So thank you everybody for joining today's member community session. Before we get started, we'll just review a few housekeeping notes. As a reminder for this session, it's being recorded and will be available along with the ability to claim your CME through the Academy's online learning portal. For the best attendee experience, please mute your microphone when you're not speaking. You're invited and encouraged to keep your camera on and to select the hide non-video participants button. This will ensure that speakers are prominent on the screen. To ask a question, please use the raise your hand feature and unmute yourself if you're called upon. Alternatively, you can use the chat feature to type your question in at the bottom. Please note that time may not permit for the panel to field every question, but they will do their best to answer your questions. Then just another quick note about the Zoom platform, the microphone and video controls are located on the bottom left of your taskbar, and they're controlled by the caret to the right of the icon. The red lines through these icons indicate that those functions are off and you can click them to turn them back on and click them to turn them back off. Participants can use the chat function in the middle at the bottom of the taskbar and you can bring those up by clicking those icons. And you can also use the raise your hand function in the reactions section of the bottom right corner of the taskbar. To hide any non-video participants, you can click on the three dots on the top right of the screen to hide any non-video participants. Thank you very much, and I'm going to turn this over to the community director, Dr. Whiteson. Thank you so much, Christine. And hopefully everyone can see my slides and welcome to the exercises medicine community session. We're going to be together, hopefully for three hours or thereabouts. And we have a great lineup of speakers for you, which I will just go through very briefly. This is your community. This is your session. Do interact with us. Chat boxes and questions. We'll have a question and answer session towards the end as well. And we'll also have a time for some networking, not just here today, but also live in Baltimore. Hopefully we'll be seeing you all in Baltimore and we will have a session, which I will be letting you know more about through this forum, but it's also in the program. I can't remember exactly when it is. I think it may be Thursday morning. I can't remember, but I'll let you know. Anyway, we do have a great panel of speakers today. As you can see, a number of different topics that we'll be talking about regarding the exercise as medicine topic. It's really important for me to mention David Gater. David has spoken, spoke at our last several exercises medicine sessions and was due to speak today. Sadly, David passed away in the summer, and this comes as a great shock, surprise, distress to many of us, an incredible human being, an incredible physiatrist and physician, the leader in the field of spinal cord medicine and exercise. And certainly I, with respect, remember David and our condolences to him and his family, to his family. So I'm going to talk to you for the next 15 minutes or so regarding the history of exercise and what from the past can guide us for the future. So, some of you may know me from prior meetings and talks, etc. I work at Rusk Rehabilitation. I'm one of the associate professors here. I'm the vice chair for clinical operations. I'm the medical director for cardiac and pulmonary rehab. I also have several roles within the AAPMNR as well, which has been an honor to serve the Academy and all of you. I have nothing to disclose. A little fun fact about myself, and I think hopefully we'll all be presenting a few little fun facts about ourselves. Despite being 57, nearly 58 years old, I still am an avid soccer player, although not at the moment because as I wrote the slide, multiple injuries, I tore my meniscus in my knee. I will advocate for a non-surgical approach to meniscal healing as I've not gone through surgery, and I'm getting back into the groove and the rhythm. Also, any of you can check out Miranda Resmond-White. She's a 70-plus-year-old Canadian ballet dancer who has a wonderful program called Classical Stretch, which I do five days a week. I get up at 5 o'clock in the morning, do half an hour of her program, and it's really kept me in relatively good shape, other than my meniscus. But anyway, that's my fun fact about myself. Christine, can you put up the polling question? Everyone should be seeing the poll now, and for any questions that you can't fully see, just hover your mouse over the answer, and you should be able to read the whole option. And I'll read it off as well while people make their choices. The Exercise is Medicine movement can trace its origin to the Olympic Games movement, 2007 collaboration between and publication by American College of Sports Medicine and the American Medical Association, the Indus Valley region of India, 2000 BC, Pythagoras, Physical Education Movement of the American Association for the Advancement of Physical Education, 1880. A few more moments to mark your answers. All right. I think, do I end the poll, or do you, Christine? I can end it for you, no worries. All right, there's still a few changes. Oh, there we go. That's good. Okay. Well, we'll come back to that answer or that question in a little while, but just briefly, I'm going to go through the past. We'll go back to 2007, and then we'll go back a long way. We'll talk about the present, and then we'll nudge to the future. So, a couple of references which you may be interested in looking at. I found these really interesting. I was noticing that there were a couple of questions that were coming in. So, a couple of references which you may be interested in looking at. I found these really interesting. I was no history buff at all, but I just thought this would be a challenge and of some interest to understand why we're here, where we are today. So, these are two references which you may be interested in reading through at some point. 2007, yeah, that was the date, the year that the American College of Sports Medicine coined this term, Exercise is Medicine, not to be confused with our community session or community title, which is Exercise as Medicine. I tried to be original, changed the word. But this was, as I said, a global initiative, not just in the United States, but a global initiative, really to get people to think of exercise as medicine and to use it and to prescribe it. In terms of preventive, in terms of treatment, et cetera, and to really bring it into all lines of medicine. But as I discovered, and I want to put it across to you, what is old is new again. And let's go back to the Indus Valley region of India. Actually, the civilization started close to 5,000, just about 5,000 years ago. In 2000 BCE, this was a vibrant civilization, really gave rise to the Hindu culture and this tridosa doctrine of an approach to medicine and health. The tridosa doctrine stated that doses controlled all functions of the body. Disease occurred when doses were not in equilibrium with each other, but health prevailed when the doses were in equilibrium. Dasratha, 600 BCE, was the first physician to prescribe exercise, these are his quotes, it should be taken every day, only to half the extent of his capacity, I'm going to say hers too, otherwise it may prove fatal. We're going to come back to that, if only people had learned from that, but we'll come back to that statement. But certainly, there was a feeling and a thought that excessive exercise could be harmful. Naraka, 250 to 100 BCE, a physician, really the founder of Ayurveda medicine, and advocated daily exercise because, again, it alleviated the doses, especially the Kapha dosa, and had beneficial effects on the body. As well as the Indus River region, the Yellow River civilization, China, 2600 years BCE, as well, this was the origin of the yang and the yin. Yang being identified and associated with life and health, and yin being associated with disease and death. I'm not going to try to pronounce his name, but I will not do it justice, but this Chinese physician, between 25 BCE and 250 CE, this East Han dynasty prescribed exercise because of its yang effect. Another area, another geographic area in time, the Mycenaean era in Greece, Homer, 750 BCE, again, discussed exercise as a national duty, and there was a focus on exercise in terms of gymnasiums were built to allow people to exercise. Pythagoras, not just a mathematician and an astronomer, but an athlete as well, also advocated exercise, daily exercise for health reasons. To restore harmony and to achieve a healthy state, a daily exercise regimen was required, and all these exercises and athletic performances that you see down here are still exercises that we do today. Herodotus, 500 BCE, a teacher of Hippocrates, we'll come to Hippocrates next, also emphasized the therapeutic effects of exercise. Hippocrates, eating alone will not keep a man or woman well. He must also take exercise, food and exercise, while possessing opposite qualities, yet work together to produce health. Again, this is clearly a theme and an understanding that the value and the benefit of exercise as medicine, and Hippocrates was the first recorded physician to actually write an exercise prescription. Again, to quote Hippocrates, it can contribute much to the recovery of the sick and to the preservation of health in case of those gymnastics exercises, and is useful to whatever one wished to apply it. The Roman Empire as well, another source and feature of discussions on exercise. They started to talk about the intensity of exercise and the need for intensity in order to lead to exercise to be beneficial for health. If exercise, for health reasons, the exercise had to be moderate, and they defined various different exercise in terms of swift, like running, vigorous as in lifting heavy weights, violent in terms of jumping, and they prescribed and used exercise for various different health conditions as well. The Olympic Games, and the Olympic Games, we see this history and tradition from 776 BCE until 393 BCE. The Romans weren't so keen on the Olympic Games. They did their best to make sure that the Olympic Games were held in the best possible conditions. They did their best to do away with the Greek ideals and philosophies. It wasn't until 1896 that the modern Olympics came back into play. Interestingly, and some of you may know the story in terms of the marathon and Pheidippides. Pheidippides was the messenger that carried news of the Persians landing at Marathon. 490 BCE, ran 149 miles, I guess. Pheidippides was the initial Iron Man or ultramarathon runner, except didn't do so well, and Pheidippides died after that run. Interestingly, there is a report on what may have caused the death of Pheidippides. Again, there's the reference. You can read it if you have some interest in looking into that. exercise, as well as being historic, has also played a role in art, or there has been art that's depicted exercise. And I'm not going to go through this in any detail, but just to show you some of the artwork that have depicted exercise and how it's been so important and essential through the ages and through our culture. And as well, women in exercise. And certainly, while in the past, it was the males who were the athletes and the warriors. There's no doubt that women are represented in terms of exercise, and the value of women in exercise. And again, this is where the art comes into it too. Well, we're going to jump forward a little bit to the 1880s and the physical education movement leading to the formation of the American Association for the Advancement of Physical Education, and books being published as well about physical education. The early 1900s, see all the changes, certainly in the United States, recognizing in terms of what the etiology of disease was. And at that time, in the early 1900s, infectious diseases were really the number one cause of disease and death. And so the emphasis really was on treating these diseases rather than preventing them. The American Medical Association recognized that there was poor training, poor teaching of physicians and medical students, and looked around this time to really change how medical training was delivered, reducing the number of colleges, developing residency programs, and really, again, emphasizing this role of physicians in curing rather than preventing. So really, this movement away from exercise of medicine and more to looking at curing infectious disease was partly led by the American Medical Association. And this led physicians as well to move into that direction and move away from the idea of physical exercise as part of medicine. Exercise began to lose the attention of the medical community. Around the same time, colleges and high schools and the YMCA started to build gymnasiums and started to introduce exercise and sports into their culture and into their education as well. And we saw the rise of physical education. This was more about teaching about exercise rather than was about why exercise is good for the body and good for health. The focus started to change. And those people who were brought in to run exercise programs were not physicians, but they were people who themselves had participated. And maybe they were teachers and coaches because they were themselves excellent in that particular area of sport. In the early 1900s, the Playground Association of America emphasized the playing of games rather than the health benefits of exercise. The American College of Athletics published a report in 1929, which really showed that college directors of physical education were not necessarily trained in medicine or trained or educated in this field, but more of them had been on a football team rather than had an education in this field. When it came to World War I and World War II in the 1950s, the fitness level of American youth was really significantly poor because the emphasis on exercise had changed to more recreation and less about health. And when it came to drafting soldiers and testing the American youth, it was clear that we did not compare to international colleagues in terms of health and fitness. And this spawned the development of the President's Council on Youth Fitness in 1956. Around that time as well, 1964, Franklin Henry published physical education and academic discipline. And this is where the terms and the science developed exercise science, human movement, kinesiology. This is when research was spawning into, again, the value and the benefit. The pendulum swung back to realizing and recognizing that exercise actually was a medicine and not just a recreation and not just a pastime. And various different laboratories and epidemiologic studies culminated in science and evidence really supporting the fact that there was this association between poor fitness level, lack of exercise and poor health. And in the 1960s with the formation of the American College of Sports Medicine and partnerships with the American Heart Association and the American College of Cardiology. A landmark publication by Hans Krause and Wilhelm Raab in 1961, hypokinetic disease as in we're not moving. Diseases produced by lack of exercise. And it was clear that there was this association between lack of physical fitness versus increased physical fitness with disease prevention, health maintenance, well-being and longevity. So through the 1960s and the 1970s, we saw changes. No longer was it infectious disease that was causing disease and death, but it was unhealthy lifestyles. Now it was less than 1% of deaths caused by infectious disease. And the science and the data started to reveal chronic and degenerative diseases as the leading causes of morbidity and mortality. Exercise also started to become fashionable because it started to become profitable with businesses developing aerobics and clothing lines. So exercise started to come back into the mindset. But there was also clear evidence that lack of exercise, lack of training was associated with many chronic and degenerative diseases. And many people, many Americans were affected by this, and it was significantly expensive. 1979, the Surgeon General's report on health promotion and disease prevention really focused us. And again, another landmark publication in JAMA that correlated low levels of physical fitness and then higher risk of death from all causes. Again, well worth a read. Physical fitness and all-cause mortality, a prospective study of healthy men and women. But this really, again, started to focus on the need for exercise as medicine. And sure enough, November the 5th, 2007, at the National Press Club in Washington, sponsored by the American Medical Association, American College of Sports Medicine, so was born Exercise as Medicine, followed by a publication in 2009. So that brings us really up to where we are today. And if I can be so bold and give my opinion that physical medicine rehabilitation, we embrace as physiatrists exercise as a rehabilitative modality, more as recovery protocols rather than as medicine. It's something that I think we have room to grow into. Certainly in my field, cardiac and pulmonary rehab, we recognize that exercise is good for recovery, but also we see it as a risk factor modification for cardiovascular risk factors, and also in terms of secondary prevention and wellness. The oncologic rehabilitation, we may hear some of this from Dr. Sokoloff in a little while. Oncologic rehabilitations have also started to embrace exercise as medicine. Neurologic rehabilitation programs as well. We've heard from Elliot Roth in another meeting last year about the value of aerobic exercise in stroke and brain injury recovery. Sports medicine physiatrists as well, we may hear some more about that today as well, in terms of return to participation protocols and protocols to enhance performance. And many individual physiatrists as well use exercise as part of wellness. But there's clearly an infiltration of use of exercise as medicine, but maybe we can do more. And so I just want to prod your minds and provoke a little bit and say, what could the future of rehabilitation look like if we really focus on exercise as medicine? Well, my belief is that we really should be integrating exercise in terms of functional recovery, but also secondary prevention. And we see this in the cardiovascular disease model. We see it in the oncologic model and the neurologic model that exercise really can play a role in terms of primary and secondary prevention. We also see that aerobic exercise can positively impact the inflammatory and immunologic system and how much disease is underlain by abnormal inflammation and immunology. Arthritis, cardiovascular disease, cancer, infectious disease. We've just been through a pandemic. Those people who've been active in exercise have done better through COVID and past than those who have been sedentary. Do we see the role of the physiatrist in terms of primary prevention? Can we as physiatrists reach out to people out there and use exercise as a primary preventive modality? And do our inpatient and outpatient centers, do our institutions, our departments of physical medicine rehabilitation, do they evolve to really bring exercise central, not just as recovery, but as primary and secondary preventive centers? So going back to my polling question, and I think some of you, most of you perhaps got this right, which I'm quite happily, I would not have answered this right before I started to do this research, but it was the Indus Valley region of India, 2000 BCE, which really can claim to be the origin of exercise as medicine. Well, that's just about it from me for now. I hope I've provoked you a little bit. I did find, as I did the research myself looking into the history of exercise, it was of interest. I hope you have as well. And we're going to be moving along. Again, we've got a number of speakers. Noel Blanco is going to be speaking now in terms of the benefits of exercise for chronic disease management. And I am going to stop sharing, and I'm going to let Noel share his slides. Noel, go ahead. Can you hear me? Can you hear me? Everyone, can you hear me? Go ahead, Noel. All right. Okay. So as Dr. Wyson said, I'm going to be discussing the chronic disease in exercise. One thing, just a little fun fact is I did compete on American Ninja Warrior in 2018 in Dallas. If you look me up, you will not see any video of me because there were over 125 contestants. So about 30 people get some screen time. So I just wasn't that phenomenal or interesting to get some film time. But you can see the video I submitted on YouTube if you want to look it up. But I actually wanted to- Noel, let me just interrupt you because I just made a faux pas because, number one, I didn't formally introduce you. So while we all look at your incredible photograph, just for everyone's understanding, Noel Blanco is a PGY-4 resident. And I have to say, I'm really so happy that you're presenting because you're really looking forward in terms of your future career. But Noel is a PGY-4 resident at Geisinger Medical Center Physical Medicine Rehabilitation Residency. Prior to residency, he worked as a general medical officer in the U.S. Army and medical director and primary care physician of a correctional facility in El Paso, Texas. As Noel has already said, he was a contestant on American Ninja Warrior in 2018 and has a strong interest and focus in general rehab and musculoskeletal care. Sorry for interrupting. Sorry for not formally introducing you. But, hey, this is live show. So I jumped in. Anyway, go ahead, Noel. So, yeah. And this picture just shows some of my painting that I used to do. So I have no conflicts or disclosures except for my personality and humor, hopefully inspiring an active lifestyle. My one disclaimer is that you'll see some pictures of my son doing some active activity and also a few of my wife and my daughter and some of my family members. So... Noel, your screen is being blocked by a box. Oh, sorry. Well done. My apologies. So here's my question. Exercise promotes the following benefits for chronic disease. A, clinical improvements of body mass, waist circumference, lipid profile of obese patients. B, clinical improvement of pain function, performance, and quality of life of patients with osteoarthritis of the knees and or hips. Clinical improvement of fasting glucose, insulin levels, fasting blood sugar, and body mass index of type 2 diabetics. E, all of the above or none of the above. Christine, can you share the polling question? Yes. How much time should I give? That should be it. I don't think anyone's got any other answer than all of the above, but you go ahead. So my objective is that this lecture will briefly focus on the prescription of physiatrists of exercise medicine for chronic disease management. There will be a focus on the exercise considerations through the lifespan of a few diseases and in pregnancy will be presented. Just a brief outline. So this Department of Health and Human Services provided this simple to read and free manual for promoting exercise and providing guidelines of exercise with examples. It is a key reference for my slides as it targets policymakers and health professionals. There are plenty of fact sheets, posters, videos, interactive tools that are free, and it's also provided in Spanish. First off, I have no impartial bias towards children or pregnant patients, but of course, the majority of our patients are adults. So people are not exercising in generally, especially the disabled. And here's some stats to remember. Adults with disabilities who get no physical activity are 50% more likely to have certain chronic diseases than those who get the recommended amount of physical activity. One in two adults with disabilities get no aerobic physical activity compared with one in four adults without disabilities. If we encourage our patients to exercise, 82% of patients were found to engage in activity. So hesitation, most people are fearful of looking foolish, sweating, feeling stressed, busy, not knowing how to use the exercise equipment, or it brings back horrible memories of exercise that was used as punishment. Being teased or worse, failing at a team use sport or being labeled as clumsily, slow, or as an uncoordinated child. Other reasons for avoiding exercise include MSK injury, potential trauma, delayed onset muscle soreness, pain, rhabdomyolysis, or athletic triad that maybe some patients are aware of from Dr. Google. However, there are some several positives that sound better than the prior slide, and more gratifying and offset the negatives by improving weight, posture, skin, cognition, and memory, energy, sleep, sex, well-being, mood, health conditions, pain, and disease. And here's my daughter. This is last week in Long Beach, California. Bradham listed these physical benefits, improving organ flow, endorphin relief, improving pulmonary cardiac function, muscular strength and endurance, more efficient neural improvement processes. And it can also increase muscle hypertrophy by greater number of actin and myosin filaments and myofibrils. And also there's greater than normal length causing new sarcomeres to be added at ends of muscle fibers instead of shortening. The American College of Sports Medicine exercises medicine program encourage us to consider physical activity as the vital sign simply by asking two questions. On average, how many days per week do you engage in moderate to vigorous physical activity such as a brisk walk? On average, how many minutes do you engage in physical activity at this level? And the guidelines for age and disability are generally describing the physician assistance guidelines for Americans. If anything, remember these simple mnemonics for exercise prescription, MDFIT, mode of activity, duration of activity, frequency, intensity, timely follow-up, FIT, frequency, intensity, time and type. And it can be expanded to FITBP with the additional letters representing the volume of exercise and the progression. Now I'll discuss a few chronic diseases and further positive benefits with their respective improvements for the patients. So the general advice for chronic health conditions in adults with disabilities recommend 150 to 300 minutes of moderate intensity or 75 to 150 minutes of vigorous intensity, aerobic physical activity, or an equivalent combination of moderate and vigorous intense aerobic activity. If possible, muscle strengthening activities of moderate or greater intensity of all major muscle groups, two or more days in a week. Maintain some activity if limited of completing aerobic and vigorous activity. Next I'll bring up a few common conditions. For obesity, this retrospective study observed a nine month study of high intensity interval training and resistant training exercises over two to three times per week. 62 of the overweight and obese subjects had statistically significant improvements of BMI, waist circumference, max exercise capacity, fat mass, and lipids and reduction of metabolic syndrome. For osteoarthritis, 77 randomized controlled trials confirmed statistically significant improvements in pain, function, performance, and quality of life. For diabetes, this study, they took down 2,242 records, narrowed it down to 11 meta-analysis articles. They did show that there was improvement, but not statistical significance. But yes, it was a little disheartening that this article showed that, but I'm still going to encourage exercise to your type two diabetics. And for selected things such as Parkinson's, MS, spinal cord injury, and stroke, it showed improvements in function, walking balance, or walking imbalance, speed, endurance, muscle strength. And this is all mentioned in the physical activities guideline. In addition, neuropathies, which can show improvement with exercise, but there's a focus on the affected muscles of the affected nerves. Moving on to children, any activity is effective. Children and adolescents with disabilities are more likely to be inactive than those without disabilities. Youth with disabilities should work with a healthcare professional or physical activity specialist to understand the types and amounts of physical activity appropriate for them. When possible, children and adolescents with disabilities should meet the key guidelines. When young people are not able to participate in the appropriate types of amounts of physical activities needed to meet the guidelines, they should avoid being inactive and do anything that's going to stimulate their heart rate. Here are a few unique benefits for children. It can improve cognitive function for youth 6 to 13 years old. It can, high cardiovascular fitness has a decreased risk of developing cardiovascular disease in adult life. Weight-bearing exercises in pre-pubescent girls has been shown to enhance bone mineral density accumulation, which will have beneficial impact on peak bone mass. And sleep promotes mental freshness and physical elements such as boosting immunity, endogenous release of growth hormone. My brothers and I personally have dealt with exercise-induced bronchoconstriction. So this study showed that physical activity can provide some significant benefits. Lou, again, reviewed several small studies, and I just took a few of them. But the first study revealed lung function improvement, symptom improvement, and quality of life. Whereas the second study showed force vital capacity percentage improvement and symptoms. And the third study was interesting, showing that physical activity plus meds versus meds showed improvement of lung function and quality of life when compared. So our colleagues up north for the Canadian Pediatrician Society had the following recommendations for asthmatics. Kids can take part in any kind of physical activity as long as their symptoms are under control. Physical activity can help develop stronger lungs. Activities like swimming are less likely to cause problems with asthma than activities that involve a lot of running. I prefer running or being on top of the water surfing. Parents should record symptoms, triggers, and treatments to share with doctors, teachers, coaches, and caregivers about a child's asthma and how to recognize, prevent, and treat breathing difficulties. Pregnancy. And this will be the last that I'm going to cover, which I found had some significant and important pearls. Similar to non-pregnant adults, 150 minutes of moderate physical activity per week or 20 to 30 minutes per day is encouraged by ACOG. It is safe for female athletes and other women who have been physically active before pregnancy to largely maintain their training habits, while inactive women are recommended to gradually add exercise into the routine for their own health and for the health of their baby. Despite these important effects of physical exercise, most physicians are not instructing their sedentary pregnant patients to exercise. Safe activities to advise are wrist walking, swimming, water aerobics, spinning, yoga, Pilates, strength training, jogging, or running. And there can be physiologic and morphological changes of pregnancy that can persist for four to six weeks postpartum. These activities should be, activities on your back should be avoided after the first trimester and contact and collision sports or high risk of falling or abdominal trauma should be avoided. Absolute contraindications are if there's a short in cervix, placenta previa, after gestation week 26, persistent bleeding and restricted lung disease. The benefits, decrease excess weight gain, excess postpartum weight retention, there's benefits for the future, I'm sorry, decrease future obesity for the child and mother, macrosomia, preeclampsia, reduced length of labor, postpartum recovery, avoid cesarean section. This will not lead to microsomia, preterm delivery or early pregnancy loss by exercising. So in conclusion, promote exercise to our patients, consider giving prescriptions to patients as they will listen, as proven in one of my slides, about 82% will take this into account. Emphasize the improvement of quality of life, function and pain to patients, to plant the seed for them to consider exercise and encourage the benefits for mom and the baby. And again, just getting the kid to move and be an example. So with my question, yeah, everything is true. Yeah, everything is true. So references, any questions? We had a dad date with the kids in El Paso. Noelle, thanks so much for sharing your family with us as well. It's so nice to know the person as well as the brain. So thank you. If there are any questions, please put them in the chat. Noelle, you can stop sharing your deck. In fact, Matt, you can share yours as soon as Noelle stops. And our next speaker is Dr. Matthew Bartels. Matt, a friend and a colleague and actually a mentor of mine as well. He's a chair in the Department of Rehabilitation Medicine at Montefiore Health System, Albert Einstein College of Medicine, has MD and MPH degrees from Columbia College of Physicians and Surgeons. He obviously went through internal medicine and rehabilitation medicine residency programs at Columbia Presbyterian Medical Center here in New York. He's published widely. He speaks nationally and internationally. His focus and interest is in cardiopulmonary rehab, heart and lung transplant rehab, biomechanical interventions for musculoskeletal pain exercise and cognition, and development of new models of post-acute care delivery. Matt, I'll let you carry on. Thank you so much. Well, thank you for the introduction. I'm going to start my timer so that I can stay on time because we don't want to run too late for everybody. And it's great to actually be able to talk to all of you. I'm going to be talking about the approach to physiatric prescription, blah, blah, blah, basically talking about looking at post-acute sequelae of COVID or PASC. Disclosures, none pertinent to this. And here's the pre-test question. And I guess we can actually have the survey put up. My question is actually about patients with post-acute sequelae of COVID, PASC, otherwise known as long COVID in the general public, can respond to exercise treatment to improve their recovery. Which of the following is true about the guidelines for exercise prescription? I have a single choice. And I'll give everybody a few seconds to read the answers and then put in their response. All right. Do you think we're close enough, Jonathan? I can move it forward. All right. So we'll close the survey. And I see lots of answers in one direction. So these are our objectives. We're gonna talk a little bit about PASC, talk about some precautions, know what to assess in a person who may have PASC and learn about how to write a quick prescription. So PASC is like and not like other conditions. Jonathan and I have been on multiple guideline or statement groups right now. And if you want to get a lot more information, you can go to the Academy website and we have some very good papers that are actually talking about in detail a lot of this. However, the big thing about long COVID or PASC is that it's pretty new and undiscovered. This is kind of fun in one way and that we're actually getting to be on the ground floor of a new chronic condition and actually be able to really make an impact for patients before this is something that becomes chronic and misunderstood. It has a lot of overlap with a lot of other areas of rehabilitation. And we leverage the similarities in those areas in order to make a recommendation for what we do and then use the principles from these other conditions. However, there are very unique issues in PASC and that it's unusual that there's a lot of patients that have multiple simultaneous conditions. And this kind of causes problems for us using exercise as medicine in this group because sometimes, although most of us who are in cardiac and pulmonary rehab, like Dr. Whiteson and I, are very interested in pushing as hard as we can and have the patients advance as much as possible, there is an overlying fatigue that a lot of patients with PASC have that actually acts much more like a chronic fatigue. And so it requires that we have to modify our exercise and our activity prescriptions that way. There's also issues with attention and cognition, particularly earlier on with PASC. Fortunately, from my experience and from what I'm seeing in the literature, a lot of this does recover, although some people have very long-term deficits. There's also lingering pulmonary conditions. So whatever exercise you may be doing, you may have to consider the pulmonary condition and oxygen needs. And as was in the pre-question a lot of people answered, there is concern that even if they look, the patients look like they have normal oxygenation at rest, they may actually still desaturate. And this is something that needs to be tracked. Fortunate also, I'm seeing that people with mild oxygen deficits, this is also getting better with time and not even with specific medical treatments except that tincture of time. And then there's also the cardiac and autonomic disorders. A fair number of individuals who've had PASC who had suffered coronary injury, and it could either be ischemic where there were some hypercoagulable states, or it might actually be a form of heart failure with some direct viral damage. So those overlap, when those patients have that, prescription leverages the experience in these areas. And this is where those of us who are in rehabilitation medicine have the ability to think about multiple things at once. We can balance the idea of the fact that a patient who presenting with primarily dyspnea and fatigue may also have some neurologic and cognitive issues that may need to be accounted for. And we can create a prescription that will account for that and take that as part of the treatment so that it's not just focused on one thing. The pulmonary rehab principles apply for those with only pulmonary symptoms, cardiac rehab symptoms and cardiac conditions will have basically the same thing as our cardiac rehabilitation prescription for ischemic or for more of the patients, what we see with our heart failure patients. And neurologic rehabilitation principles apply for those with isolated neurologic symptoms. But if you have some mild neurologic symptoms along with cardiac and pulmonary, you can create that hybrid program. And for the biggest consideration that I've seen in a lot of our patients is fatigue. It's the largest open variable in that in all of our patients, whether they have pulmonary, cardiac, autonomic, neurologic symptoms, if they have an overlying fatigue, it needs to be taken into account as you modify the program to allow them to be able to progress without actually making them suffer more. And the cognitive intention issues are also very important. A lot of the patients don't have the ability to concentrate long-term. So in the neurologic rehabilitation programs, you may need to modify to take into account for the fact that there are cognitive issues. But since we've always been working with patients in cognitive deficits with stroke and with brain injury, this is something that fortunately the folks that we work with and the patients can get treated by people who have experience dealing with cognitive issues. The attention deficit issues are also sometimes problematic and that recall and remembering what the precautions are and other things that they need to do may be impaired. So cardiac considerations, you should probably always include heart rate, blood pressure and intensity guidelines. And it was nicely brought forward, the FIT principle, but you really want to focus on what your modality is, how long you want to do it, how intense it is. And also you need to have precautions. You need to have the precautions of not to exceed or go below certain blood pressure, heart rate or other intensity measures. The other thing that we use significantly in patients with cardiac disease is the rating of perceived exertion. And that rating of perceived exertion that is very helpful with the patients with fatigue because that often can be your best indicator that a patient is fatiguing more rapidly than you think. And that means that you will then moderate that exercise program from your standard cardiac program. Pulse oximetry may need to be added because so many of the patients have asymptomatic hypoxia with exercise and that residual COVID injury to the lungs and of course, exercising in a hypoxic state doesn't actually help the patient and actually cause harm. So supplemental oxygen is something that may be now part of the program, although not usually used with your traditional cardiac program. And then finally, the autonomic dysfunction. A lot of these patients may have tachycardia, orthostatic hypotension, postural orthostatic tachycardia syndrome or other manifestations of autonomic dysfunction. And so that should also be taken into account and that's why the vital sign guidelines are so key. For the pulmonary portions of the rehabilitation program, you really have to think about where the symptoms may come from. There's often several elements involved in the pulmonary components of the past pulmonary disease. It's usually an interstitial lung injury. So it looks like a restrictive lung disease, not that it's exactly the same as idiopathic pulmonary fibrosis or other fibrosis, but it is more fibrotic with hypoxemia and lack of diffusion of oxygen. Patients often have a persistent cough, which will usually be nonproductive. And they often complain of persistent dyspnea, particularly with activity. There may be an underlying cardiac injury. It's not rare in COVID. So sometimes if you seem to see a patient with more dyspnea than you think is present from their lung condition, then you may actually want to make sure that they don't have an underlying cardiac issue as well. Once again, autonomic, cognitive and neurologic issues may be present. And you use supplemental oxygen as needed and also hopefully work towards weaning the oxygen. I've had several patients, it's taken up to a year and a half to two years, but they are able to eventually wean off the supplemental oxygen. If not with all activity, at least at rest and at night, and then sometimes with higher levels of exertion, they still use it. And you always monitor fatigue as a separate issue because it has to be recognized that it can be present. And if you work into that fatigue, you can actually make the patient have a longer recovery and actually maybe even regress and have more symptoms. The dysautonomia is rather common and you'll see a lot of patients complaining of tachycardia. It's often asymptomatic or mildly symptomatic, but some patients come in with severely debilitating palpitations and tachycardia, or they may be getting very lightheaded with any orthostatic changes and maybe finding that they're very dizzy lightheaded. You do need to separate dizziness from lightheadedness because dizziness may actually manifest as a part of a neurologic syndrome that's still persisting rather than the lightheadedness, which is more instead of the room spinning, it's the curtains are closing down. You have to take these symptoms seriously and you have to modify your exercise accordingly. So for example, more seated exercise rather than standing exercise, and also longer warmups and cooldowns may be needed, and or you may not have very high intensity, but you may just have prolonged increased periods of activity rather than really formal exercise. Monitor for the fatigue, consider the medical interventions in combination. So if you're seeing a lot of these autonomic symptoms, it may be worthwhile to work with an autonomic specialist so that you can actually get the patients on salt supplementation or other medications that may actually help with modifying their blood pressure responses. The cognitive and neurologic sequelae of PASC, traditional rehabilitation prescriptions often apply very well to the cognitive and neurologic sequelae. Neuropsychological services are very key in helping to get these patients into the right treatments and also to help design a program of compensations and then recovery. But you also wanna make sure that the cognitive or neurologic symptoms are not due to the cardiac autonomic pulmonary or fatigue issues. So for example, if somebody is having a lot of autonomic dysfunction with fluctuating blood pressure, they may look like they're having cognitive issues when they're actually having hyperperfusion because of the fact that they are not actually having a sustained normal blood pressure. Or if they're having chronic hypoxemia, which is asymptomatic, that will cause people to have decrease in attention and memory. So you do need to be a little bit broader in your evaluation to make sure that those cognitive issues don't have a medical underlying cause or contributor. Make sure that there's no over fatigue because that in and of itself will cause a lot of problems with attention and monitor for the cardiac issues. Oxygen saturation, once again, is key. And this is where we want you to just make sure that the patients have pulse oximetry. Fortunately now, it's readily available and many, many patients who've had COVID or who have been treated for COVID do have the home pulse oximeters. Fatigue is probably the number one complaint of most people who are survivors of COVID. It can be very mild and usually very self-limited and hopefully self-limited and resolving, but it can also be very severe and cause severe disability and inability to return to work, to return to normal activities. You do need, once again, to make sure that hypoxemia, cardiac failure, cognitive, autonomic, or neurologic issues are not contributing to the fatigue so that you're actually identifying that this is a fatigue that's an essentially chronic fatigue that's related to PASC. Your exercise program is modified to focus on improved levels of activity within tolerance, focusing on not getting the patient to be more fatigued after bouts of exercise than they were prior. And this is especially important in following the day after. If a patient does exercise and is fatigued that day from the exercise, that may be normal, but if they're more fatigued the next day, that was too intense a program and it needs to be modified. So the no pain, no gain mentality that we use with a lot of our recovery doesn't work in these patients. And you need to support patients emotionally by addressing the comorbid issues and physically by addressing those issues, because this is something that is very, very, very hard to deal with, because you often have people that were very high functioning who now can't resume their normal activities and are frustrated. So how do you address this with your prescription? Well, you have to have a broad net, not a tunnel vision saying, oh, you came in here with just a neurologic problem. I'm giving you a neurologic prescription. You need to make sure vital signs, precautions, and limits with maximum and minimum heart rates and blood pressures are present in all prescriptions. You have to include oxygen monitoring and SpO2 monitoring because you want to make sure that the patients are actually not hypoxemic and have target levels and precautions. Oxygen is good for the patients. And it's good for you as the clinician because it means that you're confident that you're not hurting the patients. So hypoxemia will exacerbate almost all of the issues. So you want to monitor for it and make sure the oxygen is available. This may lead to a little bit of a battle with insurance companies. Currently, the oxygen supplementation for long COVID survivors has been extended for another year, but that may be a problem in the near future if that doesn't get automatically extended because some of these patients don't have the classic justifications that you would see in a patient with COPD or other disease. Make sure you have the monitoring guidelines for fatigue and make sure that this is being assessed with perceived exertion and teach the patients how to manage their fatigue. And then once again, don't forget autonomic dysfunction. Really assess the patients. You might want to do a evaluation in the office looking for orthostatic hypertension and dysautonomia. So a sample prescription, this is long. This is not eval and treat, you know, report back to me. This is getting a resting heart rate that's between limits, having a peak heart rate of less than a certain amount. Assess the recovery of heart rate. Make sure that patients are not having prolonged post-exercise tachycardia. Blood pressure ranges between minimums and maximums. Some of these patients may present very hypotensive or hypertensive, but you don't also want to have patients exceed high blood pressure or thinking of autonomic dysfunction. If during activity, they start to drop their blood pressure, then that may be an indication that that level of activity is too intense. Oxygen saturation greater than 90% and monitor for fatigue, looking very closely at perceived exertion and reported fatigue. So in conclusion, I'd love to talk more and more and more about this and give you lots of examples of specific prescriptions, but patients with PASC respond well to exercise and to increased activity and to rehabilitation interventions, remembering that you don't want to over fatigue them. There needs to be appropriate appreciation of the contributions of that fatigue and also worry, concern about hypoxemia, cardiac and autonomic dysfunction that wasn't prior noted so that you do need to monitor these patients a little bit more closely. Simple modifications will often allow for monitoring and most of your therapy and or other physiology colleagues who will work with these patients can do the monitoring. It's not that complicated. Pulse oximetry actually fortunately is now readily available. And add precautions and guidelines for all the vital signs. Remember hypoxemia, fatigue and guidelines, looking at making sure that you actually keep in mind all of the potential sequelae of having long COVID or PASC. And this is the answer to the pre-test question, which I don't think was much of a surprise for most of you, that supplemental oxygen can play a role in exercise and PASC even for those with normal risk of saturation. And I've got some links here for all of the guideline statements that were done through the Academy regarding exercise and recovery for PASC. And thank you. Matt, thank you so much. That was wonderful, really very informative. And Talia, you're gonna share your screen next. You can get sharing. And Talia also has been involved with a lot of the post-COVID and PASC collaborative work and has also been a very active member of this community and every year has spoken. So Talia, special thanks to you for being so active, so involved, so willing to participate and to teach your peers. Dr. Fleming is a Medical Director of the Stroke Recovery and Post-COVID Rehabilitation Programs at JFK Johnson Rehabilitation Institute at Hackensack Meridian Health in Edison, New Jersey. He's an Associate Professor in the Department of Physical Medicine Rehabilitation at Rutgers Robert Wood Johnson. And clinical interests and research interests include neuro-rehabilitation transitions of care. Talia, thank you so much for speaking today. Thank you so much for that fun introduction and for joining us today. I appreciate you taking your time out of your busy schedule to be here with us during this presentation and just an honor to join this group again for another year. So in light of our time, I'll jump into the presentation itself. I have some disclosures related to my stroke recovery work, but nothing related to this particular activity. So this is my picture. This is November, 2019 at the Philadelphia Half Marathon. A little bit about me. This was my first half marathon and it very well could be my last half marathon. Definitely had a lot of fun while doing it. This is pre-COVID, things have changed since then. But in Philadelphia, the course actually runs through a lot of the historical sites there. So I got a chance to feel the energy of the people. If you haven't done a half marathon before, I encourage you all to at least go to one, stand on the sides, ring the bells, cheer the people on because it really does help. So it's a little bit fun about me. So here's our first question. Christine, can you share the polling question? So I'll read it to everyone. And for those of you who may not be able to see the screen, which of the following statements are true concerning the position of the World Health Organization with respect to the state of physical activity around the world? So choose one. A, global estimates show that one in four adults and 81% of adolescents do not do enough physical activity. Two, economic development is associated with increased physical inactivity. Three, physical inactivity is one of the leading risk factors for non-communicable disease mortality with 20 to 30% increased risk of death compared to people who are sufficiently active. Number four, the World Health Organization has created an action plan applicable and adoptable to all countries, providing countries a roadmap for implementing a national response with a whole system approach to implementing physical activity levels. Or D, all of the above. So I'll give you a couple of seconds to put, select your answer. It's probably enough time. Can we get any results? Ah, we have a winner. So the objectives today, we're gonna describe the World Health Organization's perspective in terms of demonstrating the physical, mental, and emotional benefits of exercise and physical activity. We're gonna explore specific exercise recommendations from the World Health Organization and also examine how we can translate these benefits to our patients and communities. Really important, how do we put this into practice? So one, demonstrating the benefits. In general, they define physical activity as any bodily movement produced by skeletal muscles that requires energy expenditure. So that includes leisure, transportation back and forth between locations, and part of work. They define sedentary behavior as very low energy expenditure. For example, sitting or lying down, especially at extended periods. And they specify that this sedentary behavior can be linked to detrimental health. They define exercise as a type of physical activity that involves planned, structured, and repetitive bodily movement done to maintain or improve one or more components of physical fitness. So they took a look at different data points really around the world, and they defined that there's a crisis that's going on right now. In terms of current levels of physical inactivity, globally, we are really insufficient in terms of providing the physical activity that's needed to maintain health. Worldwide, one in four adults are not sufficiently physically active to protect against common chronic diseases or to improve their health. That was a staggering number that I thought. Really, they're finding this globally. Economic development is associated with increased physical inactivity, and they're finding that it's more than two times as high with high-income countries. So in high-income countries, one in four men and one in three women are not needing the recommended doses of exercise. They're finding that's in part due to more sedentary time at work and at home and also more passive modes of transportation. Lastly, they found that more than 80% of the world's adolescent population aged 11 to 17 is not getting enough exercise, with about 85% of adolescent girls and 78% of adolescent boys are not meeting the criteria. So we talked a little bit about this earlier. I feel like this is gonna be a theme throughout the evening, how physical activity improves physical fitness, cardiometabolic health, bone health. It's also shown to improve cognitive outcomes in terms of academic performance and executive function. It can improve mental health and reduce adiposity. And in adults, it's shown to improve all-cause mortality, cardiovascular disease mortality, as well as cancer mortality. The risks of inactivity are as follows. Physical activity is one of the leading risk factors for non-communicable disease mortality, with 20 to 30% increased risk of death compared to people who are sufficiently active. So again, another layer showing us that how important physical activity is. Higher amounts of sedentary behavior are associated with poorer outcomes in children and adolescents, as well as adults. So let's look at specific recommendations from the World Health Organization. In general, these are the minimum recommendations for what is needed for good health. The recommendations are separated by age and then they also go into special populations. So I'll breeze through some of this in the interest of time. They break it down into children that are under five years old, specifically infants that are less than one years old. They recommend several times a day, at least three minutes of tummy time or on their prone position. They specify not being restrained for more than an hour, no screen time and adequate sleep for these infants less than a year. For children between one to two years, they recommend 180 minutes per day spread throughout the daytime. Again, limit that time restrained in a stroller, high chair or carrier. Limited screen time. So age one, no screen time. Age two, less than one hour per day. And again, promoting adequate quality sleep with regular sleep and as well as wake times. For children three to four, 180 minutes per day with specifically at least 60 minutes of moderate to vigorous intensity. And also three times per week strengthening muscle and bone. And looking at adults age 18 to 65, they recommend either moderate intensity or moderate intensity sleep. And again, they recommend 60 minutes per day of specifically moderate to vigorous intensity throughout the week. And also three times per week, strengthening muscle and bone. And looking at adults age 18 to 65, they recommend either moderate intensity aerobic type of activities for 150 to 300 minutes per week or vigorous activities between 75 to 150 minutes per week. They also recommend at least two times per week muscle strengthening for all muscle groups. And again, increasing the activity beyond this time will improve further health benefits. When sedentary, they recommend replacing a lot of sedentary activities with low intensity activity. So they may not be able to do that So they made a point to say that if you physically can't get up and move around a little bit counts more than not doing anything at all. In particular adults over 65, again, we have the 150 to 300 minutes per week of moderate intensity activity as well as 75 to 150 of vigorous intensity activity. For this group, they also emphasize functional balance and strength training activities for three times per week. The World Health Organization also talks about special populations. I'm not gonna go into too much here because we have other presenters that will go more in depth. But if you are interested, they go into pregnancy and postpartum. They go into children and adolescents with disabilities as well as those with chronic conditions including hypertension, diabetes, and cancer. In general, this is a summary recommendation. So if you wanted to print this out, this is available and kind of give this to your patients as a one-stop shopping in terms of the recommendation. So that's another helpful thing that I found useful sometimes in the office. And now lastly, we're gonna see how they recommend to translate these benefits to our patients. They put together an active toolkit which they developed this global action plan really promoting what they want the globe to show changes from 2008 on through 2030. And their goal is to target a 15% reduction in global prevalence of physical inactivity by 2030. So they came up with four objectives and 20 evidence-based policies. They broke the four policies into main areas. They talked about active societies, active environments, active people, as well as active systems. Active societies, they took a look at how they can communicate this message differently, how they can look at benefits as well as large participation events and building capacity and infrastructure for how we can do this. In terms of active environments, they looked at what policies need to be integrated as well as safety protocols and really developing public open spaces to be able to execute these types of activities. For active people, they wanted to take a look specifically at how they can partner with schools, healthcare organizations, and how they can target specific populations such as older adults and those who have trouble with activities. And in terms of the systems, they really wanted to take a look at government. How do we develop data systems to collect more information as well as using evidence-based protocols and advocacy to really push this forward? And they conceptualized this as a whole systems approach for how different countries can do their best in terms of moving their population towards more active lifestyles. So taking a look at our question again, as we all know, all of the above, and now we know the reasons why. So thank you very much for your attention. And if you have any questions, put them in the chat and I will answer them. Thank you. Talia, thank you so much. That was vibrant and so interesting and very, very helpful. And there are some questions in the chat for all the people who've been presenting. There are some questions, so we'll answer them in the chat and maybe we'll have time to talk again a little later. So next up is Jonas Sokolov. Jonas is a physiatrist, a friend and colleague of mine here at Rusk. He underwent residency training in physical medicine rehab at Harvard Medical School, Spaulding, and then fellowship training in musculoskeletal and sports medicine interventional spine at Kessler Institute and early part of his career at Memorial Sloan Kettering Cancer Center. In 2018, actually came and joined us here at Rusk Rehabilitation. He's a clinical associate professor of rehab medicine here at NYU Grossman School of Medicine. He has tremendous passion regarding lifestyle medicine. I think we'll hear some of that passion in his talk right now. Also research and peer review publications in terms of the role of lifestyle interventions to improve life in people living with and beyond cancer. He's a member of the American College of Sports Medicine's International Roundtable on Exercise and Cancer and sits on the executive committee of ACSM's Moving Through Cancer Task Force on exercise oncology. Jonas, it's an honor and a pleasure. The floor is yours. Thank you. Can you hear me okay? Yeah, perfect. Okay. One disclosure. I sit on an advisory board for a physio yoga company, Three's Yoga. Should we put up our question? I don't have a slide for that. Okay. What is the minimum amount of recommended exercise for individuals undergoing cancer treatment to help improve cancer-related health outcomes? Examples, depression, anxiety, physical function, lymphedema, et cetera. And if you can't see the whole response, you can just hover your mouse over it and you'll see the whole response. Okay, moving on, we're gonna show the poll. All right, okay, so if we think about the current model of how we rehabilitate people living with and beyond cancer, right? I mean, most of us just in general in physical medicine rehabilitation, we're working really mainly with an impairment driven model, meaning that somebody comes to us with some sort of specific physical complaint or impairment. We diagnose them, we assess them, we evaluate them, we may prognosticate, and we come up with a treatment plan, an intervention, right? And we really tend to focus really mainly on that one sort of area of body region in many instances. For example, in cancer rehab, somebody may come to us with post-mastectomy pain syndrome, for example. So we'll look at the upper body, upper limb movement, the shoulder movement, and we'll focus specifically on that area to alleviate pain, to improve range of motion and the like. In my practice, being sports medicine trained, this was a model that was passed on to me by Jay Smith from Mayo Clinic. It's sort of the baseball diamond approach, being that we're in the playoffs of the baseball season, like, you know, it's really apropos. Somebody comes to us, again, physical complaint or impairment. The goal is to get them back to a successful return to play, successful return to life. You have to get them to first base, the first step, you have to have pain control, right? Whether that's prescribing medications, performing injections, prescribing some sort of orthotic, performing integrative modalities, osteopathic manipulation, acupuncture, et cetera. You have to have pain control as the first step. Next step to get to second base, restoring range of motion. Third base, we start to work on strength and endurance and working on the, rounding third, working on the whole kinetic chain, maybe treating body regions above and below the problem area. And then hopefully the person gets back to what they want to be doing, right, in life. But something's really missing there. Really what belongs on the pitcher's mound is lifestyle, lifestyle intervention, which I'm very passionate about and try to incorporate it in my oncological rehabilitation practice. So we look at cancer in itself, and unfortunately the disease is not really going away anytime soon. While we've gotten better at curing some cancers, certainly better of screening and identifying, diagnosing cancers earlier, unfortunately we've gotten much better at sort of prolonging life and not really coming up with a cure. And the incidence of cancer is actually on the rise. It's the second leading cause of death, but it's believed to, it's going to overcome cardiovascular disease in the very near future. It's going to become the number one cause of death actually worldwide. According to the World Cancer Research Fund, analysis shows that about a third of the most common cancers actually are preventable through lifestyle factors. So an optimal diet, maintaining a healthy weight, knowing that obesity is associated with at least 12 different types of cancers, and of course, regular physical activity. We can actually prevent a lot of these cancers actually from occurring to begin with. So there's numerous studies available on the role of healthy lifestyle behaviors as it relates to the disease. There's lifestyle guidelines actually from the American Cancer Society, American College of Sports Medicine. However, we know that people living with or beyond cancer are really, they're not really more inclined to change their lifestyle habits. Really, it's physiatrists really have that opportunity to have that teachable moment with our patients, really inspire them to really change their lifestyle, intervene from a lifestyle perspective. We get to follow our patients over the long haul and really intervene in that way, which I find very rewarding. Now, American College of Sports Medicine round table on exercise and cancer, which I feel really blessed to be a part of, the second round table. The first round table met in 2009, came up with their guidelines. I think they were published in 2010, essentially looking at all the randomized control trial data to come up with guidelines on how we should prescribe exercise for people living with and beyond cancer. Now, from that time in 2009 up until about 2018, the amount of randomized control data almost doubled, actually, almost tripled actually in that time. So it was really, they had to reconvene the round table and really revise those guidelines because of all the amazing data that was coming out. So I was lucky enough to be a part of that and we met and then came up with three papers, two of them published in the ACM journal and one was published in the journal CA. Essentially what we discovered from our analysis was that we now had data that showed exercise is preventative for at least six different types of cancers, which you can see on the slide. We found out that sedentary behavior was actually, there's moderate evidence to indicate that a lack of physical activity actually increases your chance of developing endometrial colon and lung cancer. Moderate evidence to suggest that if your chances of surviving breast and colon cancer were much greater if you did exercise before you were diagnosed. And if you began an exercise habit after the diagnosis of breast or colon and prostate cancer, your chances of surviving are actually greater. So literally you're using, we're literally exercise as a medicine, right? And that's what I really love about the field of oncorehab is that I feel like I'm actually able to treat the disease too. If I can help my patients get on an exercise program, I can actually intervene on the actual disease process and prognosis itself. What we were really looking for from that second round table was, is there a specific dose, right? Looking at a FIT prescription, which is so eloquently covered by some of our speakers earlier in this presentation, right? The frequency, the intensity, time and type. That's how we essentially prescribe an exercise program, using that acronym. Was there a minimal effective dose that we could prescribe to help with some of these outcomes and help with survival, right? Well, we did find that when we looked at specific health outcomes and we did a pooled analysis of all the data that we had available up until that time, we actually found that exercise can actually improve many of these, what we call cancer-related health outcomes. So reduced anxiety, fewer depressive moods, overall better physical function, quality of life. Lymphedema, okay? Especially with resistance training. Fatigue being a huge one. Almost every single cancer patient will get fatigue at some point or another in the continuum of care. Now, if we looked individually at aerobic training and we saw these benefits for these outcomes that you see there on the slide, and we looked at resistance training, we saw benefits, but when we combined the two modalities, combined aerobic with resistance, we seem to capture more, that we were able to get more health-related, cancer-related health outcomes when we combined the two modalities. And what we found was, yes, there was an actual, what we extrapolated was that there was an actual minimum effective dose. And that dose was 30 minutes of modern intensity aerobic exercise, at least three days a week, or 20 minutes of vigorous exercise, three days a week, combined with total body resistance training or strength training, two days a week, right? And that was the minimum effective dose. And that's what we were trying to get our patients to adopt in oncological rehabilitation, when we see patients in our oncological rehabilitation program. Or the question really isn't, should we be prescribing exercise as physiatrists, but how do we optimally do it, right? So when do we do it, right? How much do we prescribe, right? Who should do the actual prescription? Who should be doing the actual education or actual training? Who should be monitoring? How frequently should patients be exercising? And then what's the safety? How safe is it for the patient? So when? Absolutely throughout the entire cancer care continuum, from the time of diagnosis, all the way through the treatment phase, into remission, and even in the palliative phase of care, there's always a role for exercise. So we wanna start right at the time of diagnosis, get a baseline physical assessment, educate and advise. If patients need to get on a prehabilitation program, if we're able to do that, we're able to get it covered, then we should absolutely do that because it's gonna help them get through their treatments a lot easier with less side effects. When they're going through treatment, when they're getting chemotherapy, when they're getting radiation treatment, okay? After surgery, they should be on an exercise program. In the UK, there's a program that's similar to our Moving Through Cancer program. And there's patients while they're getting infused, they're on an exercise bike, for example, right? That's becoming more and more the norm now in oncology. What? Well, moderate intensity, right? Moderate to high intensity has been shown to be safe for people living with and beyond cancer, okay? If patients are not willing to exercise at that level, then low intensity exercise, such as yoga, various movement, Alexander technique, Qigong, Tai Chi, so forth also does have benefits, especially on psychological benefit, anxiety and depression. We definitely wanna get them moving. How much? We talked about that earlier. We did find that minimum effective dose of the 30 minutes of moderate aerobic or 20 minutes of vigorous aerobic, three days a week at the minimum. This is the minimum, right? The goal would be ideally to get them to the recommended guidelines for all healthy adults, which was again, very nicely covered by our previous speakers, plus the total body resistance training, right? And that could be with weights, that could be with resistance bands, that could be body weight resistance. Who? Who should be doing the actual prescription? Absolutely physiatrists, right? Physicians. They need to be aware of these guidelines. They need to be aware of the benefits. They need to be supportive. They need to be prescribing the exercise. When it comes right from the physician, patients are likely gonna be more willing to adhere to a program. They're likely gonna be more willing to exercise to begin with. They actually get a written prescription from their physician. Physical therapists absolutely play an intricate role, especially in our program here at Rosk in helping to facilitate the exercise prescription. They perform very in-depth movement analyses. They understand the disease, at least the folks, the physical therapists that assist them to seeing cancer patients. They understand the biomechanics. They understand where their impairments may be in movement and how to get them, let's say, on a resistance program without causing injury. Exercise physiology absolutely can play a very valuable role in facilitating exercise prescription, community-based exercise trainers, such as those that you might find in like the Livestrong program, for example. And of course, there's also self-directed. Many folks do come to us with a history of exercising. They get a diagnosis of cancer and they stop. They're just, well, I have cancer. I'm getting chemo. I was told, my oncologist told me to take it easy. So I stopped. But they may have a knowledge, a previous knowledge, and they don't know that it's safe for them or even advisable for them to get back on a program. So they can do a self-directed program. And that brings us to safety, right? So we wanna understand the disease. We understand where the disease lies. If they have metastatic disease, if they have metastasis to the axial skeleton or to the appendicular skeleton, is there a risk for pathologic fracture? What types of treatments are they on? Are they on cardiopulmonary toxic treatments? Are they on neurotoxic treatments, right? Do they have chemotherapy-induced peripheral neuropathy, right? We may not want somebody with chemo-induced peripheral neuropathy to go on a treadmill, for example, right? Risk of injury. So we wanna be able to accurately assess the safety of getting that specific patient on a program. Do they have underlying risks that would preclude them? Would they need clearance? Would they need more advanced testing? Cardiopulmonary, for example. These are all things that we need to consider. But if not, then we wanna make sure that they can advance to a program. Now, in our third round table paper that was published in CA in 2019, we wanted to promote this assess, advise, and triage approach, right? So that means we wanna be able to assess where patients are at really at every single visit. And this is across all healthcare disciplines, oncology, radiation oncology, surgery, certainly in rehabilitation medicine. We wanna actually ask the patient how much exercise they're getting in on a regular basis. We wanna ask them how many days during the past week have you performed physical activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more? Getting a sense of their aerobic, right? Exercise, how much are they doing? How many days a week then are you doing in the past week? Have you performed physical activity to increase your muscle strength, such as lifting weights or calisthenics, okay? We wanna get that assessment. And if they're not currently meeting those guidelines, we wanna advise them on what those guidelines are. We wanna educate them and set the bar where they should be going, okay? We don't wanna be so forceful and tell them that you have to be there. We wanna allow them to get there gradually but we want them to know what the goal should be. Then we wanna advise them on what they should actually do, prescribe them the exercise and then triage, right? Who should be performing? Who should be prescribing? Who should be educating? Who should be actually teaching the patients what to do? So we need to assess, are they safe to exercise on their own? Would it be more beneficial for them to go into more of a community-based program? Many studies suggest that a supervised program has more adherence than when someone is gonna do it on their own. I know for one, I like to exercise in classes. I take classes. It's very hard for me to do it on my own. Supervised program might be a better fit for that person. You need to get assessment of that. Certainly if they're a little bit lower level, like an ECOG score of three, hopefully not more, but if they're early at that level and they're a little bit lower level, then they may need to be more in a very sort of monitored, maybe an outpatient-based rehab program. So we do have prescriptions actually available that we actually give to our patients. These can be found on the Moving Through Cancer website, which is, you know, Moving Through Cancer is a subsidiary, if you will, of the Exercises Medicine Movement. You'll find this prescription there. And essentially the guidelines are right there. It kind of explains what moderate and vigorous intensity is to the patient. We use the talk test, right? Moderate would be that they wouldn't be able to sing a song but they would still be able to have a normal conversation, but they can't sing. At that level of intensity, 30 minutes, at least three days a week, strive to do more. Strive to do these, you know, five or more days a week. Combine that with strength training, total body strength training, hitting every major muscle group in the body at least twice a week, okay? And then finally, through the Moving Through Cancer movement initiative, we've developed this infographic for patients, really explaining to them, and hopefully in a very simple, easily understood way, what they should actually be doing. You can see the icons there, as far as a minimum effective dose of exercise to help improve those health-related, cancer-related health outcomes, such as fatigue, overall physical functioning, lymphedema, and et cetera. And this actually comes with a booklet that goes way deeper into that. With a booklet that goes way more in depth. And that is it. Thank you. Any questions, please email me, and below you'll see the website for our Moving Through Cancer initiative. Thank you so much. It was an honor to be with you. Do I want to post the question again? Or not? I don't know if we're going to post the question again in terms of, oh, there we go. It's put up. There you go. Go ahead, Jonas. What's the answer? It's a moderate intensity, three days a week, combined with a two days a week of resistance training. That's the minimum you want your patients who are living with and beyond cancer to achieve. Thank you so much. Wonderful, Jonas. Thank you so much. In our schedule, we actually scheduled to have a little break at this point. And I am fine with a little break. I'm also fine to continue going. I know some of you can post in the chat if you want us to break. If you need two minutes for a bathroom break or to grab a glass of water, or our presenters, you can unmute or stick your thumbs up if you want to continue. What are the thoughts? We can continue right on, or we could, I'm seeing Neil and Matt saying continue. Yeah, Melissa as well. Melissa's up next, so I can understand that. Okay, well, it puts us back on schedule because we were 10 minutes delayed, but as I said, we do have wiggle room. So why don't we just continue right on? We've got great momentum. We have four more talks to come your way. And so we'll do that. Melissa, why don't you go ahead and share your slides? Dr. Melissa Tinney is a Clinical Assistant Professor in Physical Medicine Rehabilitation at the University of Michigan. She works in the Amputation Program and Adaptive Sports Program Director in Ann Arbor VA Healthcare System. Also serves on the National Medical Team for National Veterans Wheelchair Games since 2017, and is on the Executive Board, University of Michigan Adaptive and Inclusive Sports Experience and Wheelchair Tennis Coach. I just have to say before you get going, Melissa, that every speaker, and it just, you know, it makes me smile and it encourages me. There's such a wealth of experience in this community and great examples to us all in terms of what can be done and what can be achieved and so much variety. So all of us speaking, but I'm sure others who are listening as well. I mean, we all have different experiences of exercise as medicine, but it is really heartwarming to see physiatrists playing such a varied role around the country and a leadership role in all of these organizations. So I just congratulate everyone and it's such a pleasure to listen. So anyway, enough said, Melissa, go ahead. Thank you so much, Jonathan, for that kind introduction and comment. So I guess we could start with the polling question. Maybe we'll start there. And so this is more for just kind of gauging the audience as to kind of where we're at as a group. Not so much that I'm trying to find a correct answer at the end. So anyway, you can pick, I think it should allow you to pick any of the choices, as many as you want. And while we're waiting for the results, I'll just mention a little bit about me. So this summer, so I do teach beginner wheelchair tennis for our adaptive program through Michigan Medicine. And so we had a guest coach at one of our clinics this summer. And so he's the storm trooper, is kind of an unofficial mascot for the University of Michigan. And you see him in a lot of sports events. So that was pretty cool. All right. Like someone said, fingers crossed and wishful thinking. Thanks for being honest. I appreciate that. Well, hopefully I can give you some tools after today's discussion because that's kind of where I felt like I was left with in my practice for a period of time. All right. So I'm going to talk about really what happens after. Everyone has given these amazing descriptions and guidelines really going over how much we can impact our patients' health. I do have one disclosure. I do work for a benefits corporation that is looking at adaptive sports and the adaptive sports movement, looking at global industry and how we can move the needle on access to adaptive sports equipment and programming throughout the world. So I really wanted to talk about advocacy because I found myself in this role as I'm prescribing exercise in my own practice. And so really wanted to discuss with you about how we can advocate for equitable access to medical equipment and programs to really facilitate, you know, the exercise prescriptions that we're hoping to achieve for our patients with disabilities. So today I wanted to go over objectives. So the objectives are reviewing barriers for participation, reviewing current insurance policy limitations. Someone in the chat had kind of mentioned a little bit about or had asked about insurance coverage. Identifying tools and strategies to improve access. Discussing current legislative efforts and also identifying resources. So two-thirds of people with disabilities do not participate in sports. So, you know, this is a narrow definition in regards to activity. But in this reference, they talked about sport as a activity that involved physical exertion with or without a game or competition, or with or without a game or competition elements with a minimum of 30 minutes at least two times a week where skills and physical endurance were either required or to be improved. And one-third of people without physical disability were identified as not participating in sports, but two-thirds for those with disabilities. So, you know, what are the reasons that somebody might not participate in an adaptive sport or recreational activity? So certainly there are a lot of different barriers and you can see a large variety. But a big one is access, really access to equipment, access to programming, transportation, expense, you know, there's a lot of different things. Categorically, you could kind of break these down into like the physiologic barriers, which a lot of us are very obviously familiar with. Emotional, again, some of you have already identified, you know, that those fears or hesitation. And then logistical, which I'm going to be focusing a big chunk of that towards the end of the talk. So this was already referenced in one of the talks earlier today, looking at the CDC and their discussion of people, you know, the health of people with disabilities. And so certainly I think this graphic really helps kind of lay it out that, you know, we see the numbers really jump in regards to comorbidities, which is why we're here discussing what we're discussing. So really certainly we've already identified that a person with a disability may be less likely to engage in physical activity due to higher rates of chronic disease. But certainly thinking about a condition being severe or fluctuating or progressive certainly has an impact. And again, you know, common musculoskeletal injuries could have a greater functional consequence for our populations that we're treating. So certainly there's inherent risk to any sport, but certainly risk is, you know, it can be increased and really can change somebody's life course. This was a photo from the National Veteran Wheelchair Games in Tampa. Certainly makes you want to close your eyes. So I really wanted to focus on lack of infrastructure as one of the big barriers and multiple facets of this really in regards to healthcare, sports programs, equipment access, and transportation. So CDC also summarized, you know, healthcare access barriers for those with disability. So one in three do not have a usual healthcare provider. One in three have an unmet healthcare need because of cost in the past year. And one in four did not have a routine checkup in the past year. Certainly those of us who have, you know, have seen, you know, our patients will fall off, you know, their regular checkups, things like that can certainly see that that can be a problem. So lack of education or knowledge. And I think that kind of goes across, you know, all facets of who might encounter a person. So from the patient and participants' knowledge of what is possible, from the providers knowing what they can recommend and how they can facilitate things, the school systems, and really how they might be able to provide this education to children with disabilities and certainly our sports educators. So, you know, in all sports, it's not unique to hear pay to play. And you see that in able-bodied sports, but certainly when you're thinking about adaptive sports, obviously the cost becomes much greater when there's a huge investment to be able to get specialized equipment to participate in that sport or activity. And so I just wanted to show you just kind of a spectrum of the costs of a variety of different pieces of adaptive sports equipment. So you'll see there on the top left, there's a power soccer power chair. It's a very specialized running blade for prosthesis. The wheelchair on the top right is an all-sport wheelchair that can be used for wheelchair tennis, wheelchair basketball. On the bottom left is a monoski for downhill skiing. In the middle bottom is a sled for sled hockey. And you'll see a hand cycle on the bottom right there. So this is just an example of what is available. Right now, a lot of insurance will not cover, you know, sports equipment. I am fortunate to practice in the VA system, and there is a mechanism for veterans to obtain this type of equipment to engage in adaptive sports. But this is just a small listing from a large organization called Move United, which helps support adaptive sports programs across the country. And so here's a list that they have shared on their website. And you can see there's a few here, but really it's not enough to fit the need if the model is to have somebody apply for a grant with a charity, and that's their mechanism to be able to engage in their sport. So just as an example, this was taken from one of the nonprofits that were listed, the Kelly Brush Foundation. You can see over the course of three years, you know, their applications grew, but it's such a small drop in the bucket of where they can impact. Now this foundation is more focused on winter sports. So just to highlight, you know, the insurance industry will certainly be quick to provide, you know, sponsorship for big events like, you know, races, marathons, et cetera. And they even talk about, you know, well-being and reaching health goals. But when you look at policy coverage and the determinations for not medically necessary in regards to prosthetic coverage, you'll often see that it's, you know, no part, no coverage for participation in recreational activity. So what are the things that we can do knowing that we have all these barriers? So certainly tools and strategies to facilitate, to advocate, to educate ourselves and our patients, I think, is really, I've learned a lot along the way. So to facilitate participation, I know some, you know, there was some discussion in the chat about, you know, what do you do if somebody doesn't want to go to the gym. Certainly over COVID, Move United was instrumental in getting a lot of the chapters. There's over 200 adaptive sports organizations that have contributed to a free on-demand, you know, exercise portal. Basically, I think this could apply to any population that we're talking about. It's probably the largest catalog that's available in our country, and I certainly recommend it. And there's a large variety that kind of suits all different interests, I think, from like more Zumba-related classes to things that are more, you know, fitness-related strength training. So anyway, that's another option, and I know that Zoom was mentioned. Really thinking about strategies of how we can include in our evaluations and in our documentation, you know, the idea of expanding, you know, the ability to perform exercise in ADLs would be a really big shift in our field, and I actually don't think in a big shift in the sense that we don't already think about it, but it would be very strategic and purposeful for us to define it and to include it in all evaluations. And obviously, we would be leaning on our therapy colleagues to also be, you know, advocating to include this in the standard documentation. Another strategy that might move the needle is thinking about, you know, adapting coverage for exercise-based treatments from insurers, and certainly a lot of you are probably familiar with the Silver Sneakers program from Medicare, where they have classes and on-demand videos for, you know, no additional cost. I think that something like this for someone with disabilities would be an amazing thing for us to consider, you know, nationally. Move United is one avenue, but I think that there is a way for, you know, potentially to work with insurance. Speaking of insurance, so, you know, to talk about expanding health plan coverage is, you know, sounds like really pie in the sky, but actually one example where there was some success in impacting access is in Maine. So, they had an act to improve outcomes for persons with limb loss, and this was actually signed into law in May of 2022. And if you look down at the bottom, it actually defined, you know, for, you know, somebody who is under 18 years of age, so they focused on children having access for, you know, a prosthesis that's appropriate to meet the medical needs of the enrollee for recreational purposes is applicable to maximize the enrollee's ability to ambulate, run, bike, and swim, and to maximize upper limb function. So, that was very clear definition and pretty huge for the state of Maine, and I hope that other states will follow suit and we can use this as an example. And so, I know that we talked about the World Health Organization. Certainly, the United Nations also has had, you know, clearly defined that participation in recreation, leisure, and sport is one of the articles in the Convention on the Rights of Persons with Disabilities, and certainly this was echoed last year by the High Commissioner to the Human Rights Council. So, it's definitely on the global consciousness, and, you know, I think that we have, you know, through our patients and educating our patients and our own position as leaders in this area, I think it's very important that we, you know, use these, you know, statements and these large governing bodies, you know, supporting this, that we include that in all of our work. So, you know, another strategy, or I wouldn't even say strategy, really one consideration, I think we've seen it in the state of Michigan where I am, is that athletes with disabilities are are basically highlighting that it's discriminatory for them not to be able to participate at their fullest level as their able-bodied counterparts. And so, in 2015, there was a deaf wrestler who won the right to have an interpreter beside him during his wrestling matches, and this was Kemp versus the Michigan High School Athletic Association. And so, if we fast forward, you can see that actually just this last spring, they officially added wheelchair races to track and field tournament season and added a new Paralympic swim event. So, so it took some years later for it to actually happen, you know, but I'm hoping that this will gain momentum. I'm hoping that a lot, you know, in several states you'll see this, you've seen this change, but Michigan had not been on that bandwagon until recently. And I wanted to talk about current legislative action. So they're actually, this is pretty exciting, through the Amputee Coalition of America, they have really put a lot in advocacy for access to prostheses for physical activity. And so, there's the Access to Assistive Technology and Devices for American Study Act. It's the AAA Study Act. So, it is going to identify the best care practices for people living with limb loss or limb difference so they can be replicated across health systems, which will improve health outcomes, you know, hopefully for the, you know, larger limb loss community. You know, certainly, this is really highlighting like the two thirds of 2.1 million Americans living with limb loss or limb difference never receive an appropriate prosthetic device. And there's not very much analysis that exists to explain how those decisions are made, or if the individuals are getting access to the care they need. So, this is really a huge step in the right direction. And it's bipartisan sponsorship, which is also, you know, always a good thing. So, also want to talk about, there's a national petition going around for the rights of Americans with disabilities to exercise. And this is through a nonprofit called Forest Stump. This is actually the picture of the person on the front of my slides. This is her nonprofit. She is an alum of the University of Michigan Business School, but started a nonprofit called Forest Stump. It's an incredible campaign. Check it out. Move United also has a wonderful campaign called the Inclusive Playbook. This is really geared towards children having, and also thinking about, you know, not just children with disabilities, but their able-bodied, you know, classmates, and really thinking about the broader picture, and really keeping it at the consciousness that everyone gets to play. And I just want to, you know, wrap up with that there are a lot of advocacy groups and campaigns. So, Kids Can Move is through the American Orthotic and Prosthetic Association. Move United, as I mentioned, the UN has a Decade of Healthy Aging. There's a lot of resources there. Adaptive Sports Movement, which I'm involved with. NCHPAD, I don't know if any of you are familiar with NCHPAD. They have a huge wealth of resources on their website. Adaptive Sport Labs is really looking at leadership and business in adaptive sports organizations. Diversity in sport is a big campaign, and the Paralympics, our International Paralympic Committee has an I'm Possible campaign focused on, focusing on education of children. Again, there's so much to cover in this realm. I know I kind of blew through it. I want to make sure I stay on time to keep us on track. There are all my references, and I have a couple of quick plugs. I had a recorded session from Monday, if you want to check it out, if you're interested in adaptive sports. That is there. Then we have a networking session on Friday, the 21st in Baltimore, if you're interested to connect. You can plug away, Melissa. That's what this is about, and we're very happy for you to promote what you're doing. It's really incredible work, as is everyone. Congratulations for all you do, and very inspiring. Sophia, you can share your slides. Thank you, Melissa. Thank you so much. You can share your slides, Sophia. Dr. Sophia Pulek is a friend and a colleague, works here at Rusk Rehabilitation, the clinical instructor in rehabilitation medicine and medical director of transplant rehabilitation here at Rusk. The focus of Sophia's work is on cardiac and pulmonary rehabilitation, and really specifically heart and lung transplant rehabilitation. She runs our inpatient program for heart and lung transplant. Sophia, take it away. Thank you. Thank you. Thanks, Jonathan, for this introduction. Just making sure everyone can see my screen and also can hear me. Thumbs up? Yes? Okay, great. Perfect. We're going to talk about long-term exercise goals in a very specific population, heart and lung transplant patients. Are current exercise guidelines relevant in this population? I don't have any disclosures, and this is my fun fact. This is my third child, my son, Neil. He is as adventurous as the character in the Matrix movie. I think these guidelines were already mentioned a couple of times in the previous presentations, but I just wanted to list them here. This is the brochure available to the general public from the US Department of Health and Human Services. This basically tells the general public to exercise, to try to aim to 150 minutes per week of moderate intensity aerobic activity, or 75 minutes of intense activity, or a combination of the two, and resistance exercises or muscle strengthening activities twice a week. They also list various strategies on how to implement these activities into daily life, and so they have these nice and colorful pictures here, and I think overall it's a very helpful brochure. In their publication, they also list various benefits of exercise, such as decreased incidence of cardiovascular disease by about 14 percent, decrease in cardiovascular disease mortality by 40 percent, reduction in blood pressure, reduction in incidence of hypertension, weight loss, prevention of weight regain, and reduced and slowed weight gain over time, as well as decreased incidence of type 2 diabetes by 25 to 35 percent, and decreased risk of adverse lipid profile. Sounds wonderful. Can these guidelines be applied to transplant? We'll look into that. Additional benefits include brain health, reduction of anxiety, improving cognition, reduction of risk of dementia, risk of depression, improvement of quality of life, decrease in the risk of falling. And if a fall does occur, it prevents or decreases the risk of injury. So can we use these guidelines in the transplant population? And more importantly, is it safe to exercise for this specific group? So in cardiac transplant, actually benefits of exercise have been documented. I do have to mention that unfortunately, there are not that many or any randomized controlled trials out there that involves specifically post cardiac and lung transplant groups. However, the studies that are available, which are mostly observational studies, do indicate that, for example, one study eight to 12 weeks of high intensity interval training can decrease heart rate at rest and increase heart rate at peak. It can also improve peak VO2, which is oxygen consumption, otherwise indicating fitness level. Other studies report 23 or more sessions can decrease the risk of major adverse cardiac events by as much as 60%. They can lower readmission risk by 29%, which is a huge thing in this category and overall improve quality of life and decrease symptoms of depression. In the lung transplant category, additional benefits include improvement in exercise capacity as indicated by six minute walk test and VO2 peak measurements, skeletal muscle function, decrease in muscle fatigue, decrease in perceived dyspnea, improvement in bone density, health related quality of life and overall survival benefit. How do we make sure patients exercise in a safe manner? Well, just like for any other patient category, we need to perform a very thorough examination, well, history, physical, vital signs, look at labs and tests. Stress test can give us additional information about exercise tolerance and help us provide established parameters and goals for these patients. Repeat exercise stress testing is indicated at the end of the program so we can document outcomes. Education is extremely important in this patient group because patients need to be familiar with their symptoms, medications that they have to take for the duration of their life, side effects associated with them, glucose levels, measurements, how to manage their oxygen supplementation and how to monitor their oxygen saturation. They also have to recognize and be able to recognize signs and symptoms of possible complications. And we need to establish precautions for them and inform them of these precautions. Some of the complications that we need to be aware of in the post heart transplant group. So one of the major ones is primary graft dysfunction, essentially when the graft does not take, essentially when it fails. There's also immunosuppression, infection, neurotoxicity and renal toxicity are common because of the prolonged ischemic times, anesthesia, as well as some of the side effects of immunosuppressant medications. Hypertension is very common. It's multifactorial partly because of the immunosuppressants such as cyclosporine, which can induce renal vasoconstriction and also presence of peripheral vascular resistance from high circulating catecholamines in the end stage heart failure patients. They can also have metabolic abnormalities such as glycemic abnormalities with steroids and they can also have rejection and they need to have regular end myocardial biopsies in order to establish presence of that rejection and the extent of it so the treatment can be administered. Some of the, so physiology of the transplanted heart is not the same as a regular heart physiology. We need to be aware of the fact that the transplanted heart lacks the vagal tone. And so this results in resting tachycardia, which is commonly seen in this patient population. Their exercise at the onset is preload dependent. So it's very important to have a good hydration and hypovolemia is actually not very good for this patient population. Prolonged exercise or continuous exercise is dependent on circulating catecholamines. Unfortunately, this mechanism is not very quick to adjust the heart rate. And so their rise in heart rate and fall in heart rate and recovery are very slow. Peak heart rate and systolic blood pressure can only reach about 80% of a normal or a non-transplanted individual at maximal exercises. And ADO2 difference, which is the ability of the peripheral tissues to extract oxygen from the arterial blood is 24% lower than in a non-transplanted individual. This actually illustrates the difference in heart rate changes, depending on exercise time in a transplanted individual, which is the blue line and a non-transplanted individual, which is a pink or red line. And you can see that while you start at the higher heart rate as a heart transplant patient, you actually end up with a lower peak at peak exercise than a regular individual. And the rate of recovery is actually slower in this patient population. So transplanted lung physiology is also not the same as a regular lung. And so we have to take into consideration that the lung is also denervated, which means patients lose their core reflex. And so they need aggressive chest physical therapy and they have to also follow aspiration precautions. This is compounded by the fact that they have mucociliary clearance decreased and also their pulmonary vascular resistance is increased. On top of that, their bronchial blood supply relies on pulmonary arterial flow, which is low in oxygen. And so collaterals do form, but in the post-transplant, especially the first 30 days after the transplant, it's essential for these patients to have regular bronchoscopies in order to look at the anastomosis site and make sure there's no necrosis, there's no infection such as aspergillus, which loves necrotic sites. Also presence of bronchial stenosis and bronchial malacia can be detected by bronchoscopies. And of course, all of that can affect exercise. The new graft is susceptible to pulmonary edema, probably because of lymphatic clearance interruption. And so we have to be careful with IV fluid administration. So while we have to keep transplant patients well hydrated, we probably have to kind of go slow with the lung transplant patients. Because of this particular phenomenon. So what happens based on this physiology with the post-lung transplant patient? They have difficulty with secretion clearance. They need aggressive chest PT and pulmonary toilet. They can have orthostatic hypotension, immunosuppression. They can have hypoglycemia related to steroids. They can have electrolyte abnormalities such as with tecrolimus, which leaches out potassium and magnesium, by the way, lowering their seizure threshold. They can have cognitive issues because of medications as well as events around the surgery itself. They can also have swallowing issues and dysphagia, and they're at high risk for infection. And they have to be on a regular prophylaxis for cytomegalovirus, PJP, I should say, not PCP, pneumonia, and fungal infections, as well as reactivated latent donor infections. Jumping back to heart transplant. So some of the precautions we need to keep in mind for these patients. So they have a vertical sternal wound. They have multiple drain sites, multiple sites from procedures such as cath preoperatively, as well as endomyocardial biopsy access sites, which are usually the neck or even the upper arm. Orthostatic hypotension. They can have restrictive tachycardia, as we mentioned. They're immunosuppressed. They can have hypoglycemia. Muscle weakness is multifactorial and can happen due to some of the medications such as cyclosporine, which can actually inhibit oxidative enzymes in the muscles, as well as myopathy related to steroid use or critical illness. They can also have diaphragm injuries. Electrolyte abnormalities, we mentioned. Cognitive issues. They're at risk for infections. We need to be aware of the signs of rejection of the graft, including acute heart failure, arrhythmia, and sudden reduction in exercise tolerance. And one thing to keep in mind, ischemia does not present with chest pain. And if these patients have chest pain, it is unlikely to be ischemia. Again, this is a denervated heart. So ischemia usually presents almost the same as signs of rejection with CHF, arrhythmia, and sudden reduction in exercise tolerance. Lung transplant precautions are very similar. I'm just going to highlight the differences. Incisions are usually inframammary or clemshell incision for the bilateral lung transplant, and thoracotomy or flank incision for the single lung. They have the same or similar drain sites and inguinal area of access to interventional procedures. They can have orthostatic hypotension and surprisingly, tachycardia, but for a different reason, probably because of deconditioning and decreased lung volumes. They are prone to have atelectasis, so it's important for them to learn breathing exercises as well as do aggressive chest PT. They are prone to pulmonary edema. They can have vocal cord dysfunction as well as reflux, dysphagia, gastroparesis because of potential nerve injuries to the laryngeal and vagus nerves. Immunosuppression and hyperglycemia are the same as in heart transplant. Muscle weakness, again, can result from critical illness or steroid myopathies as well as immunosuppression-related weakness. They can have electrolyte abnormalities, cognitive issues, at-risk for infection. Probably aspergillus is more prominent in this patient group. Again, it loves the anastomotic sites, and so they need to be prophylaxed for that. And signs of rejection for this patient group includes hypoxia, sudden increase in oxygen requirement, achypnea, pulmonary edema, effusions, and imaging would show bronchiolitis obliterans or ARDS signs. So for the exercise in the heart transplant patient, basically we follow the same protocol as the heart or cardiac rehabilitation. Phase one is inpatient. Phase two is outpatient with telemetry monitoring. That should start with a formal exercise stress test. In a heart transplant group, we cannot really go by the heart rate. And so the usual use of carvonin formula of cardiac rehab does not really work very well here because they don't have such a great range in heart rate. Remember, we talked about vagal denervation. So we go by the work scale or rate of perceived exertion scale. And these numbers are listed on a scale of six to 20, essentially. But we aim for 13, 14, but work towards 16, 18, which is slightly more intense and probably will get better results. Education is key. Again, we want to prevent readmissions. We want to prevent adverse effects of medications. And we also need to teach these patients to healthy lifestyles, nutrition, and so on. Phase three is maintenance. No telemetry required, just like regular cardiac rehabilitation. And this is where we can aim for general guidelines. So it's not necessarily that these patients can achieve the guidelines we mentioned for regular population right away, but certainly they can aim for it. Can they do intense athletics or competitive athletics? Yes, it's possible. So apparently, re-innervation is possible within six to 12 months post-transplant. And so this means that aerobic training can improve deep VO2, which is oxygen consumption. High-intensity interval training may be superior to moderate exercise while training. And it's certainly safe if we take into consideration all those precautions we just talked about. There is a compensatory physiological change such as expanded plasma volume. And that leads to increased stroke volume in this patient population. So that kind of makes up for the heart rate that's not so easy to control in this patient population. And increase in muscle oxidative processes and strength can certainly result from exercise programs. And that leads to increase in ADO2 difference, which I'm listing this formula here for better visualization. ADO2 difference is actually a major factor that we can address with exercise. And it can lead to better VO2s and that translates into better fitness. So yes, with proper training and considering precautions, competitive athletics is possible. Post-lung transplant exercise. I kind of put it roughly into three phases as well. Very similar. We need to take into consideration the oxygen parameters, oxygen saturation, teaching patients to self-monitor as well as self-administer chest PT and be able to do breathing exercises to improve chest wall strength. So very similar to heart or cardiac rehabilitation. And again, the goal is to achieve those guidelines 150 minutes per week and twice a week resistance training. In summary, so exercise recommendations for adults can be applied to the heart and lung transplant recipients. We have to make sure that we know the physiology that is present in this patient population that's different from a regular heart and lung physiology and take into account potential complications post-transplant. We also need to assess the patient and recommend safe exercise programs to them. Additional benefits of exercise for this patient population include increase in exercise capacity, improvement in bone density, overall quality of life and reduction readmission with the likely effect on overall health status. Thank you for listening. And this is my contact information. I hope I didn't misspell it. Yep, that's my email for any questions. And thank you for having me. This is just the list of references. Sophia, that was great. Thank you so much. And I think we all tend to forget that some of our sickest, sickest patients, number one, they do well with transplants and number two, they have great aspirations. And I put a little question in the chat for you about patients that I see that you've taken care of that come to the outpatient program. And I don't know if they're joking or not. They're asking about, can they run marathons? But I'll let you all answer that in the chat. Thank you. Aditya, if you want to start sharing your slides. Next up is Aditya Raghunandan and forgive me, I hope I pronounced your name correctly, but Aditya is an assistant professor in the Department of Rehabilitation Medicine at UT Health San Antonio, is board certified in physical medicine rehabilitation, electrodiagnostic medicine and sports medicine and is also has a certification as a registered musculoskeletal sonographer. Aditya specializes in the care of acute and chronic musculoskeletal sports as well as spine conditions and is also involved in the care of patients at the post COVID recovery clinic at UT Health San Antonio. Aditya, thank you so much. And we're looking forward to hearing your talk. Awesome. Thank you so much for having me. Can everyone see my slides and hear me? Okay. Yep, perfectly. Awesome. Thank you. All right. All right. So I have no relevant financial disclosures. Really four main objectives for this talk. Briefly gonna do an overview of long COVID syndrome. Dr. Bartels did a really good job going through this. So I'm just gonna hit some of the highlights here. Specifically, I'm gonna highlight. Oh my God. Yeah, top said they can't catch up, right? I'm gonna specifically highlight. I had a top pair. Can everyone put on mute because we're hearing some chat coming through. Forgive me. Thank you. Thank you. Go ahead Aditya. All right, no problem. And then I'm gonna go through long COVID syndrome specifically as it relates to athletes and talk a little bit about graduated return to peak performance. So just first some fun facts. All of us have been given some fun facts about what we have done in the past. So my prior life, prior to going back to residency, I spent eight years in the Navy. I did three tours as a flight surgeon. Got to spend some time with some very interesting people. Flew in some very fun aircraft. Have about 500 hours or so of flight time in military aircraft. But like a lot of the air crew like to point out to me, some of that time was, good amount of time was spent sleeping. So take that with a grain of salt. As far as my polling question, if you wanna put that up for me. So for athletes, for elite athletes, those who are COVID positive, who only experience above neck symptoms, tend to recover more quickly and may be able to safely resume to full training quicker than athletes who experience only below neck symptoms. This is a true or false question. So I'll give you guys a couple of seconds to answer that there. All right. All right. So we'll come back to the answers either at the end or in a little bit. Okay. All right now. Perfect. Okay. All right. So starting kind of from the beginning as far as long COVID syndrome, I think it's important to put some definitions on the table just so that everyone's on the same page here. So there's a couple of different terms that people use. One is post COVID conditions. The other one is long COVID syndrome. There's also past or post acute sequelae of SARS-CoV-2 infection. So post COVID conditions kind of encompasses majority of these definitions. So it's a wide range of both new returning and ongoing health problems that people have had, and really the crux of it is starting four weeks or more after the initial infection or presumed infection of COVID-19. Long COVID is a syndrome characterized by a variety of persistent symptoms and health effects after the initial resolution of the initial infection. And then PASC, that's the newest definition that was proposed by NIH in February 2021. And then you may also hear the term long hauler. Long hauler are, especially with social media, there's been groups that have kind of formed after COVID, specifically patients with long COVID syndromes, and they call themselves long haulers. So these are COVID-19 survivors with lingering residual effects. So just a quick pathology with COVID, there's both the SARS-CoV-2 and SARS-CoV-1 enter host cells via the ACE2 receptor, which are expressed in multiple organs, most abundantly in the heart. But autopsies of SARS patients have shown that it can affect multiple organs, including heart, kidney, liver, skeletal muscles, central nervous system, adrenal glands, thyroid issues, sorry, thyroid glands, et cetera. So this is the reason why we're seeing patients with multiple symptoms and multiple interactions of different symptoms as well. So as far as the pathogenesis, so this is, we're still kind of in the discovery phase of this. I think there's a lot of question marks still out there as to what the pathogenesis of long COVID is. Inflammation, post-inflammatory cytokines and antibodies are kind of the leading proponents right now as far as what the proposed cause is. There's also some thoughts about spike proteins that are kind of lingering, that can cause recurrent infections down the road. And then I've listed some of the most severe complications that some of the patients can have associated with this. As far as symptoms that patients experience, it really runs the gamut. And the reason is there's multiple mechanisms that are interplaying with each other and there's multiple pathophysiologies that can all kind of interplay and cause even the most common of symptoms. So because of this complex interplay between the immune system and inflammatory system, we need to take a holistic approach to these patients. And the same goes for athletes and non-athletes. So as far as athletes specifically, the good news is the vast majority of athletes, almost 94% of them, with COVID-19, the acute infection were asymptomatic. And this is based on a large systematic review and meta-analysis that was led by a team out in Brazil and published in BJSM this year. They looked at 43 different studies and almost 11,518 athletes, a very, very large study. There's a variable proportion of athletes... ...free app, which generally wakes you up at the exact time... There was a... Again, whoever is unmuted, please mute yourselves, it's the right thing. Thank you. Please mute. Thank you. So a variable portion of athletes have lingering or persistent symptoms. Depending on the study we're looking at, it ranges anywhere from 3.8 to 17%. They're usually mild in nature, but some of these can affect return to play decisions and timing. So I'll go through some of that in the next couple of slides. The other thing that was interesting, which was kind of highlighted early on in COVID and long COVID syndrome is the effect on myocardial tissue. And they looked at specifically multiple different markers, sorry, diagnostic markers and things like myocardial manifestations on EKG, echoes, cardiac MRIs, elevated troponins, et cetera. So they found about 5% of infected athletes had abnormal findings in these. But the thing that kind of confounds some of these studies is there were no controls with similar age groups looking at these markers. So it's kind of hard to say if there's a direct link, if there's a causal relationship to these or not. And also you have to take some of these with a grain of salt. For example, endurance runners or endurance athletes tend to have abnormal EKGs at baseline. So some of this might be unrelated to COVID as far as the long COVID sequelae, but interesting things to think about. Other clinical implications, which are kind of interesting to think about with athletes versus non-athletes. So the symptoms that we're seeing, so majority of patients being asymptomatic, that's about less than a third of symptomatic patients compared to population-based studies. So the reason for that, there are a couple of proposed theories. Some might be that they have closer, athletes have closer contact to medical staff assessment. So they may get detected earlier, even in very mild symptomatic cases. They also may have a higher likelihood of being able to participate in screening studies. And obviously there's the potential obvious role of high levels of physical activity, which may be protective for some of these athletes as well. So as far as these symptoms that athletes are presenting with post-COVID, it's very similar to what we're seeing in the rest of the population as well. So the anosmia and dysgousia tend to be relatively high. The cardiovascular and cardiopulmonary symptoms tend to be a little bit lower. Fatigue still exists. I'm not sure if you can see my arrow, but in that top left in the red there, fatigue is still about 9%. It's more so in the acute phase and tends to get a little better in the longer phase for some of these athletes. So just things to think about when you think about returning to play and getting these patients or athletes back to their level of activity that they're at. As far as how we approach evaluation and management, so this is a very busy slide, but I'm going to highlight specifically the top line here, which is fatigue, which is very common in the general population and can be pretty debilitating for an athlete who's used to very high levels of activity. So first thing we need to do is rule out other potential medical problems. So make sure we're looking at anemia, hypothyroidism, hypoxia, other cardiopulmonary effects. So general screening tests or evaluations like CBC, thyroid functions, looking at their oxidation levels, EKGs, ECHOs, chest X-rays, et cetera. So make sure those patients are getting screened. And then as far as management of fatigue, the one thing that should be noted and highlighted, especially if you take care of athletes, is don't miss post-exertional malaise or myalgic encephalomyelitis or chronic fatigue syndrome. So this is an entity that's been around for decades, and it's kind of come back to the forefront with long COVID patients. And the good thing about that at least is that there's been a lot of funding funneled that way, which is kind of helpful, but still there aren't a lot of answers. So we still have to take a step back and a holistic approach to these patients. So exercise in these patients should be introduced gradually, performed pretty prudently. And if they have any red flags like fever, breathlessness, muscle aches that are getting worse, they need to be stopped and evaluated prior to continuing to progress them. Post-exertional flares can be pretty extreme. So I've had patients who are high-level athletes who now have fatigue or extreme levels of fatigue from just clicking the mouse or watching a screen or TV. So these can be relatively extreme. It's especially important to consider these when you're trying to get someone back to very high levels of care and they're getting fatigued with very low levels of work or activity. Specifically for athletes and patients in general, this can have a pretty significant impact on their mental health. So cognitive behavioral therapy, I think of this very similar to how we take care of patients with concussion or post-concussive syndromes. They have, CBT has a positive effect on fatigue levels, work and social adjustment. It can help with their depression, anxiety, and hopefully their post-exertional malaise as well. There's no specific pharmacologic treatment for post-COVID fatigue. So really it's focusing on symptomatic treatments of the table that I mentioned previously, and then addressing common post-viral fatigue type symptoms. So things like physical pain, recurrent headaches, malaise, cognitive impairment, unrefreshed sleep, things like that can be very helpful in getting these patients back on track. So doing what we do best, which is taking a big picture approach to their nutrition, their sleep, and addressing their stress can go a long way for these patients as well. Dr. Bartels mentioned some of the guidance statements. This is a QR link or a QR code, so if you have your phones handy, take a picture of this. This will link you directly to that AAPMNR website with the guidances on there. There's a lot of good guidances for pediatric patients, autonomic dysfunction issues, cardiovascular complications, fatigue, breathing discomfort, cognitive symptoms, et cetera. So take a look at it. It's a great place to do some deep dives, especially with patients that we're seeing now. As far as management of these patients, so a lot of things that we do in rehab at baseline is what we do for long COVID patients as well. So taking a big picture community-based approach to them, getting them home-based care or rehab if they need it and they can't get to the gym or get to a physical therapy setting, respiratory rehab, cardiac rehab, autonomic reconditioning. The other big thing is this entity called pacing or energy windows. So what we work on in therapy for athletes are the four P's, which is highlighted in one of the guidance statements on fatigue, which are pacing, prioritizing, positioning, and planning. So pacing is avoiding the push crash cycle. So athletes specifically love to go up to 100% as quickly as possible. So really trying to contain them and giving them limits as to, okay, we're going to do some small manageable chunks of like, these are our goals for this week. We're not going to go beyond that. Next week we'll plan to go higher. Same thing with prioritizing. So if you have an activity that you really need to get to that you feel like you're going to overexert yourself this week or next week, then you plan or prioritize activities around that so that you have one day that you're pushing your pace a little bit, but the other days are less. Positioning, so like Dr. Bartels mentioned, a lot of our ADLs that we do, standing up for example, like cooking, taking a shower can be done sitting and that can conserve energy. So at the end of the day, you just have a higher energy window. And then planning. So especially for athletes who are planning meets or specific exercise regimens, encouraging them to plan day by day, even hour by hour can help for some of these very type one or type A, highly OCD type patients. Athletes specific considerations as far as management, most of the time physiatrists or a lot of physiatrists are team physicians, but if you're not a team physician, get them on board with the plan as well. Athletic trainer can be your best friend. They see the patient on a daily basis and they have the patient's interest in mind, but a lot of times they push them a little bit harder than they should. Same thing with the coaching staff. I think coaching staff now are better trained and have a better understanding of not pushing their patients or athletes as hard as they should, but still sometimes the W at the end of the day is kind of their bottom line. And then if you're dealing with pediatric patients or younger athletes, make sure you're getting the patients or the parents involved as well. So as far as graduated return to play, this is kind of a busy slide. This is, you can access this on the BGSM, which is open access from Hull et al. But the first thing to consider, even before you get an athlete to this graduated return to play, they have to be able to, one, perform their ADLs without any difficulties, and two, walk about 500 meters on a flat surface without having excessive fatigue or breathlessness. They should also have at least about 10 days of rest and be seven days symptom-free before starting this graduated return to play protocol. And less aerobic, intense exercises, so golf, for example, where you're swinging and then you're kind of taking a break, those patients, you can, they may progress a little bit quicker to their end goal of returning to competition than some that are more aerobically involved. So the big thing that Dr. Bartels mentioned, which I'm going to harp on again as well, is monitor your patients. So take a look at their resting heart rate, monitor that, have them rate their perceived exertion, and then make sure you're working on things like sleep, stress, fatigue, muscle soreness, so mitigate all those post-viral syndrome-type symptoms that they're having, and then make sure they're psychologically ready to get back into sport. So this, I apologize, the font is very small on this, but it goes through stages one, two, three, four, and then five, which is finally returning to competition. So stage one, so these are your athletes who are experiencing your above neck-type symptoms. So those are the ones you could start at stage one, so minimum of 10 days prior to starting them there. The other athletes who are below, sorry, I mixed those around, I apologize. So those with below neck versus above neck. The second ones you could start at stage two, and they should be there for a minimum of 48 hours prior to progressing to stage three. Stage three, again, they should be there a minimum of about 48 hours or so before progressing them to stage four, which is a normal level of training. And then stage five, finally, is your competition. The biggest caveat to all of these is if they have any symptoms occurring, which include excessive fatigue, while going through this graduated return to play, you stop, and then you wait for a minimum of about 24 hours with a period of rest without symptoms prior to going back to that next stage. So hopefully that makes sense. So if you're, for example, if you're at stage three, you start experiencing symptoms, you stop, make sure they're 24 hours symptom-free, go back to stage two, and then reprogress them. So the general rule of thumbs is the answer to the polling question here. So elite athletes that are COVID positive who are either asymptomatic or above neck only, so things like cough, loss of taste, smell, those patients tend to recover more quickly, and they may be able to resume sport to a quicker level compared to those who are below neck symptoms. So they have more systemic symptoms. So things like fever, shortness of breath, chills, et cetera. As far as long COVID specifically, there really aren't any specific guidelines for long COVID. So a lot of this data is extrapolated from multiple other guidances. And the one guidance that has put this together, the consensus statement is a Stanford Hall consensus statement, which was published in BJSM in 2020. So this is adapted from that. But very similar to the graduated return to play. So initially, you start off with one week of flexibility mobility before you get back into that graduated return to exercise. If they still have mild persistent symptoms during that phase, they should be able to complete about 20 minutes of walking without any increased symptoms before you get them into this slowly bumping up their intensity of either exercising or other aerobic activities that they're trying to do. If they have persistent symptoms that are more in the moderate range, you plateau them about 60% max of their activity. And you wait at least two to three weeks after those symptoms have resolved until you continue progressing them to that next stage. And then anyone who has red flags, which I'll show you in the last slide here, should be stopped and evaluated prior to going back. And they should start all the way back at stage one as far as exercise. And here are some of those red flags. So any patients who have dyspnea, syncope, who are truly fainting and passing out, they have chest pain, dull, sharp, central, or left-sided, psychological or mental health concerns that aren't getting better or overwhelming, unusually high heart rate, or they're not recovering like they used to prior to their COVID infection, persistent headaches, fatigue like we talked about earlier, and then unusually high RPEs. All of these should be a red flag. These patients, these athletes should be stopped and then taken to a specialist prior to even setting them back on this graduated ramp up to play again. So that's all I have. Hopefully, I didn't put you to sleep like I put my kids to sleep. And if you guys have any questions, I'll be happy to answer them in the chat box. Thanks. Yeah, beautiful kids. Thanks for sharing those photographs. Again, it's always nice to know the human being behind the lecture. That was a wonderful lecture, wonderful talk. And again, our journeys into PM&R and where we are today are mixed and varied. And that was a great photograph of you sleeping on the plane. But I'm sure you'd worked hard to deserve that rest. Aditya, thank you so much. That was great. Neil, if you can share your slides. Aditya, I think there may be some questions for you in the chat box. Please take a look. Neil Mesnick, last but by no means least in our marathon presentation today. Neil, Dr. Mesnick is in private practice here in New York City. He's a Clinical Assistant Professor of Rehabilitation Medicine at Weill Cornell Medical Center, is himself, I believe, a strength and conditioning coach, and has published work with the Israeli Olympic athletes with cardiomyopathy. So well-researched and well-published. Neil, thank you so much for being with us. And we're looking forward to hearing what your talk's about today. Yeah, my fun fact is I can speak very quickly. So I'll get that done. So Neil, take your time. We have time. We're scheduled until seven and you speak and say what you need to do. Do not rush. My real fun fact is that I do, open water swimming. And one of my swims was in the East River. So at five 30 in the morning, we crossed the Brooklyn Bridge, go down and swim across under the Brooklyn Bridge and that current. So I think that's something a little different. I have everybody's pictures up here, which I can't move off here. Everybody can see the screen okay? Good. All right. So I'm going to talk about strength training in general with a focus on the older adult. And I'm calling it the fountain of youth that I'm not trying to get you to live to 120 years old, but I'd like to keep you walking without a cane or a walker and as strong as you can and no meniscal injuries that keep you out of a sports that you like to do. So I should have no disclosures. And this talk, I'm not saying anything new. There's over a thousand articles. I just want to go through programming, which essentially is prescription writing on this because I'm not finding what exercise we have to do. And I know I personally, my practice have gone from saying no overhead activity to like, yeah, yeah, do some overhead activity, or I've kind of skewed away from only Pilates to some other stuff. But after, and we'll talk about who elderly is, we start looking at losing muscle mass between 50 and 70. And I'm saying it's got to start before then because we really don't have a lot of NFL players that are over 40 years old. So we're going to go through the exercise selection, the order, the volume and the frequency. So basically it's been around, I put something up here from over a hundred years ago, type two fibers are affected more. And the other thing is that we have the lower extremity being affected more than two times the upper extremity. So that take home is you can't skip leg day. Who is elderly? According to Schoenfeld, it's anybody over 50. So that guy right there. According to me, it's since I turned 53 this summer, it's anybody over 53. Why is that important? Because it does affect our ability to recover and we have to watch fatigue. So let me just run through some terms. The strength is the central nervous system's ability to produce force. Hypertrophy is just getting bigger muscles. Power is the ability to produce force with speed, which becomes more important as we get older. Compound movements, multiple muscles crossing multiple joints. Assistance and accessory exercises or anything that helps you with your compound movements. Powerlifting is a sport made up of squat, bench and deadlift. Weightlifting is a sport made up of clean and jerk and the snatch. We will not be talking about that. And I like people to really say they lift weights and that they're not into weightlifting. We will be talking more about strength training and specifically progressive resistance strength training. All the studies have said that as we get older, we must not only lift heavy weights or relatively heavy weights, we must progress. A novice lifter will see the stress of a single session to disrupt homeostasis and they will also recover fairly quickly. After about six months to two years, we'll go from being a novice lifter to intermediate lifters. And that will take an entire week long workout to disrupt homeostasis. And that's where we're going to start our planning with our prescriptions. My issue with some of the novice lifters that or our patients we send out, they think they could just keep adding five pounds to the barbell infinitum when they could really do it for maybe two or three months. Benefits, we talked about that, but we just wanna prevent injuries. We wanna improve mobility and their ADLs. I'll skip that. Contraindications, everything we would think about, but what I want to point out on this slide is what we don't see. And that's arthritis and joint replacement. We're okay with strength training and joint replacements. So here's the basis of our program, the SRA curve put forth by Hans Selye back in the 1930s. We need to stress an organism. And what does that mean? I don't know if it's the yellow rubber band or 120 pounds, but I could pretty much figure it out in a matter of weeks. It's important to see that once we've stressed that organism, the muscle will now be weaker than it was beforehand. So don't do this every day, like every other slide. It's two or three times a week. And then once we have that adaptation, let's increase the muscle. There's no reason for that muscle to adapt again, if it hasn't been stressed. Mark Rippetoe, there's a strength training coach that says you don't get strong by lifting heavy weights. You get strong by recovering from lifting heavy weights. What does that mean? I want my seven or eight hours sleep and I want sufficient protein. I'm saying 0.8 grams of protein per pound of body weight. We want to be in this sort of mid ground between a minimum effective volume where below that you're not having any stress on the muscle and the maximum recoverable volume where you start getting into overreaching and overtraining. All right, here's my exercise selection. I'm taking a page out of the powerlifting manual and saying we should be doing squat, bench, deadlift and I'll put the overhead press. I need mobility in the shoulder, thoracic spine, hip and ankle. Am I saying grandma should go out and start deadlifting? Probably not, but we need mechanically similar movements. I want to work the most amount of muscle mass and these movements are compound movements that are functional. A squat will help somebody get off a seat or a toilet seat as they get older. A deadlift, you're picking up a grandchild or a heavy box from the floor and an overhead press, you're putting a suitcase in the overhead bin and you're going to put it on an airplane. Exercise order, let's do our compound movements before our accessory work. Training volume is two to four sets, two to three times a week. In an older population, it might only be one to three sets to disrupt homeostasis. We want to work in the 70 to 80% of our one rep max range. Lower intensity is probably better for hypertrophy. How do we estimate a one rep max? Rather than sticking somebody under a heavy barbell and making them lift as much as they can, this is not a powerlifting meet, we can estimate. If somebody is able to lift 115 pounds for seven repetitions, they should be able to do about 142 pounds for one repetition. So you could use that formula there. So if we wanted to work in the 70% of one rep max, we would advise them to use 100 pounds. How many times should they be able to move that 100 pounds? And that's where we use this relative intensity chart. So the one on the right is very generic from the internet and it's cleaned up and rounded up. The one on the left is what we use in my training facility. My coach got it from his coach who got it from Russia, so it has to be good. But you'll see where 70% is about 11. So you cannot program in, somebody should do between 10 and 12 repetitions at that 70%. They will be going to 100% and beyond every time. I like five repetitions, six, seven, eight repetitions for compound movements. If you're going above eight, you probably should have a good reason for that. And this intensity chart will only work for your first set. Once you've done your deadlifts, do not use this same chart for your next squat motions. But here, if somebody has been programmed to do five repetitions at their 80% of one rep max, of course, the fifth rep will feel heavier than the first four reps. So we will divide our 80% actual weight divided by our relative intensity at five reps, which is 85.7%. And you will have them working at a 93.3 relative percent, which is probably pretty good. I'd like to stay below 95%, but if you're going to push them to 100%, they better go home and take a nap. We want the beginner lifters to be lifting a little bit lighter weight. I think 15 repetitions is just way too high. If you can get to 15 repetitions, put a little more weight on the bar. They're probably eight to 12 reps is probably really good for your accessory work, but I want those multi-joint movements in the five to eight rep range. You ask me to do five reps, you'll get five good reps from me. Ask me to do 12, I'm not sure that I'm going to get more than eight or nine good reps and then some junk reps in there. But eight to 12 reps mean you couldn't do 14 reps. If you stopped at 12 and I'm going to give you $5 for each one you do over that, and you got to 17, did we tax the muscle enough? And the answer is probably not. So you want to really start to this eight to 12 range, getting a little bit fatigued at seven, eight. Yeah, you'll squeeze out nine or 10, but you really can't get past two or three reps in reserve for a compound movement and maybe one or two for the accessory movements. And that's where machines come in really well for our bodybuilders and elderly because you can go closer to failure. When I'm designing a program, I'm going to try to keep my volume based on the squat bench deadlift and I'll also include the overhead press in there based on whether I'm working on a trait, a hypertrophy or strength. And I'm going to mix these up every couple of months, but I'll go with five sets of squats twice a week will get me 10, eight sets of bench, I'll get to 18 and a few deadlifts. Deadlift is really not an exercise you should be programming in there. It's more of a test of strength. We will get the posterior chain strengthened through hinging motions, but we really don't want to program any more than a few sets of a deadlift or even a rack pull, which is just coming off of the rack just below your knee. The strength training, as we go up in intensity, we want to decrease the overall amount of sets we're doing a week. Peaking has nothing to do with our prescriptions, it's just if somebody's trying to get their one rep max for a meet coming up. Here we have Alexander Prilipin and I want you to notice here how low the volume is. I mean, when he's looking at 70 to 80% of a one rep max, which I really don't want to go above that in anybody. I mean, 70% is really getting kind of heavy there, but he's only looking at 18 repetitions. That's not a lot. I mean, these guys are coming in doing four sets of 10, they're doing 40 repetitions. Even in a low rep range or the low intensity range with the higher reps, you're not going above 30. And I'm going to say with our older people, let's stay to the lower end of that rep range. Our exercise selection, I understand not everybody will be able to stick a barbell on their back and go up and down a few times, but we're able to do chair squats with anybody. We're able to do a goblet squat, holding a dumbbell or a kettlebell and squat down and come up. Or there's the machines if you have access to a gym. Deadlift, again, not really an exercise. We should be programming in there. Let's try to get some more Romanian deadlifts. Let's try to do even step-ups if we have to. So here's some images I want to go over. I picked these specifically because the goblet squat and the back squat here are clearly showing that the hip crease is below the patella. And that's where I want them to go down that far in order to engage the posterior chain, which I mean is the glute, hamstring and adductor muscles. A lot of people just tend to come to parallel from the lower hamstring and it's not deep enough. There's our Romanian deadlift. It means we're not starting from a dead stop on the floor, but starting up higher. And we can do this with dumbbells very easily. So he's starting strength. He's hinging his hips back. So he loads the posterior chain. With the bench press and overhead press, if we cannot do those exercises, we have the dumbbells and we have the machines. My preference to barbells is it's very unforgiving. If something in the kinetic chain is not right, one shoulder's tighter than the other, one side's weaker than the other, the barbell does not move well. I find dumbbells are sometimes a little more forgiving and machines sometimes do have to work for you. Oh, I'm at past 13 minutes. Okay. So here's the starting strength method from Mark Ripoteau where three times a week you can do squat, overhead press, and deadlift. He recommends doing three sets of five reps except for the deadlift, which is only one. This is great to start with a beginner because we can just take the barbell at the weight and just lift the barbell. And if it doesn't fatigue you too much, next time you go to the gym, you could add five pounds for an upper extremity and 10 pounds for a lower. And after 10 weeks, we should be pretty much done. Then we could switch to a wave progression where we can get a deload week in there. These are just some samples. Thomas DeLorme from our Bradham book had the auto-regulating progressive resistance. Based on time, I'm gonna finish up over here. Strong lifts are good. There's just a bunch of different programs out there. I'm gonna stop there. So I didn't get my question, but my question was a true or false, as we get older, we should be lifting more weights and it was right there. Sorry about that. Okay, I will stop. I will stop sharing, I think. Where's my, I cannot stop. What's going on here? My mouse isn't working. I will escape. All right, close that. I'm trying to stop. My mouse is not working. I'm not escaping. Stop share. Good. There you go. Sorry about that. Neil, that was great. It was wonderful information. And I think Neil was speaking directly to me because in the chat, he'd mentioned, he'd asked me if I would, before I hurt my meniscus, was I doing strength training? And he hit the nail on the head. I'd actually stop because I stopped going to the gym and stopped doing strength training. And you're absolutely right. There's no doubt that strength training is so much a valuable part of injury prevention. And that would have allowed me to keep playing soccer. And I'm one of those older individuals too at 57. So I take your message. Sorry that you were pushed for time. We're gonna finish up very quick. I don't know, can you see my screen that finishes off with the business meeting? Do you see that? Yep. Okay. Let me just, there we go. Okay, so number one, I wanna thank everyone for staying the course. We're just about done. We're actually gonna, we'll conduct this business meeting and networking in Baltimore. So hopefully I'll see all of you there. And these are some of the questions that I will be asking you, which will be to review the goals of the exercises medicine community. And here we have goals stated and I'm showing them now so that they can be recorded. But we will discuss them again in Baltimore. You'll be able to read through them. And every community has to have a chair. There's no reason why they can't be a co-chair. This is my third year. I have one more year. I enjoy this. I'm happy to do it again. But I'm also happy for others to participate and get involved. And then as has been discussed at prior meetings and some have said that they would like to be involved, maybe having someone search the literature or being involved in research or sharing research, someone involved in setting up an education program through the year, someone involved with helping us understand how we can make this clinical, how we can actually incorporate this guidance and advice into our daily practice. And then also someone to help the wheel click around through the calendar, someone in the operation side of things. So if you're interested in being more involved, certainly reach out to me. And these are some other thoughts as well in terms of how we can think about exercise as medicine for our rehabilitation population at all stages through our rehabilitation population for all different organ systems, et cetera. And I guess, are there any other considerations to discuss? So at this point and realizing and recognizing that it is late in the day, I'm gonna call an end to this meeting unless anyone has any major reason why we should continue talking. If there are any questions, please do put them in the chat. I wanna thank everyone. Oh gosh, you know what? I have to share my screen again because here's my share. Can you see my screen again, hopefully? Yes, okay. So here are the thanks to the speakers, to Christine and all of the APMNR team, to our attendees and to the entire exercise as medicine community. We have, I think close to 1500 members, which is really fantastic. So, and they will have access to these talks by the way in the playback session. I'm not sure how that works, but they'll have access to this in maybe the annual assembly rewind. I can't remember exactly what it's called. And I think that was my last slide so I can stop sharing. And unless there is anyone who's saying we shouldn't stop, I'm gonna call an end to this session. I wanna thank you all again and we will meet in Baltimore. So, oh, Noel has the little baby there. That's wonderful. All will be- Dad duty. I gotta help out. Dr. Dad duty, I love it. Multitasking, I love it. This is actually my favorite study position, having her in my arms, have the right hand free if I could study and write. Well, that's wonderful. Well, congratulations and enjoy. Mine are now 23 and 17. They grow up quick and they talk back more and they remind me how stupid I am. Parenting, it's interesting. Yeah, it makes me think about how much I abused my parents as a kid. Yes, yes. Listen, I still have that wonderful part of abusing my parents too. They're in their late eighties and I give to them what my kids give to me. All right, everybody. We're gonna call it a day. Thank you so much. We'll see you in Baltimore. Take care. Thank you to everyone. Thank you.

exercise prescription

post-acute sequelae of COVID-19

PASC patients

individualized exercise prescriptions

vital signs

oxygen monitoring

precautions

fatigue levels

post-exercise recovery

supplemental oxygen

physiatrists

comprehensive assessment

cardiac transplant

lung transplant

exercise tolerance