PASC. Again, with regards to dietary recommendations in ME-CFS, there are some recommendations, including eating foods or eating little and often, every three to four hours, foods with a relatively low glycemic index, as in complex carbohydrates, and again, a balanced diet that's high in antioxidants, fruits and vegetables and fish, et cetera. In those people who have fatigue related to autonomic dysfunction, salt and water intake is very important. And for those who have muscle atrophy, and we've certainly seen a lot of people with significant muscle atrophy, then appropriate caloric and protein intake as well is important. In terms of pharmacologic therapy for PASC fatigue, we really had no recommendations. There was no consensus on the use of supplements nor on medications. No rating for the science to catch up with what we feel may be beneficial, and more to follow on that. But as of this time, no pharmacologic recommendations. So as I've gone through my talk, and we review back on our polling question, which of the following is correct in relation to fatigue and PASC? Is reported in up to 35%? That's not correct. Actually, it's reported in many, many more patients than 35%. Rarely persists the past three months. We're seeing it six months, 20 months on, still persists. As well, the pharmacologic therapy, we have no evidence about that to date. Should be differentiated from ME-CFS, absolutely yes. You can get very significantly caught and not benefit your patient if you're recommending progressive exertion without considering the fact that they may have symptoms similar to or have ME-CFS. So in conclusion, do not confuse fatigue with other conditions, particularly post-exertion malignant ME-CFS. Fatigue has multiple etiologies and confounding factors, and it's very common in PASC. The management of fatigue and other disease states, cardiologic, oncologic, and neurologic encompasses a multimodal approach. Rated progressive activity and exercise is a common thread in managing fatigue really of any etiology. Fatigue in PASC, as we know, is common. It can be moderate to severe, variable but persistent, and limits daily activity tolerance. Activity and exercise for the management of PASC fatigue should be titrated to symptom severity and slowly progressed, and should include stretching, strengthening, aerobic, and balance exercises. As well, incorporate pacing, healthy diet, sleep hygiene, and psychosocial support, and scientific evidence for the use of supplements and medications is insufficient at this time. So thank you for listening. These are my references. I do encourage you to read the Multidisciplinary Collaborative Consensus Guidance Statement on the assessment of fatigue, and look out for others that will be published in the near future on cognitive function, on breathing, and on cardiac and autonomic dysfunction as well. With that, I want to thank you. I'm going to stop sharing my slides in a moment, and we're going to—or right away, and we're going to have Dr. David Gaider prepare, and he's going to come on and share his slides as he'll be giving the next talk. An introduction to Dr. Gaider. Dr. Gaider is a tenured professor and chair in spinal cord injury medicine. He's a fellowship director in the Department of Physical Medicine and Rehabilitation and chief medical officer of the Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis and Jackson Health System co-director. He also has NIDILRR, South Florida Spinal Cord Injury Model System. He's a research scientist with the Miami Project to Cure Paralysis and at the University of Miami Leonard Miller School of Medicine. And as I said, everyone's going to give a fun fact. Dr. Gaider's personal fun fact, he was a pole vaulter back in the day, and he still enjoys a good volleyball game. Go for it, Dr. Gaider. It's all yours. Thank you, Dr. Whiteson. Hopefully you can hear me now and see my slides. We're going to move forward. I have no financial conflicts. My disclosures are listed on this slide. We have a polling question for you all, which will start. What is the most important aspect of exercise prescription for persons with spinal cord injury and choose one, aerobic fitness, upper body strength, body composition? Personal goals or exercise modes? And you can go ahead and put those in. I'm going to give you just a few seconds. I'm a bit behind time, so why don't we go ahead and show the polling answers, if you would. All righty. So my title gave this away. And so those of you really on the ball have picked that up already. So I'm going to go ahead and move forward. We're going to be talking through basically the neurogenic consequences of spinal cord injury, particularly with regard to metabolism, body composition. I'm going to be talking through energy balance, and then hopefully I'll have time to go through three cases with you. We'll see how well I can get through this. So first off, persons with spinal cord injury have an obligatory nitrogen loss that is muscle mass primarily, but also bone loss due to paralysis. They have sympathetic blunting also associated with the spinal cord injury, particularly those with injuries T6 and above. They have an anabolic insufficiency that is tied with the lower muscle mass and bone mass. And they also have a blunted satiety so that they don't know when they're getting full as well as you or I would do. We recently put together a special issue in the topics in spinal cord injury rehabilitation on neurogenic obesity that is reflecting excess body fat of more than 22% for men or 35% for women. And that's because of the things we just mentioned, motor paralysis and obligatory sarcopenia sympathetic blunting, anabolic insufficiency and blunted satiety that ends up creating a positive energy balance. The neurogenic obesity we know and we've talked about specifically in this volume mediates the metabolic syndrome of insulin resistance, hypertension, dyslipidemia, thromboembolism and coronary artery disease. Some really great manuscripts in this particular special issue, I'm going to be focusing primarily on the exercise interventions today, recognize that spinal cord injury has both somatic as well as autonomic dysfunction, dependent upon the level of the injury, the higher the injury, the fewer muscle groups are left. And as we mentioned before, sympathetic nervous system arises from the thoracolumbar regions of the cord. So we end up with having a significant number of comorbidities that need to be considered when prescribing exercise, particularly cardiorespiratory dysfunction, but as well the neurogenic sarcopenia and likelihood for upper extremity overuse, as well as a metabolic syndrome. Now, really metabolic syndrome, we reported out a couple of years ago in 473 veterans, about 50% of whom had tetraplegia, that essentially 57.5% had metabolic syndrome, according to the International Diabetes Federation criteria. We followed that up, sorry, followed that up recently. We reported out in 72 individuals, we did four compartment modeling, which is the gold standard to determine obesity. And we found that 97% of this population truly were obese. 83% had dyslipidemia, 32% had fasting blood sugars over a hundred milligrams percent or were under treatment for diabetes, and 43% had hypertension. What? Yes. Spinal cord injury patients with hypertension. So that almost 60% had metabolic syndrome. Now we'd recently put out the cardiometabolic risk guidelines for persons with spinal cord injury. And we did follow along with the usual guidelines that is moderate to vigorous exercise of at least 150 minutes a day, but recognize moderate to vigorous exercise is defined as three to six minutes. Now a minute, one minute is three and a half milliliters of oxygen per kg per minute. So this means people need to be exercising at 10 and a half to 21 milliliters of oxygen per kg per minute in order to gain those benefits. So I'll come back to that in a moment. If we're going to intervene for obesity, we need to have baseline information with regard to body composition, total daily energy expenditure, and total energy intake as we go through this. So our recent paper also provided a predictive equation for percent body fat that includes age, sex, weight, and abdominal skin folds. Recognize that a BMI typically underestimates obesity and spinal cord injury. So in this study, a BMI of 27 correlated with percent body fat of 42%. So that means yes, 42% of the person's mass was in fact fat mass. So our daily energy expenditure is comprised of our resting metabolic rates. That's about 75% of it for persons with spinal cord injury, thermic effective activity in the thermic effective food. An individual like myself typically has a total daily energy expenditure of 2,800 calories a day. If I was to have paraplegia, that would drop by about 25% and tetraplegia would drop an additional 25%. So that my total daily energy expenditure would only be about 1,200 calories a day. So recognize that when we talk about oxygen consumption, one liter of oxygen consumed is approximately five kilocalories. So we had done work back and reported in 2010, looking at veterans and their physical activities. What was the energy cost for those? And essentially what we found was a metabolic equivalent for somebody with spinal cord injury wasn't three and a half milliliters of oxygen per kg per minute, but was in fact significantly less 2.7. And so we actually used that in a ratio to help put together an equation for total daily energy expenditure. If we know the person's basal metabolic rate, you multiply that times 1.15. And we reported this out in terms of how can you quantify what the person's energy expenditure is. We also reported recently on nutritional status for spinal cord injury and a systematic review and meta-analysis demonstrated that essentially for 606 individuals, they had an excess calorie production of approximately 58,000 kilocalories per year. That would have gained them 16 plus pounds of adipose tissue per year. We reported out, actually just came out this month in the British Journal of Nutrition, seven authoritative guidelines with regard to dietary recommendations, and I don't have time to go into those because I want to really talk about the exercise prescription. This is the prescription that all of you put together for whatever populations you're prescribing exercise for. We have published extensively on this back in 2009. I reported out how to put together a prescription for cardiovascular or strength or flexibility or some combination. The Canadian group, the Spinal Cord Injury Rehabilitation Evidence, updated their cardiovascular health exercise guidelines, indicating that functional electrical stimulation, anaerobic exercise, as well as body weight supported treadmill training can improve cardio fitness health. However, we have to keep in mind that for the population that we're working with, many of them don't, and particularly those with tetraplegia, have a peak VO2 that is right around where we would expect the three metabolic, that is moderate exercise realm to begin. Many of them can't achieve that level of exercise, and trying to exercise between three and six minutes is really challenging for anybody with spinal cord injury, depending upon level of their injuries. Our folks are really at the very lowest end of the spectrum with regard to cardiovascular fitness, be they males or females. As you try to compare along ages, most of our folks fit into the very poor cardio fitness level range. So part of what we need to know is why are we exercising? Is it possible to improve cardiopulmonary fitness? Maybe, but more importantly, perhaps, is it possible to achieve negative energy balance after spinal cord injury? So we put together a study looking at folks with paraplegia and compared arm crank regometry versus functional electrical stimulation, leg cycle ergometry, in these individuals. So over the course of 16 weeks, we had them exercise 60 minutes a day, and the bottom line is both groups improved their percent body fat, increased fat-free mass, increased their HDL cholesterol, and increased energy expenditure per session, but their body weight also increased, and so mobility was sacrificed. I'm not going to go into detail on this slide other than to say over four months of exercise at the end, we were barely able to achieve over 100 calories per session for our folks using functional electrical stimulation. We did a little bit better for those using arm crank ergometry. And so we're currently involved with home-based exercise trials. My science project, Spinal Cord Injury Exercise Nutrition Conceptual Engagement, is an ongoing study comparing home-based functional electrical stimulation plus diet versus diet alone, and we're looking at these outcome metrics. So I know that I'm already past my time. I've got three cases. Let me at least try to get through this first one. This is a young woman with C7 complete tetraplegia. She's 5'3 and 130 pounds. 25 pounds of that had come on over the past two years. Her goal is for community mobility using an ultralightweight wheelchair. She's currently using a power wheelchair. She would like to have some weight loss and strength gain, particularly to help with pressure relief and transfers. Her comorbidities are those that I had listed previously, but particularly neurogenic hypotension and circulatory hypokinesis. What is this? This means that when you exercise with your arms, as a person with tetraplegia, you have a lot of blood pooling in the lower extremities and inferior vena cava that doesn't get back to the heart. And so you're going to be limited in terms of your stroke volume as exercise continues. She does have available to her an indoor track abdominal binder and protective mitts, but doesn't have access to functional electrical stimulation or arm crank ergometry. So her assessment, basically we found her VO2 peak to be 12 milliliters of oxygen per kg per minute, which is very low. Her total daily energy expenditure was calculated at 1,200 kilocalories per day and her body composition. Yes, she was 45% body fat by DEXA. Dietary review indicated that she was taking in 1,500 calories a day, so you can already see a 300 calorie a day bonus, unfortunately, that's going to result in more adiposity. So our prescription for her included wheelchair propulsion and using Velcro resistance bands for strengthening exercises. We would gradually increase her exercise intensity, including a 10 minute warmup, 10 minute cool down and the exercise bout. Initially, she might only be able to participate about 10 minutes at a time, needing some rest in between there. We recommended five days a week of doing this wheelchair propulsion exercise and the resistance band training three days a week, particularly for internal and external rotator exercises, scapular stabilization that are going to be necessary to preserve her shoulders and then reassess and goal alignment. I've got others that I could go through, but in the interest of time and because I have other presenters coming behind me, just briefly, we have to keep in mind that our folks have significant problems, particularly with upper extremity overuse that needs to be taken into account. Some of these folks, we can use the Karvonen heart rate method to determine a heart rate zone as I did for this individual. But again, interest of time, I'm gonna go ahead and close down and we can spend a little bit of time maybe at the very end of the session today talking through some of these things. One final note, because of the pandemic, we did find that many of our folks weren't able to access gyms. And so we did recommend virtual exercise and just report it out on this last month, including screening and prescriptions virtually to provide aerobic strength training, stretching. And most of our folks reported particularly it was helpful because of socialization during the pandemic. So I have references. Thank you. My email is here at the very bottom. And again, in the interest of time and respect for upcoming presenters, let me go ahead and just shut down and I'll stop sharing my screen, or at least I'll try to stop sharing my screen. David, thank you very much. And apologies, I realized I did chew into a little bit of your time and there'll certainly be time at the end. We will have more time as we get into the networking session to discuss some of the issues and cases that perhaps you didn't get a chance to now. The next speaker is gonna be Robbie Bowers, excuse me, Robbie Bowers, forgive me, Robbie, is an Assistant Professor of Orthopedics, Assistant Professor of Rehabilitation Medicine, Emory University School of Medicine and Emory Sports Medicine Center. Robbie is a Director of the Emory Baseball Medicine Program and is Team Physician for the Atlanta Braves in Georgia Tech Baseball. Didn't Atlanta Braves make the World Series this year? Something tells me they did, yes. And Robbie's personal fun fact, he played Division I College Baseball, enjoys all things Disney, Atlanta sports, he's having a great time right now with his wife and his three kids. Robbie, it's all yours, thank you. All right, thanks so much, I appreciate it. Let me get my screen shared here. All right, everyone can see this okay? Yes, we can. Okay, great. So I'm going to discuss today, and I just didn't catch a little bit of something different in what was listed for my talk. We're going to talk more about exercise interventions for reducing visceral adipose tissue as opposed to weight loss. So there's a little bit of a difference there. And so I'm going to treat this as more of kind of journal club style, try to catch us up a bit in that we'll discuss a recent with you. So we're all your products of our training. So prior to medicine, they'd get a PhD in exercise physiology at Auburn University. And most of my research was in weight loss metabolism at that point. And so I still try to stay up to date in that field as much as I can, as even though in practicing sports medicine and musculoskeletal medicine on a daily basis, it's a bit difficult to, but try to stay up to date as best I can. As far as disclosures, I have nothing to disclose. So the polling question for me that we'll begin with is which two of the following choices are most effective at reducing visceral adipose tissue or which two of the following modalities will give you the most effect in reducing visceral adipose tissue? I'll give everyone a few seconds here to answer that question. And then we will determine the answer as I go through my talk. Okay, and we see here as far as reducing adipose tissue, the most popular answer is aerobic training plus resistance training. Moderate to high intensity aerobic training did not get any votes. We see some for resistance training, some for diet, and some for high intensity interval training. So we will determine that answer as we go through this. So this is the review article that we're going to discuss. It was published earlier this year in February. It's a very good review and network meta-analysis to determine the effect of exercise intervention dosage on reducing visceral adipose tissue. And so first we must understand what visceral adipose tissue is and this simple figure to the right here can tell us that. So you have your subcutaneous fat which sits over the muscle layer, but underneath the muscle layer, you have this visceral adipose tissue which surrounds the visceral organs. This is highly associated with all-cause mortality and cause-specific mortality. It increases the risk of many metabolic disorders such as type 2 diabetes, cardiovascular disease, everything that goes into the metabolic syndrome. We know that in order to reduce visceral adipose tissue, lifestyle modification are more effective than pharmacological interventions. And as far as lifestyle modifications go, exercise has a greater benefit than diet does. Now, this is where visceral adipose tissue and weight loss kind of diverge in that we know that diet is more effective for weight loss. Roughly, you can see different numbers, roughly about 80% of weight loss is related to diet. And that's where when someone who practices musculoskeletal medicine on a daily basis, lots of patients with hip osteoarthritis and knee osteoarthritis, and many of those patients feel as if they can't lose weight because of pain and they hurt and they can't exercise. Well, if they're just aggressive with diet, they actually can make great leaps from a weight loss standpoint. But from a visceral adipose tissue standpoint, exercise is actually more important for that. So just a different way of saying it is, exercise is more effective in reducing visceral adipose tissue than weight loss is. And data even indicates in some places that visceral adipose tissue can be more harmful than just excess body weight. And that's why sometimes you'll see someone who is obese or morbidly obese, but maybe doesn't have as many metabolic deficiencies as you would think or metabolic diseases. And that could just be due to the ratio of subcutaneous adipose tissue to visceral adipose tissue. Whereas you could see someone else that doesn't have that much excess body weight, but does have more of their adipose tissue in the visceral organs, which can be causing metabolic diseases. And in this way, this just shows that exercise and how exercise confers health benefits beyond just weight loss. So through the reduction of visceral adipose tissue, you can get profound health benefits and you may not see significant weight loss with that. And then also exercise can be effective here in that exercise leads to a significant reduction of visceral adipose tissue faster than exercise is gonna lead to moderate or modest weight loss. So evidence shows that it takes about six to 12 months for exercise to lead to modest weight loss independent of diet. And you can get significant reductions in visceral adipose tissue in just three months with appropriate exercise. And so you can see the metabolic benefits sooner with visceral adipose tissue reductions. So in getting into this review paper, really what we wanna determine is which exercise modality is most effective for reducing visceral adipose tissue. Is it aerobic exercise? Is it resistance training? Is it high intensity interval training? Is it sprint interval training? Some people don't know the difference between HIIT or high intensity interval training and sprint interval training. High intensity interval training is just that, high intensity, you can determine that from various ways, 75, 80% or more of your maximum heart rate where sprint interval training are very short super maximal efforts. And so it's a much shorter period of time and less prolonged. So sprint is actually super maximal. And the purpose of this paper was as a systematic review and network meta-analysis of randomized controlled trials to identify the exercise intervention that most effectively reduces visceral adipose tissue. So just quickly, a few of the methods, we had 34 studies in the systematic review, 32 in the network meta-analysis. Overall, there were 1,962 participants with an age range of 18 to 75. There was no BMI restriction in these trials. The average range from as low as 22 in one study to as high as 40 in another. These were generally healthy participants. 15 of the studies included sedentary individuals and 10 of the studies included those with diabetes or pre-diabetes. Studies involving dietary control were excluded in that so that we could just focus on exercise and not have that diet compound in there. So for those that may be interested, if you go into the paper, it breaks down every study that they included. You can see here the population, the age, the BMI, the modality did they use, the different groups, the intensity, frequency, duration of the exercise, also the tools that they use to determine visceral adipose tissue, DEXA scan, MRI, CT scan, et cetera. So we'll get into the exercise modalities and the exercise prescription aspect of this. So from an exercise modality standpoint, aerobic exercise and high intensity interval training were effective in reducing visceral adipose tissue. So this is the answer to the polling question. The two modalities that are most effective is aerobic exercise and high intensity interval training. And there was no difference between the two. So between HIIT and aerobic exercise, neither of them are superior to the other. Resistance training, sprint interval training and aerobic exercise plus resistance exercise were not effective in reducing visceral adipose tissue. Also, we saw the effects of the aerobic exercise plus resistance exercise groups varied between studies. And this makes sense because it really depends on that ratio. So how much of it was aerobic exercise? How much was resistance exercise? And when you change that ratio, it's going to impact the results. When it comes to aerobic exercise, it must be of at least moderate intensity and there are different ways to determine intensity, whether that's percent of heart rate max, percent of VO2 max, percent of heart rate reserve, metabolic equivalence, rating of perceived exertion. But in there, it's beyond the scope of this looking into what determines moderate intensity. But aerobic exercise of at least moderate intensity, as we had mentioned previously, the sprint interval training is brief supermaximal efforts. And with these supermaximal efforts, you're actually relying more on carbohydrate metabolism for energy metabolism and you're not using fat as substrate. So that could be part of the reasoning of why sprint interval training is not effective in reducing visceral adipose tissue. And then resistance exercise seems to not be effective due to inadequate energy expenditure. So you just simply don't expend as much energy as with resistance exercises you do with aerobic exercise. And that's where you can see with that ratio in the aerobic and resistance groups. If you have a higher ratio of aerobic exercise and lower of resistance, then you're gonna have more of a likelihood of impacting visceral adipose tissue. So exercise amounts. So the amount of really is the week-to-week frequency times the duration of the session. And so the review found that there's no difference in visceral adipose tissue reduction between exercising greater than 150 minutes per week and less than 150 minutes per week. The adequate number of sessions per week would be three sessions. Certainly it could be more than that, but on the low end, you can accomplish significant decreases in visceral adipose tissue with as low as three exercise sessions per week. And as far as the duration of the sessions for the moderate to high-intensity aerobic exercise, it's gonna be 30 to 60 minutes per session. For the high-intensity interval training, it can either be 30 to 60 minutes or less than 30 minutes per session. So we see here, this was one place where they were not able to determine really the single appropriate range for high-intensity interval training as there was no difference for the 30 to 60 minute sessions and less than 30 minute sessions. As far as exercise intensity is concerned, a bit of what I mentioned previously, only aerobic and resistance exercises included because sprint interval training is super maximal, very high intensity. High-intensity interval training is just that, high intensity. And there is no difference between moderate and vigorous exercise intensity. So that's where we say for aerobic activity, somewhere between moderate and high-intensity or vigorous intensity. Light intensity was not effective. And for aerobic exercise, you see here, you can determine exercise intensity with either percent of heart rate reserve, percent of heart rate max, percent of VO2 max, ratings of perceived exertion or the Borg scale where you either have the one to 10 scale or the six to 20 scale, and then metabolic equivalents, which Dr. Gader had mentioned a bit in his topic as well. And as far as resistance training, looking at exercise intensity, that's gonna be the percent of your one rep max. So in wrapping up here, the take-home is that relative to weight loss, exercise is more effective in reducing visceral adipose tissue. From a modality standpoint, aerobic exercise and high-intensity interval training are both effective at reducing visceral adipose tissue. And the reason for this is, and the thought for why they're able to is because they accomplish significant energy expenditure to lead to reductions in visceral adipose tissue. The frequency, it can be as low as three sessions per week, but I would say if we're trying to put together an exercise prescription, if we think of that 150 minutes per week number, and that we saw that there is no change between less than 150 and more than 150. So if we said, we're gonna shoot to exercise 150 minutes per week, say do that five days a week. So 30 minutes, five days a week would be effective in accomplishing decreases in visceral adipose tissue. And it takes about 12 to 16 weeks to see significant results. So with that exercise prescription, it takes about 12 to 16 weeks to see the significant reduction visceral adipose tissue. Intensity is gonna be moderate to high intensity. And then as we had mentioned before with duration, with aerobic exercise, 30 to 60 minutes per session with high intensity interval training that can range from maybe 20 minutes per session all the way to 60 minutes. So we weren't able to, from the review, determine a specific number there. And then overall, no difference between exercising more or less than 150 minutes per week. And that's another area where it's a little bit nebulous and not as clear. But if you focus on that 150 number, I think that's a good number to focus on. And so in conclusion, these results do have real world application and that they can inform your exercise prescriptions for the general population to improve health through the reduction of visceral adipose tissue. And this is to show that exercise improves health through mechanisms beyond just weight loss. So you can use this, the results from this paper to put together an exercise prescription that are going to improve patients' metabolic health regardless of whether or not they are losing weight. So with that said, just wanna wrap it up, say more importantly than anything else, go Braves. Thanks so much. Robbie, thank you so much. Just to let you know, if you can look at the chat, Robbie, because someone had asked for the reference again for your article. So if you could put it in the chat, that would be great. Yeah, I'm happy to do so. Yep, thank you. And if you can stop sharing your slides because Dr. Amy Rabotin is gonna start to share her slides and she will give you the title of her talk. And Amy works at the Mayo Clinic in the Department of Physical Medicine and Rehabilitation and the Department of Pediatric and Adolescent Medicine is an assistant professor and specializes in pediatric physical medicine, rehab and pediatric sports. And Amy's personal fun fact, which actually really resonates with me is she loves to fly fish. Yeah. I love that. I love to surf cast and we have a little backwards and forwards. But fly fishing is an incredible skill. So much respect for you, Amy, as well as being an amazing physician. You're an amazing fisher. Right, exactly. We have some of the best fly fishing in the country here in Southeast Minnesota. So just FYI, if you ever need to come to Mayo, bring your rods. So my talk is Physical Activity Recommendations for Children with and without disability. So we have a little bit of a shift, but in listening to all the talks already today, there's so much applicability to kids in what we're talking about. So I really hope that people keep that in mind and whether you see kids or not, but maybe you can influence other people's kids or how your patients take care of their children as well. So let me get my slides to advance here. There we go. I have no relevant relationships to disclose. So let's get to our polling question. What are the CDC physical activity recommendations for children with disability compared to typically developing children? Is it the same? Is it 50% less? 25% less? Or they actually don't have any recommendations? All right. Okay, perfect. I love the almost 50-50 split. So great. So why is physical activity important for children? So really, in essence, why is exercise as medicine important for children? Well, it's important. Physical activity is important for everyone. I talk about physical activity with my parents of infants, with all the children I see, the teens, and with children with disability. And it's going to look different for all of those people, right? For infants, physical activity might just be tummy time and working on head and neck control, and then all of that development of the milestones and gross motor skills. For children and teens, you know, it might be running around, it might actually be playing a sport. And for children with disability, I hope it actually looks the same. It's some type of mobility or some type of sport for those kids. There's numerous health benefits of physical activity for kids, and we don't always talk about it. So I think that's one of the goals that I have for us today. Only about, and it varies on what paper you look at, but 25% of children are getting the recommended amount of physical activity. And that's really sad to me. And, you know, I think that's probably true of our adult population as well. And so that really just drives that we have to be having these conversations. We need to include conversations and counseling about physical activity, giving physical activity prescriptions, helping them understand and knock down barriers for physical activity. So in all of our patient interactions, whether they're adults or peeds. So physical activity recommendations for children three to five years old, it's actually to be physically active throughout the day. And kind of the recommendations are about 180 minutes throughout the day. So, and that comes in different spurts, you know, whether it's, you know, a couple minutes here, a couple minutes there, but it's really important for them to be physically active, to grow and develop. And in fact, I just saw a patient the other day who is really behind in his milestones because his mother is so afraid to put him down on the carpeting in their apartment because she's afraid it's really dirty. And he's actually having some challenges in his developmental milestones because he's not getting that physical activity. And the adult caregivers of these, of these children should encourage play that includes all different kinds of things, whether it's, you know, running, jumping, playing tag, all kinds of things. So, you know, really just being active in this age group. In the 16 to 17, I'm sorry, six to 17 year olds, it gets a little bit more specific. So for example, aerobic activities that maybe is running, hopping, skipping, jumping rope, swimming, or dancing, riding a bike. But it's, you know, the cardiovascular, the cardiorespiratory fitness, and kids can do this in short bursts, but it's up to 60 minutes every day is what they're really recommending. It should be moderate to vigorous, just like Dr. Bowers was talking about in the paper review. So, you know, really there's a lot of crossover there, but we want to, we want to make sure that they're getting that aerobic, moderate to vigorous aerobic activity. Muscle strengthening and bone strengthening should be part of this and at least three days a week. And so that might be unstructured play, such as playing on playground equipment and climbing trees and playing tug of war, kind of all the, all the good old games can be great. And as they get older, then it becomes, you know, lifting weights or working with resistance bands and bone strengthening activities. So, you know, just as an adult, it's the impact activities. So if that's running, jumping rope, playing hopscotch, you know, everybody's got sidewalk talk now, so use that to make a hopscotch path. But all of these, those are type of examples, but again, that aerobic activity is 60 minutes per day. And then the muscle strengthening can be part of that at least three days a week. So let's get to the answer to our polling question. So the physical activity recommendations for kids with disability are actually the same. And so let's talk about that a little bit. So what the exact statement says is when possible children and adolescents with disability should meet the key guidelines. So meaning that six, depending on their age, meaning the 60 minutes of moderate to vigorous physical activity every day, and then getting the bone, the muscle and bone strengthening activities. And they've go on to further say when young people are not able to participate in the appropriate types or amount of physical activity, they need to meet the key guide to meet the key guidelines. They should be as active as possible and avoid being inactive. So really the big challenge that I see is that children and adolescents with disability are not, they're more likely to actually be inactive than those without disability. And some of my research has been confirming that as well. And so it makes it so important for us to have these conversations with kids with disability and their parents to encourage conversations with us as healthcare providers, with physical activity specialists or other people to talk with and places to go to help them understand what types and amounts of physical activity may be appropriate for them. And to give them examples of people that do it. So I'm constantly pulling up the Paralympians and different people in when I'm in with a patient to show them examples. So does exercises medicine apply to the pediatric patient? I'm hopefully I'm proving that yes, it does. So there's physical activity or physical benefits, excuse me, such as healthier weight and lower body fat, stronger and healthier bones and muscles. Better heart and brain health, better endurance and higher levels of fitness, possibly improved sleep quality, which then affects what we're going to talk about in the next slide with mental health and cognitive and behavioral benefits. And what some of the research is showing that over time, if kids are really getting involved in physical activity, that the longer term, that it lowers their longer term risk factor for cardiovascular diseases, diabetes, and some kinds of cancer. And as I talked about before, too, there's that gross motor development component, you know, the hand-eye coordination and the foot-eye coordination that we all take advantage of all the time and just how we move about. And all of these physical benefits apply to children with disability as well. Children with disability have some of the same chronic illness risks that typically developing children do. So this is, again, another reason why we really have to have these conversations. And in terms of mental health and behavioral benefits, and then cognitive benefits as well, these are always, when I start to talk about this with patients and their parents, this is the topic that always seems to get the, piques the interest of the parents. I think they hear like, oh gosh, they're going to behave better and they're going to do better in school. Well, maybe we should start talking about this. So in children, many studies have shown that physical activity can help with mental health, including depression and anxiety. And it actually might show some protective, some protection over time to depression and anxiety in children who may be predisposed to this based on family history. And on average, kids who participate in physical activity have lower levels of depression, anxiety, psychological stress, and maybe have more positive self-image and self-confidence as well. And children who are provided opportunities to be active throughout the day, during their school day and whatnot, actually show better focus during school. They may behave better during school, and this includes kids that have ADD or ADHD. And actually, physical activity may show even better benefit for behavior in children with autism spectrum disorder during the school day. There's some studies that show decreased perseverative behavior during the school day and easier redirection if they get different bouts of physical activity throughout the day. And physical activity can improve attention and academic performance, and many studies have shown this. In fact, I'm always aware, like if I have to go take a board exam or something, I'm always going to work out beforehand so I can make sure my brain function is as good as possible that day. But some of the studies have shown that physical activity positively affects academic achievement, academic behaviors, and other indicators of cognitive skills, such as concentration, memory, verbal skills, math skills. So really important, and this is something that really resonates with parents. So how do you get kids moving? It's really hard. You can say, well, go do this or go do that. And just like in the adult population, that's not going to work. So we have to find something that they like. Do they want to have dance parties? It needs to be fun. It can be a competition. It can be a bingo board to start to get these healthy habits. It can be, you know, working to get a prize, whether that's a sticker or some screen time or anything like that. So we talk about how to find something that they really like to do that's fun and motivating for them. I talk a lot about getting moving as a family. You know, can you take a family walk at night? Can you have the family dance party? Or when you're watching a television show, if it has commercial breaks, everybody gets up at the commercial breaks and does squats and jumping jacks or something like that. And a lot of times I'll pass along this 25 ways to get moving at home from the American Heart Association, which is really, you know, I always tell kids like, bring this, check off all these boxes and bring it back into me. And we can give you some stickers or whatever, some kind of prize. But it's a nice, you know, they realize that movement isn't just a sport and movement isn't just, you know, 60 minutes all in one full swoop of activity. It's these different pieces throughout the day with, you know, either on their own or with their family. And I really encourage them to start small and slow and don't aim for perfect. You know, I put on here, dance like no one's watching. You know, your dancing doesn't have to be perfect. And in fact, Hip Hop Public Health, if you haven't checked it out, it's a super awesome website that has all different kinds of activities that have different public health messaging and different ways to get physically active, both for kids with disability and kids who are typically developing. And I'll also pass along, you know, get to your parks and rec. What's out there for you to participate in? And, you know, even Wii Sports, I know we try to turn them a little bit away from the screens, but gosh, if they're getting involved in Wii Sports, that's okay. They're moving. And so I really just try to encourage that to get them to get going. And a lot of times I'll also kind of flip it and say, you know, rather than moving more, sometimes sitting less makes more sense to a kid. So how do you make sure when you're sitting, you think, oh, I shouldn't be doing this as long. And it's so important to think about the barriers to physical activity and help with them. And this is, I think one of my favorite infographics of all time with this equality versus equity. And, you know, I think as physiatrists and as people who are promoting physical activity and exercises medicine, we have to be really aware of, you know, we can give somebody a bicycle, but if it's not the right bicycle, they can't use it. And so how do we help eliminate those barriers and advocate for our patients and their families to be able to participate in physical activity? Because we all know how beneficial it is. So in closing, just to hopefully you've taken away that physical activity is recommended for children with and without disability, and we want them to be as physically active as possible and get those little teeny movements throughout the day that all add up even. The physical activity provides children physical, mental, and cognitive benefits, and they're just abundant. And so we'd love to see all of our kids taking advantage of that and to encourage something they enjoy and to keep that conversation going. So with that, I will turn it back to Jonathan. Amy, thank you. I had a question for you. Is fly fishing a good exercise? Um, my heart rate doesn't get up very much with that, but it's good for my mental health for sure. You just have to say yes. All kinds of fishing are good exercise. Exactly. It's movement, right? You got to walk to the river. It's true. It's true. Amy, thank you so much. Yeah, thank you. And I'm going to resume my video just for a few seconds as well as Amy stops sharing her slides. And we have actually got back a little bit on track. So I thank everyone for their efficiency. I'm not sure. We did have a five-minute break scheduled. I'm not sure if we really need to take that or we can just move right on. Yeah, I think it probably is best if we continue. We have momentum, so let's keep going. So if Dr. Bartels can start to share his slides. So we're going to move into sort of the second half of our presentations. We have three more presentations. This first one is going to be done actually between Dr. Bartels and Dr. Kimme. So I'll introduce them both now, and they will just move smoothly on in their talk. They're going to be talking about aerobic fitness and social functioning in individuals with schizophrenia. Dr. Bartels is a professor and chair in the Department of Rehabilitation Medicine at Montefiore Health System, Albert Einstein College of Medicine. And his expertise is in cardiopulmonary rehabilitation. He certainly taught me a lot, as I'll try to follow in his big footsteps. He's published in multiple scientific and review papers and as well as an invited speaker. His personal fun fact, and this is a good one as well, he loves trains, all types and sizes. And he has a large model railroad. And I remember, and I told Matt this, when I was about three or four years old, my first books were Thomas the Tank Engine books. And those were the most precious to me. And so I still love Thomas the Tank Engine. So I'm with you, Matt. And Dr. David Kimme is an associate professor and program leader in new innovations in schizophrenia. He's director of the Experimental Psychopathology Lab in the Department of Psychiatry at Icahn School of Medicine at Mount Sinai. And he's also a research scientist, New York Mental Illness Research Education Clinical Center in New York, James J. Peters VA Medical Center in the Bronx. And David is brave. His personal fun fact is he is an avid Knicks fan. And this season he can finally admit it in public. And I said to David, I thought that was a little premature. But he's bold and he is exclaiming to everyone that he's a wonderful Knicks fan. So hopefully there is a successful, as the Atlanta Braves have been for Robbie, but we will find out. Matt, it's all yours. Thank you for that great introduction. So we are now actually going to start to talk about this topic, which is very interesting. It's exercise interventions for people with schizophrenia, looking at neurocognitive and social functioning benefits. But the way we're dividing the talk is into some of the baseline information about normal individuals who do not have any medical or psychological conditions. And then we'll move on to schizophrenia with Dr. Kimme. So my disclosures, there's a couple of grants that are related to this research, but otherwise my consulting and other things are just cardiac rehab and conditioning. So here's our polling question. So mine is, which of the following is a benefit of aerobic exercise in normal, healthy individuals? And I don't see the poll. Oh, did it go somewhere? I don't see it. There it is. Improved exercise capacity tested by exercise testing, improved mood and decreased anxiety and depression, improved memory, improved inflammatory markers and improved attention. You can select all of them that you think may apply. I'm not giving you any hints by telling you to take two or one or three. Give folks a couple seconds. And okay, let's move on and let's see what people chose. Wow, everybody's doing everything except the inflammatory markers are not getting the full credit. Okay, very interesting. All right, so let's now move on. So we're looking here at trying to see whether we have a novel application of exercise training for cognitive and brain function. The talks today are actually all excellent. I have talked mostly about physical benefits, health benefits, but I'm glad to see with our last talk with Amy that we were looking also at some of the psychological benefits as well as the cognitive benefits. We know the benefit of exercise for primary health prevention. And we also know that there are some cognitive benefits, but we also had a suspicion after doing some of the research that I'm gonna present that we might wanna move on into some of the psychiatric disorder populations. Now, there's a lot of benefits. In any population, and unfortunately in the United States it's pretty much uniform. There's poor general health. We have a lot of obesity, a lot of sedentary individuals, and multiple metabolic syndrome is actually running rampant. And there's also a lot of smoking. And that isn't necessarily something that you cure with exercise, but those who tend to smoke tend to exercise a little bit less. And some people who do exercise seem to actually smoke less. So we thought to apply these cardiac principles to aerobic exercise in the novel group, but we'll first talk about some of the baseline research that was done. So we knew that in normal individuals that aerobic condition with moderate exercise over 12 weeks improves conditioning. So you can do that on the VO2 testing. You also improve memory, you improve cognition and attention, and you improve quality of life. And there's also evidence in depression, but there was not really anything clearly done in schizophrenia. And so that's why we were actually very interested in looking at working with this population. So some of the work that we've published recently in the last few years, we did large studies in younger adults. And of course, some of these study populations are convenience populations, and you can criticize because they're mostly college age or medical school and graduate student age, because they were our ivory tower populations that we can get our hands on. We assessed 132 individuals in this one group. We looked at age 20 to 67. So we got some of the professors and some of the faculty involved as well. And the way this is going, there were 66 in exercise and 66 in stretching, where they spent the same amount of time, but were very closely monitored not to actually increase their heart rate. So they got no aerobic benefit, and they did not do strengthening exercise with that. And we had 66 in the beginning of the exercise, and it dropped to 44 at the end, and 50 of the stretching continued. There were 70% women. The average age was 40 with a standard deviation of 13. And we had a pretty decent spread of ethnicities in this study. Now, if you take a look at this, the interesting things that you find is that we also looked at this divided by young and old, split by the age of 40, which was our average age. So if you looked at the older individuals with aerobic training, there was a nice increase in VO2, which was then persistent at week 24. So this was actually, there was some persistence of that benefit of training. Whereas in the younger individuals, there was a nice benefit, but after the washout period at week 24, there wasn't actually a continued benefit. And as expected, the stretching group in both did not really show any major benefits. Then we looked at executive function, and it was very interesting to see that with the aerobic conditioning in the older group, there was a very nice increase in the executive functioning. And there was also in the young group, a nice increase. And the nice thing here was in both groups, this persisted to week 24. Whereas with the stretching group, there was some benefit in the younger group, but it didn't persist as highly. But the older group seemed to do very, very well with executive functioning. We don't have enough time here to go into the exact details of how exactly we tested all of that. This is done with standard neurocognitive testing. We also looked at executive function, and you can see that there was a trend for improvement in executive function as patients exercise in the aerobic versus the stretching groups. And it kind of held out for all years of age. So the interesting thing though, is that the greater difference was seen in the older population. So as we are all aging, it is probably more important for us to do the aerobic exercise for our cognitive and brain function than it is even as a younger person. So Amy was saying that she did the exercise before her exams, when we were younger, we may not need to do it as much, but I think now when we have to do our recertification, it's much more important for us to exercise before we partake in those kinds of activities. Now, we also looked at exercise and cognitive function in an aerobic exercise 33 versus control 11, looking at college students. And you can see that there was increases in function in both the exercise and control, but it was significantly better in this monthly PACE auditory serial task, going, increasing with time. So the other thing too, was to look at heartbeat tracking task by looking at mental tracking. So it looks at the stress and there was a significant improvement in the exercise group with the IA score versus control. So not only do you think better, but you actually are less stressed with that mental activity. And then in healthy older individuals, we just tested 74 adults in four groups and we did a 12 week intervention. And in that intervention, we did the same thing here, but now we actually also put in this group, there was some cognitive training, which was a video training. And the video control was just to watch mindless videos, which did not have any cognitive effect. And it was shown that in the individuals who had exercise with cognitive training, they had the greatest benefit, but exercise itself was the same as cognitive training alone. And they were both better than the control situation. So you can actually, for individuals who are normal individuals, especially older individuals, do both a form of cognitive training as well as exercise, but the exercise sort of turbo benefits that. And you can see that as time progresses, the benefit increases. So going from six weeks to 12 weeks, you get a greater benefit than just at six weeks. Now, the one thing that I had to take out because we do have a very limited time here was that we also had done a study looking at the inflammatory markers. And inflammatory markers, interestingly, in the younger group actually increased with exercise. So aerobic exercise actually increased inflammatory markers. Whereas in the older population, it decreased. So the answer there for that particular one of the questions was maybe. Depends on what group. So that was kind of a trick question, which is why I didn't want to make it have a definitive answer. Exercise in normal, healthy individuals improved everything that we had in the poll question. And it is a depends, whether it's a younger population or an older population or a population with medical conditions, but whether the inflammation goes down. So if you have a high basal inflammatory state, exercise can improve that. And that's particularly true in people with multiple metabolic syndrome, as well as individuals who have cardiac disease. But if you're a young, healthy individual, it may actually increase your inflammatory state. And that may not all be bad, particularly if you consider that that may help you with reparation of any small micro injuries that may occur. And it may actually be revving up your immune system slightly, although high levels of training, you know, decrease capacity of your immune system. So exercise training in normal individuals, both younger and older have cognitive benefits, but more in the older. Trials with aerobic exercise versus control stage show benefits in prior studies. Exercise alone may be as effective as cognitive training alone. And the use of exercise can have both health benefits as well as the cognitive benefits. And there is some evidence of possible benefits in gray matter expansion. And I also didn't spend the time to show those slides because they get very confusing, but there is actually some evidence that in some of the memory areas of the brain, there's increase in gray matter, which for all of us as we get older is a good thing to find. So with that, I'm actually going to stop my share and allow Dr. Kimmy to take the next step. Thank you, Matt. I hope you're seeing my screen now. So I'll pick up where Matt left off. So it looks like there's quite a bit of evidence for the cognitive benefits of exercise for non-clinical populations. We in our work focus on people with schizophrenia, and one of the reasons focusing primarily on cognition and schizophrenia is that while the general focus on schizophrenia is on the psychotic symptoms, it's actually more the cognitive difficulties that patient experience, difficulties with memory, executive functioning, et cetera, that are much better predictors of overall functioning. So this usually makes the difference between somebody who's able to go to school or work versus somebody that just sits at home and does very little. And there's extensive literature documenting this cognitive deficits in this population. This is one example of them. As you can see here, there's multiple domains of cognitive functioning, processing speed, attention, vigilance, working memory, et cetera. And generally the findings in the literature are that people with schizophrenia score between one to two and a half standard deviations below healthy controls. This is a result from the matrix cognitive battery, which is probably the gold standard in schizophrenia cognition studies. So the most healthy individuals score around 50 and people with schizophrenia in this case score between 25 to 40 range. Now the cognitive deficits in people with schizophrenia are actually also accompanied not surprisingly by a very sedentary lifestyle. Many of our patients do not do much. They don't do much of a physical activity. This is just an example from a few years back. We published this looking at the comparison between 32 individuals with schizophrenia and 64 age and gender match healthy controls. And you can see the distribution of scores. Essentially most healthy individuals will score around 30 or so in terms of their VO2 max. So about 40% of the healthy control scores at that level or higher. In contrast, only 6% of our patients had a sort of a normalized aerobic fitness as indexed by VO2 max. So based on this information, I mean, you have a population here that has cognitive deficits. They tend to be also very sedentary. We had this idea of like, well, if we improve the aerobic fitness, would that trickle down to neurocognition? And this is some baseline findings from that study. And actually you can see the correlation is quite high. There's a basically correlation between aerobic fitness VO2 max and the total all composite score of the cognitive battery is 0.57. And also there's a high correlation 0.46 in which functioning as reported by family members. This is not by the patients themselves. So based on that, we thought, well, you know, this may call for developing a protocol for that, try to see if patients will exercise and we can improve their aerobic fitness. And that will translate to cognitive benefits. And the, oops, I think I skipped a slide. Here we go. So we designed a study, this is a pilot study funded by NIMH, an R21 grant. We had a modest gym at our medical center and pretty much standard gym equipment, the treadmill, stationary bike, et cetera. One concerns we had is that, you know, well exercising, you know, running on a treadmill can get old very quickly. So we thought about trying to make it more interesting. And our secret sauce was trying to use active play video games. This is an Xbox active play games with Kinect software. And essentially for those of you that are not familiar with this, let's see. Okay, here we go. Unfortunately, here we go. So this is what it looks, essentially people standing in front of a screen there. The Kinect is a camera that create an image and place it in a virtual environment. It's an avatar. And as the person is moving, the avatar is moving simultaneously. This is a package. So essentially this is what the patients will see on the screen. And in this task, basically their job is to punch ice boxes. As you can see, this is adjusted to various level of difficulty. It's interval training is about 30. I think the commercial software that is available on the shelf. And there's about 30 games in the package. About half of them are aerobic in nature. Each one of them about three to five minutes. So essentially you play the games, but also you can get a really, really good workout of this. I have it at home. I work out with my daughter and you get your heart running really, you know, very well with this. So we published the result. This is a paper that we published about 2015. And these are results here, comparison of people randomized to aerobic, 12 week of aerobic fitness versus treatment as usual. The blue diamonds are the aerobic fitness. As you can see there, this is the change, the correlation between changing aerobic fitness and changing total score on the cognitive battery, which is 4.54 was significant. If you look at head to head comparison, the dark blue columns here is the VO2max. So the aerobic exercise group improved their VO2max by nearly four points from about 22 to about 26. And versus a virtually no change in the treatment as usual group. And in terms of neurocognition, again, the aerobic exercise group improved their cognitive functioning by 40 scores versus a small decline in the treatment as usual. And this is kind of just a reference sort of like the degree of the magnitude of the change. I mentioned earlier that patients tend to have cognitive deficits scoring about one to two and a half standard deviation below the mean of healthy control. So if you use that standard of 40 scores, this is the equivalent of up to 40% of recorded deficits in this particular study. Essentially, we cut a quarter of the cognitive deficit within 12 weeks of exercise. More recently, we looked at whether this cognitive benefit extend to more social functioning as well. And the results suggest that... Problem with my slides here. Here we go. Yes, the results suggest that yes, actually there is improvement in aerobic fitness was significantly predicted, predicting enhancement in social functioning as indexed by self-reports, by informants, usually a family member, as well as by a clinician that did a semi-structured interview by 47, 33, and 25% of the variants accounting for... This is controlling a host of other covariates. And in terms of looking at... So this is something that we published just last year. And then looking at mechanism, it seems like this is operating primarily by bottom-up improvement in emotion awareness, the ability to label emotions, as well as by emotion regulation, decrease in use of suppression, which tends to be a less effective emotion regulation strategy. So these findings at this point, I mean, there are quite a bit of studies that looking in using aerobic exercise to support, improve functioning and symptoms and cognition in people with severe mental illness. This is a paper that came a couple of years ago by European Psychiatric Association that essentially recommended that physical activity should be incorporated into standard treatment. This is kind of a quote from that paper. Our comprehensive review provides clear evidence of that physical ability has central role in reducing the burden for mental health symptoms in people with depression and schizophrenia. Our guidelines provide direction for future clinical practice, specifically providing convincing evidence that it is now time to professionally deliver physical activity interventions, move from the fringes of healthcare to become a core component of treatment of mental health conditions. So this is our European, a little bit ahead of us in the US, we're still not there. We actually, our group is going to have a study that's looking at essentially our findings in a much, much larger multi-site study. We hope to have the data available in hopefully a year and a half or so. But again, the overall, the findings suggest that this is something that can improve, aerobic exercise is something that can improve both cognition, social cognition and functioning in people with serious mental illness. Thank you. David, thank you so much. And Matt as well, really fascinating data that you have there. And I'm sure there may be some questions a little later. So David, if you can stop sharing and Dr. Fleming will start to share her slides. Talia Fleming is our next presenter is going to be talking about the benefits of exercise after stroke and brain injury. And Dr. Fleming is a physiatrist working at JFK Johnson Rehabilitation Institute in Edison, New Jersey, is medical director of the Stroke Recovery Program and also is involved with the post-COVID, as I mentioned before, she's on our collaborative and has been very instrumental in terms of health equity. So she runs the post-COVID rehabilitation program and aftercare program. Dr. Fleming is a clinical associate professor at Rutgers Robert Wood Johnson Medical School and clinical assistant professor at Hackensack Meridian School of Medicine. And her sub-specialty is in brain injury. She's brain injury medicine certified. And Talia's fun fact, personal fun fact, is that she enjoys the Spanish language with a minor in college, Latin dance and Spanish food. It all sounds great to me, especially the dance. I think dance is fantastic. And I think everyone here appreciates the dance as wonderful exercise too. So Talia, it's all yours. Take it away. Well, muchas gracias for that introduction, that great introduction. Thank you everyone for for joining us today. In the interest of time, I'm going to jump right into it. We'll be talking today about the benefits of exercise after stroke and brain injury. I do not have any relevant disclosures related to this work. And our polling question is, exercise has the following effects on the brain. One, increased cerebral growth factors. Two, improved cerebral angiogenesis. Three, increased hippocampal volume. Or four, all of the above. I'll give you a couple of seconds to go ahead and note your answers. What's interesting about stroke and brain injury medicine is that there is some crossover. So we're going to be looking at the evidence-based medicine related to both areas today. All right, if everyone's had a chance to put in their answers. So interesting, no one felt about the growth factors. We had a couple of takers for the cerebral angiogenesis and the hippocampal volume. Three quarters of the people said all of the above. Great, we'll get a chance to take a look at that a little bit closer. So for some statistics, cerebrovascular accident or stroke is a change in the blood flow to the brain. There are about 800,000 new stroke diagnoses in the United States every single year. And stroke is a leading cause of serious long-term disability. Traumatic brain injury is caused by trauma to the brain, and there are at least 2.8 million people that have a TBI every year in the United States. Over 5 million Americans live with a TBI related disability. So for both groups, we're looking at a pretty decent population. We've talked a little bit earlier in the presentation about some physical benefits of exercise. Talk about improvements in aerobic capacity. There's also enhanced glucose regulation, improvement in blood pressure, as well as arterial function. We also know that there's interventions from exercise that can promote plaque stability. They favor changes in the vascular wall function. And both, they have important implications for the management of patients after stroke or vascular events like a heart attack or cardiac event. What's showing is that there's more evidence showing that improving cardiorespiratory fitness and engaging in regular physical activity or exercise after stroke has overall broad health benefits. So when we first learned about the brain, we learned basic neuroanatomy. After that, we learned that there's different functional areas that are associated with brain anatomy. And very quickly, we learned that there's another layer to the brain altogether, and that the brain is much more sophisticated than just physical location. There's an intricate network of neurons that talk back and forth to each other, relaying messages. So stem cells in the brain give rise to neurons in the brain, which later on develop a wired learning network. Exercise can help form new neurons and strengthen the connections between those neurons. Neuroplasticity refers to our brain's ability to rewire the brain. So new thoughts and skills can carve out new pathways. And repetition over time strengthen those pathways, forming new highways. And the old pathways that we don't use get lessened and get weakened. We know that exercise can help form new neurons, and exercise can help strengthen connections between those neurons. And the proposed mechanism is a combination of neurotrophins, improvements in synaptic structure and function, enhancement in the interhemispheric connections, promoting neural regeneration, acceleration of neural function, reorganization, and facilitating compensation beyond the infarcted area or beyond the damaged area. So BDNF stands for brain-derived neurotrophic factor. If you haven't heard about BDNF and exercise in the brain, this is a great opportunity for you. BDNF is a neurochemical that's responsible for growth and maintenance of neural connections, and it helps your brain adapt and to learn, and is important in improving all forms of plasticity. Exercise has been proven over and over again to improve and increase BDNF levels, and that's really at all ages. So both animal and human research has shown that there's structural differences after exercise in the brain. Several studies have showed increase in actual growth factors. There's higher levels of neurogenesis. Longer dendrites that show a more complex morphology can be seen after exercise, and it also enhances long-term potentiation. There's alterations in neurotransmitter levels after exercise, as well as changes in cerebral blood flow. There's greater gray matter volume after exercise, and even changes with angiogenesis and high levels of synaptogenesis. These structural changes reflect the quality of my life measures. The way it shows up in real life is that they can have a positive effect on mood, it can improve sleep quality, and even enhance cognitive function. Particular to stroke, exercise may have a positive effect on improving global cognitive ability and the potential benefit for memory, attention, as well as the visual-spatial domains for cognition in stroke survivors. And this was from an article in 2016 from the Journal of Stroke and Cerebrovascular Disease, so that was a pretty important article. And another article from Neurorehabilitation and Neural Repair from 2017 stated that daily physical activity was associated with the increase in interhemispheric connectivity within the dorsal action network within the brain, and increasing that connectivity was associated with faster attention performance, suggesting a cognitive correlate, increasing network connectivity. Specific to traumatic brain injury, the Archives of Physical Medicine and Rehabilitation in 2015 had an article showing that vigorous aerobic exercise training may improve specific aspects of cognitive function in individuals with TBI, and that cardiorespiratory fitness games may also help to determine some of these improvements. In the Journal of Neurotrauma just recently in 2021, they stated that carefully titrated physical activity may be safe and an effective approach to promoting recovery after brain injury. We also know, looking not only at the function of the brain in terms of physical health, we also know that exercise can improve mental health after brain injury. From this article in 2012, show that exercise may contribute to the improvement in mood and quality of life for people with TBI and should be considered as a standard part of the approach to depression treatment. Another article in 2014 in Clinical Rehabilitation showed that exercise may be a potential treatment or prevent or reduce depressive symptoms in individuals with subacute and chronic stroke. So we know that exercise can help reduce depression and anxiety symptoms. It may also improve motivation, community participation, and quality of life, which we know is important for our patients with stroke and brain injury. Taking it one step further, looking at brain health, we also know that exercise can help in terms of neuroprotection, and there are certain articles that have come out that show that exercise may be neuroprotective in certain disorders such as Alzheimer's disease or mild cognitive impairment. Aerobic exercise in early Alzheimer's is associated with benefits in functional ability, improving memory performance, and reduced hippocampal atrophy. Another article shows that aerobic exercise increases the size of the anterior hippocampus, leading to improvements in spatial memory, and that it can actually show an increase in hippocampal volume by about 2%, effectively reversing age-related loss in volume by up to two years. Increased hippocampal volume is associated with greater levels of serum BDNF. A third study showed that combined cognitive and physical exercise interventions can improve global cognition in older adults with mild cognitive impairment or dementia. So now that we have this baseline foundation on knowing that exercise can help the brain, how do we implement this? How do we go from lab to practice? And we talked a little bit about exercise prescriptions. Specifically for stroke, although we know that there is crossover with brain injury, there's general principles that we want to take into account. Exercise should be considered as soon as the patient is medically stable, especially in the early to subacute phases. We want to provide an individualized treatment plan, personalized with supervision by a well-trained clinical professional who has experience in that area. We know that basic mobility and ADL training may not be sufficient to elicit an actual cardiopulmonary training effect for fitness. So basic physical therapy and occupational therapy may not be alone to get some of the benefits that we see after exercise. In terms of screening, we want to look at the general information, the demographics, the medical history, medications, any contraindications such as cardiac history or seizure history. We want to assess any contraindications to exercise such as whether or not we should be doing some maximal exercise stress testing or whether or not any other testing needs to be done beforehand. And we want to evaluate motor function, mobility, balance, swallowing, cognition, as well as communication before the prescription is given. In terms of the specific exercise prescription, we know that there's several components that we look for in terms of frequency, intensity, and type of exercise. In terms of frequency, the dosing is about minimum of three days per week. And we talked a little bit earlier about that goal of 150 minutes per week total. In terms of intensity, there's different gradations based on whether or not you use light intensity or about 40% heart rate reserve compared to moderate intensity, which is 40 to 60% heart rate reserve or vigorous exercise, which is greater than 60% heart rate reserve. In terms of the time or the duration of the exercise, aerobic exercise session should be at least 20 minutes long, not including the warm up and cool down periods of about three to five minutes. Don't forget those, that's very important. In terms of type of exercise or mode of exercise, anything that activates large muscle mass for a prolonged period can be used to induce an aerobic training effect. In terms of volume, we want at least a minimum of eight weeks aerobic exercises recommended to achieve a minimal training effect. We know that in our practice, we not only want to have people exercise for that eight weeks, but really have a transition to a lifestyle or a maintenance program. In terms of progression, we want to gradually progress in either the intensity and or the duration in order to accentuate that aerobic training. And again, we want to make sure that we're taking into effect any precautions that patients will have for their particular situation. In addition to aerobic training, there are other activities that we can use for exercise or movement. Specifically for stroke, the recommendations are muscular or strength or endurance or resistance training about two to three days per week. And that can range between one to three sets of about 10 to 15 repetitions and varied over about eight to 10 exercise. In terms of flexibility, we want to look at stretching, especially the trunk, the upper and the lower extremities. And we want to recommend static stretching, which includes holding the position for at least 10 to 30 seconds, at least two to three days per week. We can also incorporate other activities that challenge the neuromuscular system, such as balance, coordination. And we want to use those as complement to the aerobic and the resistance training exercises that we're already recommending. And that could be between two to three days per week. We've talked a little bit earlier today about some of the barriers to implementation. We want to make sure that we always look at this from a health equity perspective, not only from the perspective of disability, but also in terms of access to care for other underserved areas. Physical level barriers can be things such as not knowing the benefits of exercise, not knowing what to do. In terms of the psychosocial aspect, there can be changes in terms of lack of interest or energy, lack of time, or being self-conscious about being exercising. In terms of physical impairment, we also want to make sure that we're taking into account if there's any changes in terms of muscle strength, mobility, balance, or pain. From a society perspective, we want to see in terms of as their lack of support for exercise for this particular individual, and that's part of their barrier for why they're not able to continue or maintain an exercise program. Is there a lack of a brain injury specific counseling? So do they need, would they benefit from a clinician or a coach or a trainer to help them exercise? And how can this integrate well into their community? We can also take a look in terms of environmental barriers. Are there barriers to outdoor spaces? Is there stairs that lead up to their local gym? Are there heavy doorways where maybe the patient can't get in and out of? Are there accessible facilities that have modifications to the equipment so that our patients can be able to participate in different exercise? As well as training, I'm sorry, as well as transportation. Sometimes there's barriers to transportation and getting to the different facilities in addition to costs. Not only if someone has insurance, but sometimes there are associated out-of-pocket costs. So at this point, you're probably thinking, Dr. Fleming, this sounds great, but what do I do? How do I do this practically when I'm in the exam room with my patient? So this is a five-step approach to going ahead and doing that. Number one is knowing what the physical activity guidelines are. Study shows that practitioners who are more comfortable with prescribing exercise guidelines are more willing to do that within their clinic visit or within their interactions with patients. Number two, you want to ask your patient about physical activity. What activities do they enjoy? What is it that brings them fun? We're likely to participate and maintain that participation. As discussed earlier, we want to talk about the barriers to physical activities and look at specific ways to where we can overcome those specific barriers. Everyone may have different challenges or reasons why they felt like they can't participate in exercise. We want to develop that individualized program for them. We want to recommend physical activity options with modifications as needed and refer the patient to community resources and other programs as needed. So in conclusion, exercise is beneficial after stroke and traumatic brain injury. Majority of studies reveal a positive effect on physical exercise and really global cognitive functioning and both aerobic training and the combination of aerobic and resistance training appear to be effective in inducing these changes. Looking in the future, we're looking more and more as transitioning from animal models to human clinical trial models. How is it that we can improve this even more and looking at strategies that actually promote neuroplasticity? Exercise is being used as a potential use for stroke secondary prevention, which is another hot topic right now. Healthcare and customizing healthcare, this area is ripe for how do we develop exercise programs and bring it to the patient, not necessarily expecting the patient to come to our facilities, but how do we bring these exercise and movement trends towards the patient? Another area that is ripe for more and more research is really looking at that neuroprotective and neuroenhancing aspects of exercise. We talked a little bit, we joked earlier about maybe we should be exercising before we do something like a high stakes performance activity, like taking a test, but the question is how do we use this to almost hack our brains and increase performance? That's an exciting area too. Going back to our polling question, exercise has the following effects on the brain, and the answer is all of the above. Increasing growth factors, cerebral angiogenesis, and actually showing increase in hippocampal volume. Thank you. Again, excellent and really interesting data that you presented and very practical as well. I thank you for that. I think we all do. That was really fantastic. Thank you so much. We're going to move on to our last presenter, last but by no means least. I will say that for those of you who are with us, attendees, please do, if you have questions, you can submit them in the chat box, but we'll also be able to do, I think, with the numbers of people who are signed in, we can do probably a live question and answer session when we're done. Our next presenter is Anne Nguyen, and Anne is going to be presenting on Not Fit Enough for Surgery, Prehabilitation for Pancreatic Cancer. Anne is an associate professor, and she works at the University of Texas MD Anderson Cancer Center and has a specialty in cancer rehabilitation. Anne's fun fact was prior to the pandemic, she didn't know how to ride a bicycle, but pandemic and, I guess, some time at home and twins, now she rides. She can ride a bicycle and rides with her family, and again, great exercise. I think, really, all of our fun facts have been about exercise, so that's great. We're very oriented towards exercise. Anne, it's all yours. Thank you, Dr. Whiteson. Good afternoon, everyone. The topic, wrapping up the session here, we're going to talk about exercising cancer patients, so my topic is Not Strong Enough for Surgery, Prehabilitation for Pancreatic Cancer. So I have no financial interest to disclose, and this is my polling question. Which of the following tests can be used to measure exercise capacity in patients with cancer? The promised physical function, six-minute walk tests, hand-grip dynamometry, timed up and go tests, or none of the above? Okay, and so we'll look at that later on in this talk here. So this is a 15-minute talk that I usually need an hour to give like everyone else, but we're going to go through and quickly define prehabilitation, look at the evidence supporting the need for prehab, and then review what we're doing here at MD Anderson for prehab trials for patients with pancreatic cancer. So in recent years, there's been a lot of publicity and a lot in the media in regards to physical activity, exercise, and how it is important in caring for our patients with cancer diagnoses. And so just looking at cancer rehab and prehab, why is this important? In 2040, we're expecting 24 million cancer survivors, and that's because of the improved cancer detection and improved treatment. We have a growing population of survivors, meaning patients who are recently diagnosed to newly diagnosed, ones who are undergoing treatment, and that also includes patients who have no evidence of disease, who are in those stages where they're just being monitored and under surveillance for cancer. And as rehabilitation specialists, we are very good at taking care of older patients. The majority, 64% of our cancer survivors are ages 65 and older, and these patients have the more complex comorbidity profiles. They are at risk of muscle loss, sarcopenia, cachexia, risk of deconditioning, and potentially poor recovery. And so this is very important for us to get in early. And traditionally, we would see the patients for their rehab in terms of after chemotherapy or after spine surgery from spine meds, but now there's been an emphasis to try to get in there quite early, either at the time of diagnosis or close to early in treatment to help optimize these patients. And so this is a graph of function during treatment. And so for a patient who has not had prehab, they go through their treatments and they have this acute, abrupt decline during their treatments. And with rehab, we're able to help facilitate that recovery of function. But if we can go in and prehab a patient, improve their functional status, performance status, this is a term that the oncologists like to use, then they'll still have a decline in function during treatment, but hopefully they can recover with rehab afterwards and maintain that level of function. We see that in our patients in our clinic here and patients in our research trials that we have patients who recover and they're actually above their baseline level of function with prehab interventions. And so prehab, other terms that are used to describe this is pretreatment optimization, preoperative exercise, pretreatment conditioning. We're preparing patients for the potentially taxing and potentially disabling effects of cancer treatment. And these are programs that include any combination traditionally of exercise, nutrition, and psychology. We're merging multiple disciplines for that common goal. And so when you're designing a prehab program, it can be unimodal in terms of achieving one specific goal that you want to achieve for the patient population. Or for instance, with the patient with lung cancer receiving prehab, we could work on smoking cessation, improving pulmonary function, and improving coping skills. And so the goals with the prehab program are to reduce or prevent treatment, anticipate treatment-related impairments, reduce treatment-related morbidity, mortality. The payers like to see if we can decrease length of stay, reduce emergency center visits, readmissions to the hospital. And this is a term, RIOT, Return to Intended Oncologic Treatment. So this is a term coined by surgical oncologists and anesthesiologists here in our enhanced recovery programs. And the theory is if we can get in there and do prehab, improve their physical function, they could recover sooner, be candidate for adjuvant treatment sooner, potentially decrease recurrence. And we're improving outcomes by improving survival for these patient population. And so there is, you know, back to the aging population, most of our patients that we see are older patients. They're at risk of postoperative complications, increased resource utilization. The postoperative period is associated with a 20 to 40% reduction in functional and physiologic capacity. And the American College of Surgeons, they have what's called the NISQIP database, National Surgical Quality Improvement Project. And there's numerous papers looking at postoperative complications and how poor preoperative performance status may influence complications, increased mortality, patients may have prolonged recovery period if there's poor preoperative performance status. So again, we're trying to enhance this functional capacity so they may tolerate upcoming treatments. I actually completed cancer rehab fellowship here at MD Anderson in 2013, and I joined this multidisciplinary team of clinicians taking care of patients with pancreatic cancer. And we prospectively looked at 142 patients with newly diagnosed pancreatic cancer. We used the FREEDS frailty measure, which included gait speed, grip strength, self-reported weight loss, exhaustion, low physical activity by the IPAC questionnaire. And we found that frailty was present in 25% of these patients with newly diagnosed pancreatic cancer, which included curative patients and palliative patients. And frailty was not associated with increasing age or advanced stage. It was associated with worse comorbidity profile and also with performance status. Nearly 56% of our patients fulfilled the criteria for sarcopenia, and frailty was associated with increased risk of death at one year, whether they were, again, curative or a palliative treatment regimen for these patients. And so when we have this data, we said, well, how do we help these patients? What do we do? So we sat at the table. This is around the time the ACSM had released some guidelines for exercise for cancer patients in 2013, 2014. And we said, well, can the patients exercise, you ran the two feasibility trials. We said, okay, let's just have them walk. Let's give them pedometers. Let's give them resistance bands. We made videos. We made handouts for them. And then in the second part of our feasibility trial, we ended up giving them accelerometers, so research grade activity monitors, and we measured moderate to vigorous physical activity. And we found that patients through chemotherapy, through chemoradiation, preparing for that four to six period before surgery, as they're waiting for surgery, that they were exercising on average 154 minutes of moderate to vigorous physical activity a day, I mean, a week. So they were making the ACSM and ACS guidelines at that time in terms of for moderate intensity. And so that translated to that six minute walk test improving, and so that's measuring their exercise capacity, often used in patients with cancer diagnoses. That also improved their five times sit to stand, and also significant improvement in their gait speed as measured by the three meter walk test. And so we also found that increases in self-reported aerobic exercise in their weekly moderate to vigorous physical activity as measured by their accelerometers, and weekly leisurely physical activity were associated with improvement in their six minute walk test distance, and also self-reported physical functioning, and we used the PROMIS physical function short form to measure that. Interestingly, the increased sedentary activity was associated with decreased health related quality of life as we measured with the FACTEP, and then decreased self-reported physical function also. And so one of my research partners, Nate Parker, who's a PhD in kinesiology, he actually started as a grad student when we started our trials and came through as a postdoc and is now an instructor and an assistant professor now, but he conducted a mixed method studies looking at quantitative and qualitative methods to evaluate physical activity for patients in our trials, in the home-based exercise trial, and he used a social support for exercise survey and a neighborhood walkability survey, and he found there's a strong association between perceived neighborhood aesthetics and moderate to vigorous physical activity in terms of if the neighborhood was more accessible, was more felt, patients felt more safe in their neighborhood, that they had a greater volume of moderate to vigorous physical activity. And in the interviews that he conducted, he found that social support, neighborhood walkability, and resources for physical activity were associated with increased physical activity too in terms of with the interviews. Patients expressed concerns about treatment and preparing for treatment, and they also noted a lot of them noted that motivation from their physicians influenced physical activity. And so these are some of the responses that are recorded in this paper. I needed the support of my surgeon saying this is pretty critical. The stronger you are going into surgery, the stronger you are when you're when you recover. My husband was like my whip, he reminded me that every day I could maybe I could do X or maybe I could do Y. And so as we were going through these feasibility trials, we actually ran into Carrie Shadler, who's a PhD cancer biologist who did her postdoc at UPenn, and she had little mice models of pancreatic cancer who ran on little mice treadmills. And so she described the pancreatic tumor as hypovascular with this dense stroma with that compresses the blood vessels, the blood vasculature in the tumor is very immature, limiting chemotherapy delivery. So our theory is that if through exercise, there's sheer stress, and this promotes functional change in the vasculature for functional blood vessels in the organs, and this occurs during aerobic exercise, and so we can cause change in the vasculature in the tumor, that this would improve chemotherapy delivery, increase chances, reduce the tumor size, and increase chances of surgical resection, and of course, improve patient outcomes. And so this is some of the work from the team, and this is her mice experiments. So she had mice who, she had her control mice, her exercising mice, then she had her mice who received gemcitabine, which is the chemotherapy quite often used at that time for pancreatic cancer. Then she had mice who had gemcitabine while running on their little mice treadmills, and she found a significant reduction in tumor volume between the mice who received gemcitabine while exercising. And so these are her immunofluorescent stains, the dense stroma that she described, these fragmented blood vessels, and then in the exercising mice, they have open lumens signaling, and this was more consistent of normal blood vessels present in the tumor itself. So then in another series of experiments, we gave her our human patient tumors. We blinded her team to it. There were patients who were historical controls, who the surgeons had never, back then did not advise them to exercise, so they likely did not exercise. And then we had these prehab patients through our trial, and we gave her a sample of those patients too, and found very consistent findings as the mice data in terms of this dense stroma, no clear evidence of vest blood vessels there, but in the prehab patients, these open long lead lumens and elongated vessels, and a significant difference between the historical control and prehab group in terms of vessel numbers, micro densities, and number of vessels of a certain density there. And so with that, we said, okay, well, let's work on our next trial. And so we have PINKFIT, which is a randomized controlled trial of a multimodal exercise during preoperative therapy for pancreatic cancer. This is a randomized trial testing the effects of exercise on fitness, quality of life, and tumor vasculature. We actually just recently, like about two months ago, completed enrollment of 152 patients for this trial, and we're waiting for the last few patients to go through surgery, and we'll measure them about three months after surgery. But what we've done in this trial is we've randomized the standard care arm, receives a packet with like some ACS educational information on nutrition and physical activity. They receive nutritional intervention as standard of care. For our patients here, they receive a Fitbit so we can track their activity. And then the exercise arm receives one-on-one counseling from our research team. They receive resistance bands. They have received recommendations for a moderate to vigorous physical activity each week. We track their information on the Fitbits and try to help motivate them, and then nutritional counseling and resistance training in terms of just a home-based program. And so hopefully we have some data in the next six to eight months to report. And so now that we've completed enrollment, we're actually planning our next trial, which is TELEPINKFIT, a multimodal trial of a multimodal multi-site trial of prehab, where we're actually focusing on muscle mass and tele-strengthening. And we're looking at muscle strength, muscle endurance, skeletal muscle mass and skeletal quality, and of course the aerobic fitness and organization of the tumor vasculature. And we look at muscle mass through the CT scans. We're using a software for that, as we've done with some of our previous trials. And so we've submitted for some NIH NCI funding for that, and we're waiting on those results. So then, running through the trials, the big question was, well, what can we do with the rest of our patients with cancer diagnoses on campus? So we actually created in our PM&R clinic a prehab program. So we have a clinical program with a talented team of physiotherapists for our stem cell patients. We have OT also seeing these patients. And so we have referrals from surgical oncology, from stem cell transplant specifically, with what's called an enhanced recovery stem cell transplant program. We see allogeneic transplant patients ages 65 and older, the most vulnerable group of patients. And now, in the past two months, we started seeing patients undergoing CAR T-cell treatments also for refractory myeloma and lymphoma. So ideally, our colleagues are sending patients who have at least a three-week waiting period for prehab. Ideally, those patients could be ones who are receiving neoadjuvant chemotherapy or radiation. And then patients, of course, who are at risk of falls or recent falls and frail patients. And so I could spend another hour talking about our prehab clinical program and share how well that's been going and the growth over time. But back to our polling question, which of these tests can be used to measure exercise capacity in patients with cancer? And so, yes, six-minute walk tests. We have some, and there's some good normative data on patients with colon cancer in six-minute walk tests. And so I think the future of prehab and cancer rehab is to get some good normative data on these measures for patients in the future. And special thanks to my PM&R team here, who they all practice prehab and rehab. Also our senior level physiotherapists who support us, who work alongside with us to see our patients in our prehab clinic, our multidisciplinary PinkFit research team. And of course we can't do it without our funding. And this is, we created, in addition to learning to use, ride a bike, we also created home gym at our house during the pandemic and go Astros. Oh dear, we have, we have a battle on our team between the Astros and the Atlanta Braves. Yes, yes. Okay. Anne, that was wonderful. Thank you so much. I'm gonna ask you to stop sharing your slides, but I am gonna share again, let's see. And hopefully you see that correctly without my notes slides but I wanna thank all of the speakers. I mean, those were really powerful talks and learning on the spot. And there was so much for all of us to learn so much new stuff. And that was great. We talked about exercise in COVID fatigue. We talked about exercise in spinal cord injury. We talked about exercise and abdominal fat loss. We talked about exercise for children with and without disability. We talked about exercise and schizophrenia and mental health exercise and stroke and brain injury recovery. We talked about exercise for cancer and pancreatic cancer and prehab. So really a tremendous array of topics. And I guess we're at that time where we can think about Q and A. And I'm gonna stop sharing because I think we have, maybe we can all unmute ourselves or unmute yourself if you wanna ask a question, but we can certainly show our faces and even the others who are the participants here. So Emma, is there a way to have all of our faces show? I'm looking at Anne's, which is great, but can we see everyone's of equal size? I don't know, Emma, if you're listening or if that's possible, even our- Top right-hand corner, select view and you can go to group view. Okay, all right. So I don't know, maybe everyone else has done the same. Yes, thank you so much. I don't know if you see my screen or I see yours, but do we have any questions that anyone wants to just sort of ask out loud at this time to any of our speakers or presenters? I was interested in hearing more about Dr. Gater's virtual therapy for his patients at home during the pandemic. Yeah, David, yeah, you blame me for the pressure you felt in terms of timekeeping. You were far more responsible than I was, but please take the floor if you want to share your slides again and talk, that'd be great. Thank you. Yeah, this is actually not part of my slide presentation, but if you come to our website, we do have the home fitness guide that has been put together and we encourage our folks with spinal cord injury to do this program at home. I would make a few modifications to it, but the bottom line is we started doing it at a similar time each day and had a number of people sign in, not just from Miami, but from across the country. And even a few folks across the world who virtually participated in this resistance training program. And it was set up so that you could use, TheraBands and specialized equipment and whatnot. And they would actually take people through the different exercises as you would anticipate. The only ones that I would steer clear from were the overhead press. I think we need to be careful about upper extremity overuse. And that's one that I don't advocate, but for the rest of these, particularly internal, external rotator scapular stabilization exercises, all of those are beneficial. The upside of this was so many people reached out and said, you know, this saved me from a psychological social perspective in the midst of the pandemic. So many of our folks with disabilities were so incredibly isolated. And this was a psychosocial exercise program that everybody was able to participate in and they established additional relationships across the country for folks that they could reach out to. So that was one of the, I guess, unexpected side effects. Maybe we should have expected that, but it certainly made a difference for our folks with a spinal cord injury. So thanks for asking. Yeah, no, that's great, that's great. So did your department fund, I guess, a person to then run the session or to lead the session? So we were fortunate in that the Christopher Reeve Foundation supported a part of this. And we actually had a couple of individuals who, yes, went forward with that. We've got our new Lynn Rehabilitation Center. None of you have had a chance to visit, unfortunately, because it opened on Pi Day, March 14th, 2020, just as the pandemic was being initiated. We do have our gym here that is set up just in the Miami project portion of our facility for folks who could come in with wheelchair accessible equipment. We've got an Aqua program. I mean, a lot of different things to it, but so many people were not able to participate because we also had to shut down and social distancing and whatnot really prevented full gym participation. And so the virtual aspect was just a huge blessing for so many people. I'm not singling you out, Neil. Actually, you came back, but you had asked a question earlier on about strength training in the 50 plus population. Did you want to unmute and ask something to the group? Maybe not. Does anyone want to address that, though? Does anyone feel comfortable talking about strength training? This was a question that Neil Metnik had put in earlier on, and it says, I'm interested in exercises in medicine, specifically strength training in the 50 plus population. Does anyone have any experience with strength training in the 50 plus population? I don't have any more specifics from the question that Neil put in the chat, but any comments or people have experience with strength training as we get older, its value, its importance? So I'll just speak up, but I'd love to hear from maybe Dr. Bowers on this as a sports medicine specialist. My wife was a strength coach and a weightlifting coach with the Olympic Training Center for a number of years. And we have helped, the National Strength and Conditioning Association put together guidelines for all kinds of populations, women, children, as well as the older population. Some of us are fitting into that now. I think that, you know, for those folks who have continued strength training as they've aged, most will recognize that they're usually starting to have some issues with osteoarthritis. For those who are starting fresh at an older age, many of them don't have those issues, but we still recommend reducing the intensity or so the weight lifted. I still advocate for, and again, we'd love to get Dr. Bowers in on this, for anybody who's wanting to participate in sports, doing things like whole body lifts, so clean and jerk snatch, while those are, they need to be coached appropriately. I think that those are great exercises for folks to participate in. You know, the whole CrossFit side of things, I would really caution people participating in those types of activities, unless very closely supervised by folks who are familiar with the appropriate techniques. So I'm going to step back and let other folks speak a little bit about it. Yeah. I mean, what I tell people is that I'm, you know, I have patients come in and some of them have injuries, but sometimes we just talk about, you know, exercise and what they like to do. And I try to tell them that I'm not really in the business of telling them not to do things. I want to hear what they want to do and then try to figure out ways that we can work around that and keep them doing the things that they enjoy doing. From a CrossFit standpoint, I think CrossFit has it right in an extent where they do teach, you know, functional fitness and functional movements. And some of those Olympic lifts, like you were talking about, like cleans and snatches and squats and things like that. And, but where they miss out, I think, is on the teaching side, and it swings wildly from, you know, coaches that I think are trained appropriately and maybe have a CSCS degree and also teach some CrossFit, whereas others are, you know, definitely have very minimal training. And I think that's where the injury part comes in. And so I, you know, my, the way I look at it, and if we're going to take it back to, you know, strength training in a 50 plus male, it's just having a discussion of what they like to do and maybe what their injury history is and things like that, and then try to build something around that. But I agree wholeheartedly in the, you know, the intensity side of things, unless they're being very closely watched and coached, I think the easiest way to kind of scale back and avoid injury is decreasing intensity. Yes, the other consideration is to start with static, isometric types of exercises, and then cautiously move forward into, you know, the TheraBand types of exercises, and then moving into some of the more functional exercises, being careful not to increase weight or activity to a greater extent. One big difference, and again, Dr. Bowers can speak to this. I don't recommend plyometrics kinds of exercises for those of us over 50. Generally speaking, that's going to be more difficult. So the depth jumping, box jumping, those kinds of things. So just put that out there. David, you don't recommend it because you're concerned about injury or accident or? Yes. Yeah. Yeah. Those high velocity, high intensity exercises. Yeah. Yeah, those high velocity, high intensity. High velocity, high intensity are going to increase your risk of injury, definitely. Yeah. I mean, the thing that's frustrated me as I've got older and I'm soon to turn 57, you know, is I think I run like a 20-year-old until I see a 20-year-old running, and they're like gazelles, and I'm like a concrete block running. But I wonder personally if I did more plyometrics, dancing, boxing, you know, more rapid repetitive movements safely, if that would improve my skills, my running skills, and actually help prevent injury. I just wonder what your thoughts are on that. Again, it's open, but Robby, you may have more thoughts about that. Yeah, I think, you know, more kind of more agility type of motions as opposed to kind of these high load, high velocity motions like, you know, like the repetitive box jumps and things like that. So I think the things you mentioned are good and are different types of exercises, more core on speed and agility, as opposed to kind of these high load, high velocity things, which can increase injury risk. Yeah. Anne, you wanted to add something? I just wanted to add that we struggled with that. So most of our patients are older. And so we really struggled with getting patients to do resistance exercises through our prehab trial and also even in clinic when we're prescribing exercise regimen for patients. We actually just started a feasibility trial of strength training or teleresistance strength training with, we have a couple of ACSM certified trainers that we've trained to do strengthening trials. And so we check their 1RM max, we give them bands and we have them work scale and also do repetition to where the last like 12 repetitions to the last like two, like that it's more strenuous. And we use that as like the starting guide for their resistance training. And so, so far we've had, I think about under 20 patients, maybe about 17, 18 patients enrolled on the trial. These are patients with newly diagnosed pancreatic cancer all the way through like advanced cancer patients with who are undergoing chemotherapy. And we have pretty good adherence. They're coming on video like twice a week and doing the exercises. And they're doing an eight week program with their trainers. So it's doable, but it needs a lot of guidance and hand-holding and live one-on-one sessions. It's pretty labor-intensive, but we're seeing benefits with the patients for that. Thank you, Anne. I have a question for part of Matt's brain and part of Talia's brain. It's the cardiovascular side of your brains, as in stroke and heart disease, and resistance training, strength training. I'm involved in cardiac rehab and Matt is as well. And typically we focus on aerobic training. We do lightweight, sort of lightweight high repetition for some tone, for some strength, but we're concerned about the cardiovascular work and accident and blood pressure issues. So Matt and then Talia, in terms of the cardiovascular population, what are your thoughts about resistance training, strength training, and how do you approach that from a practical perspective with your patients? I guess I can jump in first, if Talia's okay with that. For strength training, generally, we have an older population, mostly with the cardiac populations. And as you said, it's gentle. We do a lot of free weights, but it's five pounds, maybe 10 pounds in somebody who's very robust. Free weights, we generally use more than we use the constrained types of activities. I have used TheraBand and can go up to some of the higher strengths. One of the reasons, that's one of the nice things to go with is it's portable and if you drop it, it doesn't ding the furniture or your toes. So those are things, but we generally don't have people doing high strength. I do have people doing squats. I do have people doing stair steps and things of that sort. So they're using their total body weight as their resistance on that. Don't have anybody grabbing a 30 pound medicine ball and doing the same thing, which would be another level. But I think in that, we'd also be worried about increasing diastolic blood pressures because patients might be starting to get isometric at that point. So it's mostly functional range level of strengthening. We do do high repetitions. So it's low intensity and high repetition. So there may be sort of an aerobic component to it. We did not with our work with the populations of people with schizophrenia do anything that really was resistance training. And that would be an interesting component to add to it because with their functional deficits, a lot of them do have weakness that probably would be remediated by this. And as far as in the stroke population, and we've been doing a little bit of this in some of our settings as well, we're really not focusing on the strength training, but I think that that would be a very functional thing. And I'll let Talia really tell you what her experience with that has been because you're really able to focus more on the aerobic. Yeah, Talia, what are your thoughts about resistance training in the stroke population? I mean, I think the studies you quoted, mostly we're looking at aerobic training in terms of neurotransmitter and hippocampal size and those kinds of things. But what about resistance work? Right, so I agree with everything that Matt said in terms of our goals definitely aren't to have higher weights when we're using the resistance training. If anything, it's lower weight, more repetition. That one study that I did quote mentioned, not only the aerobic goals in terms of 150 per day, at least 20 minutes per session, but also they did want to incorporate resistance training at least two to three times per week as part of an overall exercise program. And that was in the stroke population. Saying that, especially with stroke more than brain injury, we always wanna make sure that the patient is safe and that we're taking into the account that if there is cerebrovascular disease, oftentimes there may be cardiovascular disease. And so if you are concerned about it, that's one of the benefits of having a setting where there's other professionals that can monitor heart rate, blood rate, oxygen saturation, or maybe even teach the patients to be able to do that. There's this whole question about depending on intensity level, most of what we're recommending right now is low to moderate intensity, but as patients get into that moderate to high intensity level, whether or not they should be doing submaximal stress testing or whether or not the cardiologist wants to do other advanced testing. This way we have a better idea for what their cardiac function is. We're not just guessing or waiting for an event to happen. So those are the general principles that we're using. Thank you. I do wanna stay cognizant of the fact we've got about 27 minutes left before we're gonna reach our gong bell. And I do have a few questions in terms of sort of the business aspect of the exercises medicine community. But I do wanna say again, is it, are there any other questions at this time? Yes, go ahead, Talia. I have a quick question for Anne. Anne, you mentioned one of the resources was a hip hop, hip hop, was that hip hop CDC? I think it- Can you hear me now? Yes. Sorry about that. It's hip hop public health. Public health. Yeah, it's super awesome. I, oh my gosh, I'm trying to think of who's on the board. Anyway, but like Ariana Grande has a thing and there's all different rap artists. It's like, it's really fun. That sounds, I mean, I don't know. I know we're tying into our next thing, the business aspect of it. But if we're looking for a fun activity that may be something fun to do that we can invite the whole physiatry community too. So thank you. Yeah, some of the exercise, they'll have people in different stages, like somebody who can stand and really do a lot, somebody who's doing the dance move sitting. So yeah, it's really, and the public health message is actually on stroke. You would love this. It all started with a stroke public health message. And in, I think in the Bronx, they were trying to get messages out on how to recognize stroke for kids to recognize this and their family members and whatnot. And so then it just blossomed into this super awesome thing. Great, I'll definitely check it out. Thank you. Yep. Talia, were you suggesting that we get the membership of the AAPMNR and we have a big night of hip hop dancing together? I mean, I heard that, you know, Ariana Grande personally. So I think that that would be a great tie-in. If I know Ariana Grande personally, she has no idea who I am. It's not a bad idea, but that's a great segue. I'm gonna reshare my slides again. Hopefully you can see them. So we're gonna go through some thought processes now. And I know we sort of are a representative of our community. There are hundreds in the community and about 15 or 16 on this call right now, but the goals of the exercise is medicine community networking session, review, modify, approve the goals of the community, establish your goals from the community. And we get to know each other, which I think we've been doing quite well. So these are the current goals of the community. And if I'm not mistaken, Emma, I think we should have some polling questions here. So yeah, so there are four questions here. I don't mind reading them through. I agree, a goal of the exercise of medicine community is to collate, review and disseminate evidence of the benefit of exercise as a modality in the management of patients undergoing rehabilitation for physical and or cognitive functional limitations. It's a yes or no. So I'm answering it and you can do the same thing. I agree, a goal of the exercise as medicine community is to stimulate research to optimize a diagnosis specific exercise prescription. Goal number three, I agree. A goal of the exercise as medicine community is to implement practice changes that incorporates exercise in the continuum of rehabilitative care from the acute care setting through outpatients and into the community. And the fourth one is, I agree. A goal of the exercise as medicine community is to establish exercise as a significant tool in primary and secondary disease prevention. So once you've answered, if you can submit, and I don't think we need to wait too long if we can see the results of the poll, Emma. So, okay, I guess I set everyone up, and I'm glad that we're all in agreement, but I think this does give us some validity to what our goals are, and we'll come back to this in a few moments. The next set of questions, and I think we can put up the polling question, is what are your goals? What are your specific goals for the community? Again, I'll read them through. It's a yes, no. One of my goals of participating with the exercises medicine community is a learning didactic experience to update me intermittently on advances in this area. Again, these are yes, no answers. The next one, one of my goals of participating with the exercises medicine community is research collaboration to study exercises medicine. One of my goals of participating with the exercises medicine community is an opportunity to network and get clinical practical guidance throughout the year with like-focused physiatrists. And the last one, one of my goals of participating with the exercises medicine community is access to the board of AAPMNR to guide them to focus more in residency training and PMNR clinical practice on exercises medicine. So really that's about how do we, we want to engage the board in this, yes or no. And again, submit. And I don't think we need to wait too long, Emma, for the results. And understood. In terms of question two. And otherwise everyone was 100%. Okay, thank you. And we'll come back to that. So this is the exercises medicine community. In fact, this is sort of a model I think other communities have used too in terms of the chair, I shouldn't say co-chair, forgive me, it's a chair, it's a two-year commitment. It's an elected position. I think when we started this two plus years ago now when I set up the community, I was happy to be the chair. And then the two years was up, I think in the spring or the early summer. And I volunteered again for another two-year commitment. I do hope that as we go, as I finish out that second two-year commitment that we will have a new co-chair. Excuse me, a new chair, forgive me. Then we can talk about that as we go through this year because it's not for a little while. In fact, I think I started as of now, if I'm not mistaken, this second two-year commitment. So it's in two years from now. But then we need others to be involved. And the others are volunteer positions. It's not an elected position and we can just hear who's interested in this. And again, I know it's only a select group right now but I do want to talk about a message to the community. I know, I believe you all get my messages that I send out through FizzForum. But in terms of what do I mean by a research officer and education officer, clinical officer and operations officer? So research is, from that research perspective, who's doing research and how do we sort of share what research is being done because number one, it's interesting. Number two, how do we collaborate? How do we stimulate each other? How do we, not necessarily in terms of competition, but how do we stimulate research questions and growth in terms of exercises medicine around our departments? And how do we know what research is being completed and then in terms of publication? And I think that sort of melds into what I call an education officer, which is what are the learning resources? What are the articles we should be reading? What are the chapters that have been written? Where are the educational opportunities? What courses are being run in terms of exercises medicine? So that sort of is what I see as a role for an education officer. In terms of a clinical officer and that is, how are we turning this research and knowledge into practice? And where are the clinical programs and how can we mimic and model those clinical programs? Because if it's working well for you in your clinical setting, then hopefully you don't mind sharing that with me because I'd like to implement it in my clinical setting. And it could be an outpatient office and it could be an academic medical center and it could be a community hospital or it might be a subacute site, but how do we do that on a practical clinical perspective? And then the operations officer is really someone who could help keep the rest of us in track or on track and help to coordinate community events, not just this annual event that we're sort of having now, but if any, I think a few of you were present and we had Elliot Roth speak at the beginning of September. And we had some assistance from, I think, Sean Sanford, forgive me if I'm pronouncing Sean's last name wrong, from AAPMNR to help us set that up. But I thought it was very well attended. It was very interesting. And maybe every quarter or enthusiastically, maybe every month we can have a gathering where we have a meeting. It could be social, it could be hip hop, it could be a brief lecture and then just some networking questions or whatever it might be. But that's what I see the operations officer sort of working on an annual schedule. So those are my thoughts. I know I'm talking a lot, not giving you guys much of a chance to speak, but bear with me a second. Here's the next polling question. And that is, what's your commitment to the community? So let's go through this again. As part of my commitment to support the exercises medicine community, I'm happy to receive updates and information, but cannot commit to a more active participation. So the yes is that that's as far as I can go. The no is no, I'm actually prepared to go further. So if you answer no, it means that you're prepared to go further than just receive updates. If you say yes, that's enough for you, which is fine. So you can answer that. And then we move on to the next one. As part of my commitment to support the exercise medicine community, I would like to hear from the exercise medicine community members throughout the year and communicate, collaborate, share ideas. That's sort of a little bit further of a step. I'm not just gonna receive information, but I'm actually gonna feedback. I wanna share my thoughts and ideas. So if that's as far as you wanna go, then say yes. If you wanna go maybe further than that, you can say no. As part of my commitment to support the exercise medicine community, I'd like to participate in the function and growth of the community throughout the year. So what you're saying here is, you wanna be more involved in how this community develops and take a greater role than just hearing ideas and sharing ideas. So yes, if this is as far as you'd like to go, but no, if you'd like to go a little step further. And the final step, if I correct, is as part of my commitment to the exercise medicine community, I'd like to participate in the leadership of the community, including a planning committee and coordinating future events, including the annual assembly exercise of medicine community session. So this is really, are you prepared to be sort of a volunteer to really take part in this committee going forward? So again, it may take a little bit more thought. So we'll keep it up just a little bit longer, Emma, just so people can really understand sort of the four levels of what I'm trying to understand in terms of your commitment. So when you're ready, you can submit it, but we'll give another 10 or 15 seconds or so. My submit button isn't working. Oh, your submit button's not working? Who was that? Who said that? Sorry. Fleming. Talia? Okay. Well, you can message me offline, Talia, but I'm expecting major commitment. I know you're committed in many areas. I understand. All right. Let's see the result of the poll, Emma, if we can. Hopefully others could submit. Okay. So I'm heading right down to a number four. Okay. So maybe a few of you said that you would be interested in taking a greater role and I appreciate that. And this is anonymous. So I'm going to ask you that you email me after this is done. But, you know, others of you who are interested in other things, please do email me. Please do let me know where you stand. And trust me, I completely understand. And I'm not, you know, that you volunteered to give lectures and there are a few others who are listening, doesn't mean to say that that means you've committed. I don't have that expectation, but I think this community requires just a little bit more support. Anyway, but that's great. Do message me after this talk to let me know what you'd like to do. So these were some other thoughts that I had. Forgive me for coining a term. I hate the term disabled. It just doesn't resonate with me. And I don't mean that in a politically incorrect way, but I much prefer the perspective of differently abled, which sort of encompasses abled and disabled from our sort of previous way of thinking. So just forgive me, that's just my perspective. I'm not saying this is representative of what the Academy says or anyone else. But when we think about the structure of our exercises medicine community, you know, I think we need to think about exercises medicine with regards to differently abled, disabled and able-bodied individuals, health equity and healthcare disparities. I think is huge. And I really have to say Talia has really opened my mind. Not that I was blind, but I don't think I thought enough about health equity slash inequity. So Talia, through our interactions through the COVID collaboration, thank you so much. And I'm sure I speak for others too. I know you don't do it alone, but still, you know, your group on health equity has been amazing. So I think that's really important for us. By age, I know we've represented from the very young to the very old here. By diagnosis and organ system, we've covered many different systems here. By exercise type, we've talked about it from aerobic to resistance and flexibility and HIIT and et cetera, by setting across the continuum of care. This is one I'm particularly interested in in terms of primary prevention and the role of the physiatrist in primary prevention and wellbeing. And if it's not the patient because they've already had disease, can we influence their family members, et cetera? And how do we embrace this with regards to lifestyle? And then I think this is my last slide, which is, are there other communities that we should synergize with? And if I'm not mistaken, you are all members of other communities. So I know what I think is the answer and et cetera. So I would like to, let me just go back a few slides. So the goals of the community, did that resonate with everybody? I mean, does anyone wanna speak up and does this make sense? Is there something that we've missed out here? Go ahead, Matt. I was gonna say, I think you covered everything that is of most importance. I'm sorry, I'm on blinded video. It's really an important thing for us to actually look at the role of exercise. And I think we need to reach out to all of the other groups because I can't think off the top of my head of any of the other groups or any of the other communities that exercise is an important thing, even in all of the pain groups, because we know that people who actually are more active are suffering less from pain, or at least they're more functional with what the pain is that they have, so in the oncology group, clearly we have that. Pediatrics clearly have that. So this kind of reaches across and it's kind of core to what we as physiatrists do, which is prescribe exercise. And I think too many of our colleagues have been too afraid of aerobic exercise and more active strength training. And I think we should try to break through that because I think we can do a lot for our patients and we've not been providing what really they could benefit from. Yeah, I agree with you, Matt. And I'm gonna challenge you, push back just a little bit on something you said in terms of we prescribe exercise. I think we do a good job of prescribing rehabilitation therapy, but I think that what we're talking about here and what we've talked about in these talks is beyond rehabilitation therapy. This is real exercise as in higher intensity, different prescription. And that I think is what's missing from our curriculum as residents and our understanding as attending and as a focus of sort of the, I hate to lump this in, and I don't mean in a critical way of our association, American Academy, et cetera, or AAP, but I had a sense that this is missed. We're sort of missing this bigger picture of exercise as medicine. And I think we can all do better in terms of writing exercise prescriptions above and beyond rehabilitation prescriptions. Oh, no, I totally agree. I don't disagree with you at all on that. We really don't prescribe exercise. We just do rehabilitation prescription. But then I don't think many physicians at all do it. And so, if you really reach it out, even our cardiac and pulmonary colleagues don't seem to, especially my pulmonary colleagues, don't seem to grasp the benefits of exercise as a prescription rather than just advising activity. And then again, and I think this was referred to in several of the talks, it's not just about prescribing it, but how do you get people to do it and not just do it for a week or a month or three months, but how do you get them to do it lifelong? And I think that's what's so important. In terms of your goals from the community, do you, did I underrepresent or misrepresent in terms of your perspectives on the exercise as medicine community? Any other questions that we should be answering or needs that we should be meeting? Let me jump on here and just say, first of all, that I really would appreciate all the information from this presentation today, which was really good. This is Kathy Bell, by the way, and I work in the area of brain injury. And I do think that you make a good point. I don't think that exercise prescription is taught as much now as it was say 30 years ago when it's actually, we actually had to do it as a prescription. So I think it's a little different than it used to be, but I do think there are some other things that we need to put into this. Some of the challenges of, for instance, working with people with cognitive disabilities and behavioral disabilities with exercise are really almost a separate challenge. Trying to get more, when you're talking about exercise as a kind of a lifetime institution, the question is how to change behavior. So I think behavior change has to be a part of this, of this community as well. Significantly, significant knowledge of how you change behavior, because that is what we're doing really, other than doing prescriptions, it's changing behavior. And maybe some work on doing things like, really understanding how, for instance, things like wearables and feedback and interactions and distractions and all sorts of other things kind of help people with incorporating exercise into their lives. Kathy, thank you so much, and a really valuable comment. And I wrote a few notes down from what you said, and we'll be sure to incorporate that. And you're absolutely right in terms of behavior change and how do we accomplish that. And I'm gonna give a crude and simple answer in terms of in the world of cardiac and pulmonary rehab, we do have psychology engaged tremendously in terms of that behavior change, because we see cardiovascular disease as a disease of behavior, smoking and sedentary behavior, and obesity, poor diet, lifestyle choices. And so we do have our psychologists work with patients on that. Now, that's crude in terms of, that's just a very, very broad view of it. And I think we can do so much more, not just through psychology, but through educating ourselves in terms of models of changing behavior. And I know there's a literature on that, and I think that's really important. And you alluded to something else, which was, where does technology come in in terms of wearables and feedback? And how do we engage people sort of lifelong if we're able to through technology and through integration with electronic health records? So I think those are two very important points, and I thank you for bringing them up. I know, again, we have five minutes left. Again, I'm very sensitive to the time. And so briefly, does anyone else wanna add to Cathy? Or Cathy, do you wanna respond back or any other thoughts? No, I think, as I said, I was absolutely delighted with this entire session. I thought it was great. It left me with a lot of room for thought and also people to contact to try to get information on what they're doing. But I think this is PM&R, and I think that you should blow this horn a little bit more because this is who we are. Thank you for that thumbs up. Appreciate it. And again, I'm not gonna put anyone on the spot, but please do email me about that potential role. I will say in the past year, I have been remiss since our last community session. I know I could have done more. I know it's been a busy year for all of us. I don't wanna use that as an excuse, and I don't wanna make excuses next year. I just think, as Cathy said, we've got to toot our horn more. We've got to do more. And if it's not you, who else might be interested? Can you make recommendations? Again, get back to me. I appreciate your honesty. And again, for the sake of time, I know we don't have time for much more of a robust conversation, but any comments about any of these sort of different topics or viewpoints of exercise as medicine? I just have one quick question. As we start looking at the different officers and the positions and the goals for the group, I think there's an opportunity for us to really hammer down a little bit more. Are there certain deliverables that we can give towards the end of the year, either a presentation or an article in the journal or some other type of publication? This way, the people that are giving their time to the group and supporting it, we have something tangible at the end of the year to say this group has done this, and we can build from this to do more and more. So that may help with engagement, as well as documenting along the way all of the benefits that we're giving to the community and to the physiatry community as a whole. I think it's an excellent point, Talia. And we do give so much of our time, and I know we don't really ask for anything back other than that we continue to learn and can give the best to our patients. But having something that is tangible or publishable or a major presentation, I think really does make a difference when it comes to what we can give to not just our community, but the whole of the rehabilitation and PM&R population, physiatric population. So that's a great point, and I think it's something to be explored further. Any other questions, any other thoughts? Jonathan, for the officer positions, are they available to just faculty level members or are, let's say, fellows? We have like two fellows who's actually sat in on the session with me here and they, to listen to everything, and they're quite engaged also, but they're going to be faculty next year. So just- So, yes, I think we should never look a gift horse in the mouth. So fellows are enthusiastic and we know they're busy, but they're very knowledgeable. And so, yes, I'm happy to hear from anyone and everyone. I don't believe, but someone from the American Academy will correct me. I don't believe that a resident or a fellow can't be sort of a volunteer in this group. I'm not sure if they can be the chair, but I think they can be at a volunteer position, but I'll clarify that. But whoever it is, they should reach out to me. Again, a minute left. So here we go. Thank you to our attendees, the Exercise in Medicine community, the AAPMNR and the Annual Assembly team, Jose Lopez, Sean, forgive me, Rasta Welch. And if you were on the press call, you know why I'm calling him Rasta Welch. He's deeply into Bob Marley, as I am as well. So forgive me. Emma, and Emma, I don't know your last name. So forgive me for that. And our presenters, David, Robert, Amy, Matthew, David, Talia, and Anne. Thank you, everyone. This was really powerful and really inspiring. And I do hope that other members of our community, and I'll certainly publicize this, will listen to the recording and get as much out of it as I have, and I hope you have too. And please be in touch with me and I will be in touch with you. And those will be my last words. If anyone else wants to share anything, please do, but we have just about a time. Well, enjoy the rest of your afternoon and the other community meetings, and see you at the assembly virtually in November. So long.

physical activity

children with disabilities

prehabilitation

cancer care

physical activity guidelines

modifications

accommodations

safe participation

comfortable participation

prehabilitation benefits

patient outcomes

performance status

prehab program

pancreatic cancer

exercise-based interventions