Welcome everyone. Thank you for taking an hour to spend some time with us this afternoon. As you're going to hear many times I wish we were in person, especially here in my hometown of Nashville. But we're going to hopefully have a really good discussion just a couple of housekeeping things for you. You'll see most of them here on the slide but just as a reminder, we are recording this session. So please do mute your webcam and mic says here that we have enabled the raise hand function but we want to ask you for this session if you can please put any questions or comments in the chat box, we will try to keep monitoring those throughout the discussion and we'll try to get to as many of those as we possibly can. This session is hot topics and spinal cord injury point counterpoint to being led today moderated today by Rita Hamilton and myself. And we have four other excellent panel members who have graciously joined us and agreed to engage in the discussions. Just a brief pause here on the slide so it's Jeff Berliner Matt Davis Mike Salino and Chad swank. Just so you know if you've been involved with point counterpoint discussions previously. These individuals may be representing viewpoints around particular issues that aren't necessarily what they actively practice, they may be taking a position that's stronger one way or another than what they actually feel. So just know that they've been asked to really take aside to really get you to think about things exposures to some of the literature background data etc around these couple of issues that we're going to be talking about today. The other thing is that I don't want you to take their comments to be representative of any particular institution or hospital etc. So, this really is for academic discussion around a couple of topics today. Because this is for CME here are required disclosures, as you hopefully will know by now or will throughout the virtual conference all of these slides are going to be downloadable for you in a PDF format so you can go back and look at these at any time and learning objectives are listed here and so you can get a sense here really that the two topics that we're going to focus on today. One is around the use of exoskeletal ambulation devices during the initial inpatient rehabilitation following a spinal cord injury. And the other is around the risks and benefits and appropriate role for medical marijuana for individuals with spinal cord injury. So with that being said, I want to just set the stage a little bit here for the first topic, which is the use of exoskeletal ambulation devices and the two speakers who are going to be helping me with this are Matt Davis and Chad Swank and Chad is going to be taking the pro side of this the point I guess about how when and why to use this these devices during this initial inpatient rehabilitation phase and Matt's going to take the counterpoint that maybe we should be thinking about this a little bit differently or not utilizing these devices. Probably if you're in this talk and listening today you you know the background on this but there's clearly you know growing interest in all types of you know motorized devices exoskeletal devices and and we're trying to figure out how when and where to appropriately use them. We're going to try today to not focus on a particular brand but you may hear certain ones that have either been used tried clinically by these two individuals etc. So we're not necessarily supporting nor speaking against a particular type of device. I do want to give a caveat though that this topic is really focused on non-VA IRF care inpatient rehab facility IRF care because funding mechanisms around VA and length of stays etc. is very different and similarly LTACs we know we have a couple of you know facilities in the country that are really licensed and funded as LTACs so that the length of stays there are different and the funding mechanism is different. So you know we wanted to focus really more on the inpatient rehab facility non-VA based as really the focal point of our discussion. So with that being said we want to launch into the discussion a little bit I think maybe the best place to start is around safety and I'm going to kind of alternate who goes first between Chad and Matt not to give one bias one way or another but Chad maybe let's start with you if we can and just so the question really for you is is the use of exoskeletal ambulation devices safe in the IRF setting for people with spinal cord injury in that initial rehabilitation? Thanks Jeff I appreciate the invitation to be here today and to engage in this conversation and Matt engage specifically with you so to answer your question I guess the short answer is yes use of a robotic exoskeleton in the inpatient rehab setting is is safe. You know I guess some points to think about here each device that's commercially available is FDA approved and so obviously there's some safety issues that are addressed in their application for that. So a commercially available device is safe to use in the rehab setting with with a licensed therapist. Obviously the therapists that are using the devices are licensed and to work with with patients and would be familiar with the setting that they're in. Beyond that each device comes with safety protocols right so these protocols when a therapist undergoes training they're exposed to these safety protocols and have to pass a checklist of how to manage the device with with patients and and do it in a safe in a safe way so so each device comes with that training and part of that training is is part of safety not just the nuts and bolts of how to adjust and and use it. But if we look into the literature really the top five issues that are reported from a safety standpoint falls, skin integrity, autonomic dysreflexia, fracture, fainting. These are things certainly that any inpatient rehab facility would be paying attention to certainly any therapist that's familiar with folks with spinal cord injury would be paying attention to. You know I guess I'll use our facility as an example so we started using exoskeletons in the inpatient rehab setting about five years ago and so at this point we've used the device on over 400 patients, over a thousand sessions. Not all of those are spinal cord injury probably about 40 percent of those are spinal cord injury folks and we we have had some some of those issues but I can count them on one hand so we have had one episode of autonomic dysreflexia. Our therapists were trained not only clinically how to manage that but also had been trained on how to do it how to manage that in the exoskeleton and so they were able to safely stop the device get the person out of the device and and manage the the situation appropriately. We have not had any fractures now again in in an inpatient rehab setting you don't have the chronicity of things that you're dealing with so maybe osteoporosis isn't an issue so we haven't had any fractures. We did have one episode where somebody fainted and again that's just a lesson of orthostatic hypertension maybe where a therapist need to be paying attention but again counting on on less than on one hand all of the issues that we've experienced so broadly use of exoskeletons with trained therapists in the inpatient rehab is safe. I would I would say this also you know the trained therapist is appropriate but also you want to be screening for the type of patient is every patient appropriate for an exoskeleton no and so we would think about it from a safety standpoint who is the appropriate candidate what type of injury what level of injury each device that has FDA approval is has on label uses and so you know if you're using that as a guideline certainly that can help guide your clinicians about who might be an appropriate patient but beyond that I would say as your therapists are progressing that person to tolerate being upright tolerate sitting upright standing upright in a standing frame now you can begin to think okay they might be appropriate for use of an in a rot in a robotic exoskeleton in that inpatient setting so those are my opening comments and to summarize safe with a couple of caveats as I outlined them thank you Chad Matt your response yeah I think those caveats are things that we shouldn't ignore I mean when you look at a lot of the contraindications for these devices a lot of them are more of a concern in the acute rehab setting spine stability for instance you know a lot of people's fusions are not well established yet there's fresh surgical incisions and you want to avoid traumatizing the surgical site these patients have they're not as habituated to the orthostatic hypotension at this point and passing out is can be a real problem the stakes are a little bit higher in the acute rehab setting so if the patient does have the patient does pass out the ball or has a fracture you're interrupting their acute rehab phase which is a critical time as opposed to later in the course of their rehab trunk control is not as good in the early stages as well so I think that there's there are a lot of things that need to be paid attention to in the early phases and a lot of reasons to think twice about using these in the acute rehab setting great thank you Matt we'll move on to the second question here and it's kind of two part but feel free to attack this any way you want Matt we'll start with you but it's really about is it feasible to use an exoskeletal and emulation device with with people with a spinal cord injury during this initial orphan mission amidst all of the other competing therapeutic priorities and and this is the second part then is that answer impacted at all by an individual's anticipated prognosis for ambulation recovery so in other words is it different if the patient is anticipated anticipated to be a primary long-term wheelchair user versus someone with a high likelihood of regaining emulation your thoughts Matt is it feasible sort of I would say there we have so many competing priorities with inpatient admission we have we have good people medically stabilized we have to get them fitted with appropriate adaptive equipment we have to do family training we have to teach them how to get their bowels and bladder managed and so it's kind of like teaching the patient to drink from a fire hose just to get them safe enough to go home by the end of this you know ever decreasing length of stay and so a lot of times we're so busy doing the things that really must be done that that things like exoskeleton training seems like an elective thing that I mean in my hospital a lot of times we will say we will hold that out as a carrot to patients like we'll let you you know we'll have we'll schedule you for this once you've learned how to do this independently but a lot of times we don't we don't really have time for that because like I said the links of stay are just so short we have so much work to do typically we think of ambulation training as an outpatient goal so that does raise the question what do we what do we think of the patients who have some ability that there's some potential to ambulate I would say that for the patients who look like they might actually be able to ambulate by the time they leave the hospital typically we usually have better options in the exoskeletons exoskeletons the ambulation is is pretty slow right so the bodyweight supported treadmill training you can get a lot more steps and a lot more repetitions compared to the exoskeleton and then for the patients who may have a chance to walk within the next six months but probably not by the time they leave here they really need to be learning their wheelchair skills thank you Matt Chad your thoughts I can appreciate the the comment as it relates to competing priorities yes there are competing priorities in an inpatient rehab setting but let me see if I can tackle this question maybe both parts of it a little bit there was there was a paper published in I think October maybe of 2018 it came from STI model systems on four centers really only one of the centers was using a robotic exoskeleton in an inpatient rehab setting and they were providing you know six sessions and the rationale was whether there are other things to do and our patients only want to do the exoskeletons and so you know I think you have a couple of things to navigate here is you know the original question is it feasible I would say yes it's feasible with a plan just as your therapists have to develop a plan of care for each one of their patients it's not unreasonable maybe to include exoskeletons into that plan of care would that be exclusively what they get no probably not and that wouldn't be warranted but you can build exoskeleton use in into that plan of care for for the right patients so that really I think is is that is the question is use of the exoskeleton feasible for everyone in an inpatient rehab setting and I would I would say probably not each patient comes with sort of that set of needs and that may vary from patient to patient but it certainly certainly seems feasible for those for whom gait is a goal you're doing some form of gait training exoskeletons would be a viable option and certainly if you look at the number of staff that's required to do some of the other maybe traditional or usual care kinds of gait training it takes two or three therapists maybe another tech an exoskeleton is going to require less staff and so I think from a staffing model it not only is is feasible but it may be advantageous to use an exoskeleton but the other part of that sort of plan is there is there is a learning curve certainly and I think that has to be understood from a feasibility standpoint so you would you would want to include that into your planning from an administrative standpoint and but but as the therapists have have moved beyond sort of that learning curve and they're proficient and efficient you can very seamlessly integrate exoskeletons into the daily routine for the appropriate patient and make it feasible for the therapist for the patient and the facility. Great thank you both for those those good comments I do want to recognize we've got a couple of great questions coming up in the chat box what I'm going to try to do is manage our time well to to move through both of these topics and try to save a few minutes at the end and we'll come back and and try to hit on a couple of key questions really for both topics if we can so please continue to post those things in the chat and we'll try to circle back to them but I do have a couple more things I definitely want to get through that we have kind of talked about in advance the the next question starting with Chad is the psychological message of such an exoskeletal device is is the use of that from a psychological standpoint good or bad for individuals during this initial IRF admission? Well if if I'm honest and and maybe this isn't the forum for that but you know this is a thorny issue for for for me on the pro side and I maybe alluded to it in terms of what the the last article that I mentioned where the the patient really wants to be in it certainly that the stages of grief would be relevant here and you need to be sensitive to that but I think as each patient is going through that on the inpatient side the therapists are engaging regularly in conversations with the patient and so they have a sense where they are and they have a sense for who might be an appropriate candidate not just clinical features but also from a psychological standpoint and so you know if if you if you market the device as being appropriate for everyone and everyone's going to get in it then I would say it's a it's a bad message but I don't I don't think anyone does that and that wouldn't make sense and so if if you are using some good clinical judgment if you are having ongoing conversations with your patients then I think the psychological message of the carrot that Matt mentioned earlier it does give some hope and it gives some motivation to participate to engage in the the necessary rehab activities and then offers that hope for potentially getting to use cool technology towards the goal of recovering some level of function so I think you have to be careful with it but I think it can successfully be managed to make it a positive psychological message. Great and I appreciate those honest comments Chad and I think that it's blurring that point counterpoint line just a little bit but that's exactly where we are. Matt, additional thoughts. Yeah, I'll blur the point counterpoint myself, but I'll save that to the end of my talk. So yeah, the downside of the psychological message, it can give patients some false hope. And a lot of times if we do put patients into these devices, I mean, sometimes we do put them in the device when we know they have very little chance of regaining ambulation. And that just allows them to kind of cling to that hope longer than maybe you would want them to. It also can reinforce the idea that walking is the primary goal. And we know that walking is not necessarily the main determinant of quality of life after spinal cord injury. And there's a lot that can be, a lot of positive that can be gained without walking again. And it can devalue the efforts that we do with our adaptive rehab efforts. So stepping outside the bounds of the point counterpoint, I would say that the context that I do think is a really great, it helps with the psychological health. I think there's some patients who just really, really need to feel like they gave it their all. They made every possible effort and they had the access to the best technology. And the exoskeleton allows that patient to do that and to feel that in a way not many other types of modalities do. Great, thank you, Matt. Move on to the next question. Shifting out of direct patient care just a little bit and just thinking about this from a business standpoint and is the capital investment for an exoskeletal ambulation device or devices, is it worth it for an IRF treating individuals with spinal cord injury? Unless if we can try to just keep it specific to spinal cord injury. I know this spills over maybe into other patient populations, but help us understand the case for and against from a business standpoint. So I would say you have to think of different buckets of expense, right? So there's the cost of the device itself and none of these are cheap. And then there's the cost of updating. So just like your cell phone, it needs to be updated every couple of years. There's a new model that comes out, new updates that requires a certain amount of maintenance and time and money. And then there's the personnel costs, right? So most of the hospitals that I've seen that use these devices, they have trained or we have trained a physical therapist full-time that really focuses a large portion of their time on the exoskeleton device, because it does take a lot of time and effort to learn how to use the device, a lot of time and effort to get the patient set up in the device. Chad, what are your thoughts? You know, in the literature, there's not a ton out there that has really done a cost analysis. So there is one paper maybe that I could cite here that I think speaks to whether or not it's worth it. And that, it also comes from the SCM model systems. And again, I think the same four centers where one of the points was that if 10% of all walking sessions were in the exoskeleton device, then you would have a budget neutral or a budget savings maybe even in that particular case budget analysis. So 10% of all walking sessions, you know, at our facility, if we have 200, 225 spinal cord injury admissions per year, let's say, and only a fraction are gonna be eligible, right? So, historically, let's say maybe 25 or 30% of our patients would be even eligible to use the exoskeleton. And of those, maybe only half again, or only half of the gait training sessions were used with the exoskeleton. That's still at about 15% of the exoskeleton sessions, of the gait training sessions that were used in the exoskeleton. So I think fiscally, I think you could argue that it's doable, that it is, that it could be worth it. And that doesn't seem unreasonable, 10%. So more work needs to be done clearly, but I think that seems doable. Great, thank you both. We have one more question here in this session, and I wanna give time to the second topic, and that should allow us again about 10 minutes or so near the end for some great questions from the chat. So the last question for the two of you all, starting with Chad, is the impact of having, of an IRF having this exoskeletal ambulation device good or bad as it relates to advertising, marketing, and just the general messaging of your hospital or facility? Well, so our facility is in a large Metroplex, and I had to get with our CEO to figure out how many competing centers there were in our area. But there's no fewer than two dozen rehab centers in our area. And so absolutely, absolutely, an exoskeleton helps set us apart, right? It's maybe not the only factor, but having that technology available to patients is attractive. And so absolutely. And then I would say internally, we've asked folks, why is it that you came to our facility? You have all these other options. Why did you come to our facility? And among the reasons, having that technology as an option was very important. That was the label that was given, was considered very important by 90% of the people that came to us with a spinal cord injury. So I think that speaks to the value that it shows from a marketing standpoint. Thank you. Matt? Yeah, I would say from a marketing standpoint, it contributes a lot to the hospitals that have them. There is a lot of competition between hospitals, and some of the hospitals that have fancy types of equipment and have a lot of good advertising don't have good spinal cord clinical care. And so I would hate for somebody to choose their hospital based on the technology or the fancy billboard, when what they really need is the knowledge base and the expertise of good spinal cord injury rehab. Thank you. Great, great comments. So we're gonna conclude this first topic. Chad and Matt are gonna hang on. We'll kind of bring everybody back for the panel discussion at the end. I wanna invite Mike and Jeff and Rita to turn on their cameras. I'm gonna go back to our slides here just for a moment and share that with you again. And we'll move into topic two. Rita, I'll let you take it from here. Okay, welcome everybody. And thank you for joining our session. We have a few minutes to discuss the medical marijuana issues in our individuals with spinal cord injury. Those of us who treat spinal cord injury know that this is a pretty common discussion that we have. We're gonna try to see if we can pull the audience a little bit and that's, you know, not pull in my Southern accent. If you could answer the following questions. How often as a healthcare provider are you asked about medical marijuana? Once a week, once a month, very seldom or never. Okay, Charlie, what do we have? So it looks like most of us are asked about medical marijuana. Let's go to the next question. If your facility allowed the discussion of medical marijuana would you feel comfortable recommending its use to a patient assuming it's legal in your state? Yes or no? Okay, Charlie, that one was quick. Interesting. About 54 and 46%. All right, we'll go to the next question. Last one. How comfortable are you at addressing this topic of medical marijuana in your spinal cord injury patient population? Very comfortable, comfortable, really neutral, uncomfortable, very uncomfortable. Okay, Charlie. Pretty evenly split. Nice. I'll let Jeff and Mike look at that and then we'll go to the next slide. So what we wanna present to you all in this time since there's not a lot of time and I think the three of us could probably go on for hours about this topic. And just to let you know, there are some nice presentations that will be downloadable for you from both Mike and Jeff from the pros and cons. We've asked these two to come together. Mike will represent the for, Jeff will represent the against, both probably living in both worlds based on where they practice. So let's just pretend we have a 32 year old male with a history of a T4 Asian impairment scale, a spinal cord injury from back in 2018 from a motor vehicle collision. He comes to your clinic and he's relocated to the area and he's seeing you, chief complaint, pain management and spasticity and he needs a spinal cord injury doctor. So I'm gonna put all these questions together. But first of all, he's saying, hey, my buddies tell me about this. Can you tell me what's good or bad about me? What's good or bad about medical marijuana? And as you interview him, you also find out that he is employed and with his job, he can be randomly drug tested. You also realize that he's a pretty independent wheelchair level user and he drives with hand controls. His past history, he had a DBT and he and his partner are interested in assistive fertility and we'll bring out these points with our subject matter experts here. So Mike, I'm gonna throw this to you for several minutes of discussion of supporting our new patient with maybe use of medical marijuana. Certainly, well, first out of the gate, let me thank both Rita and Jeff for organizing this virtual presentation. I share Jeff's comments that hopefully we can do this live and at some point in the not too distant future. I know we went through disclosures, but it's important. I wanna be absolutely upfront with the audience that I am a medical marijuana certifying physician in both Pennsylvania and New Jersey. So that is a potential conflict that I wanna disclose right out of the gate. For some members of the audience who may not be intimately aware of the medical marijuana process, very seldomly do physicians prescribe medical marijuana. What they do is they certify that an individual has what is called a qualifying condition in their particular state. Medical marijuana is a swamp of legal, Stuart I'm gonna use, complexities. It is technically illegal under federal law, meaning that it is a DEA Schedule I substance. However, individual states have allowed medical marijuana to be permissible within that state. Now, how the federal government and the state governments interact is a subject beyond the scope of just a physiatry meeting and could even depend on which state and who's in the White House at any particular time. It is not a prescription. All we are saying is that an individual has a particular condition. Currently in the United States, there are about 41 states and territories that have some form of medical marijuana permissible in that particular area. If you look at those, all of them have chronic pain as a qualifying condition. Most of them have spasticity related to neurologic dysfunction. Some specifically state that spinal cord injury or injury to the spinal cord by itself in the absence of pain or spasticity is a qualifying condition. So the fact that the majority of states have qualifying conditions that fit this patient condition makes it pertinent for discussion. Now, is it the complete Wild West out there? I mean, literally, is it just getting marijuana and not having any advice to patients? Well, that's not completely true either. There are synthetic cannabinoids that are approved in the United States that includes things like Sessoment, Maranol, and most recently Epidiolex, which is a CBD only product. And in a little bit more than a dozen and a half countries in the United States, there is also a bugle spray that is a one-to-one mix of CBD and THC. You can use data from these approved products to give informed decisions to your patients regarding the use of medical marijuana. Is it the perfect correlate? No, but it at least provides some degree of correlate. Rita, is that a reasonable starting point for us to go? Sure, and then let's skip down to Jeff and see how he would handle this with his patient, same scenario. Sure, and thank you for that introduction, Michael. I would start off by discussing or showing the audience and just to stoke your fire a little bit, is that one of the things that Michael had let us know is that 41 states, this is now legal to discuss if someone has a symptom that's related to, or a person's able to get medical marijuana from a dispensary. But in 100% of states, four out of five doctors recommend a Camelot as their choice cigarette. And this doctor right here might be either happy that it was saying that he should smoke cigarettes or that everyone should have cigarettes. So I'm not sure that I'm completely on board. And once again, I'm taking the con, so I don't fully believe in this, but I figured that would be a nice introduction. That there's a lot of downside to, I know that there's a lot of downside to medical marijuana. And that's what I discuss with my patients. The first thing I would ask is, why is a patient coming to me and why are they requesting medical marijuana? For what condition? In the state of Colorado, we just did a study and 60% of my patients do utilize medical, utilize medical, utilize marijuana in the recreational or the medicinal form. I'm in Colorado, so we get to, they get to choose. So 60% is a pretty high number. So just having an aptitude to have that discussion is important. The first question, once again, is why are you coming to me and what is the ailment you're trying to cure? What are you looking to treat? And then knowing the therapeutic effects of marijuana or THC or the cannabinoids on that ailment is really important. The Bible probably for this is the health effects of cannabis and cannabinoids put out by the sciences and engineering medicine, under page manual on medicinal marijuana. But if you look at the effects of medicinal marijuana, especially on things like pain or asbestos, I'm sure we'll talk about that later. You have to make, I think as a clinician, you have to be able to make up your mind, is this helpful for my patient? And of course they get to make the overall decision, but you have to have that intelligent conversation. The second part is what is the harm or what harm can you do in that? So understanding the risk benefit ratio, right? What is the risk to cardiac effects? What are your patient's secondary conditions, comorbidities? And what are the drug to drug interactions? So I would say it's not just as easy as saying my patient has a spinal cord injury, which I don't think you're saying, Michael. My patient has a spinal cord injury and I'm gonna prescribe marijuana because it says so for medicinal purposes, that's under my checkbox. But really going through risk benefit ratios with your patient, I think as we look through it, we'll find that the benefits are not as wide or as high as we might think. And I think as we go through it also the risks, and I think just recently with the wave of states of accepting medical medicinal marijuana, as well as recreational marijuana, I think the perceived harm is really low right now when it's much higher than it could be both on an individual level and a societal level. Jeff, I know we're supposed to be antagonistic to one another, but I think in this realm we are a little synergistic. When I do a medical marijuana certification, I budget an hour's worth of time and I go through all the potential adverse events that can occur. And after you get into about the fourth or fifth thing that could happen, patient's eyebrows really start to go up and no one had told them about that. I think you're absolutely appropriate to go over the pluses and minuses of it. I never do it on an initial appointment. I think that's a disservice. I always explore what has been tried and failed previously. Having said that, if you look at some of the clinical trial data of the approved products, probably the biggest advantage to cannabinoids is tolerability. It is relatively rare for individuals, while they may have adverse events and they may have drug-drug interactions, which are appropriate to discuss, pretty rare for folks to say, I'm gonna stop using it because it's just intolerable. You mentioned about drug-drug interaction and the fourth bullet point in this hypothetical case is the note of history of DBT. It is increasingly recognized that cannabinoids have an interaction on individuals with Warfarin. In fact, I've had two patients who were on Warfarin who were interested in medical marijuana and had to stop using medical marijuana because their anticoagulation management just became so erratic. Now, there are ways around some of the drug-drug interactions. For example, sublingual or bucal administration is much less likely to have drug-drug interaction compared to oral or inhaled formulation. But I do agree with you that just checking off the box and saying, okay, you're good to go, go down the street to your dispensary is inappropriate. Rita, should we take on bullet point two a little bit? Let's do, and we're kind of there with drug testing. How do you screen these individuals? What are your recommendations with our case study here? Terrific, I'll take my approach first. All of our patients who we're going to consider for medical marijuana get some form of drug screening. Now, it's interesting in a spinal cord injured patient, it may not necessarily be the easiest thing in the world to get a urine drug test. So we typically do salivary in that room. You know, if someone comes up positive for marijuana, that gives you a suspicion that they may not be using it completely for medicinal reasons, and they're really just using the medicinal pathway for recreational use. Any physician who is going to take on the point of discussion of certifying an individual for medical marijuana needs to know the employment issues in their state. And this is one of those things that you almost need to kind of keep as an active Google search in your computer because it can almost change moment to moment. Some states say that you cannot make any employment decisions based on a positive marijuana test at the time of employment. For some, it depends on the type of employment. For example, in one of the states that I certify patients, if you drive a school bus or a policeman or a fireman, you can make a hiring, firing decision for that based on that. And you should counsel the patient before you certify them. I will admit my own mistake early on in my medical marijuana certification career. One of my patients was actually a army reservist and was subject to random drug tests as part of his reserve obligation, very topical here on Veterans Day. He actually had lost his reserve status because he turned up positive. So it is certainly appropriate to have a very, very keen understanding as to what employment law is with that. There is some data in the literature now about what impairment is like in terms of how long after marijuana administration that potential impairment can last. And that depends on whether you're an acute user or a chronic user. Jeff, do you want to pick up some comments there? Sure, I don't have much to add. I think that was a great, this point I don't think is a point counterpoint. I think really knowing the employment law and knowing where the person is employed, discussing the ramifications of utilizing medicinal marijuana, even talking to, if he doesn't know, or she doesn't know, even talking to the employer about it and making sure that he or she will not lose their job on a random drug test. If they do have a card, it's sometimes recommended. So I just want to, you know, to emphasize knowing the law of your state or knowing the law of the states that you're practicing in is of utmost importance. Sure, just quickly, Jeff, how do you handle since you have both recreational there, when you do drug screens on your SEI population, how do you handle what you find a lot of times with VTHC and you're not writing for it because they're using it recreational? Right, so we don't write for it as part of our, so I don't write for medical marijuana as part of my practice. So the question more kind of eggs in my practice is, you know, we're prescribing narcotics. I'm sure I'm gonna get a question on narcotics versus medicinal marijuana, but that's okay. And, you know, a lot of times we'll either turn, we won't check for medical, we won't check for marijuana being that's legal in our state. Or when we do check for marijuana, we will have a long discussion about the interaction and side effects of medicinal marijuana and or recreational marijuana and narcotics. Sure, and in the interest of time, I want to jump to our last bullet point because this was something that was brought out to me when we started this discussion is fertility and the use of marijuana. Mike, I'll throw that to you. Terrific, so in my survey of the states, I don't want to say this with absolute certainty, I could not see that infertility was a qualifying condition by itself. And I certainly don't want to put myself out as a fertility expert, but the idea that there are certain chronic inflammatory changes that may contribute to infertility, both in males and females is at least of a theoretical benefit. To that end, CBD does have a reasonable amount of evidence as an anti-inflammatory agent. You could see its use in other chronic inflammatory states, such as ulcerative colitis, for example. So to that end, CBD may be beneficial in helping out with fertility. However, it's relatively difficult in the medical marijuana world to find CBD only products. Almost all the time, they have some degree of THC. THC is the component of marijuana that is more psychogenic. And there is some data to suggest that THC can actually lower fertility rates. The biggest problem with much of the medical marijuana research is the difficulty between association and causation. So if you take a bunch of people and say, is this group of people medical marijuana users, they may have decreased fertility rate compared to normal or a non-medical marijuana using population. But does that mean the medical marijuana caused the infertility or were the individuals who were infertile or had fertility issues more likely to choose medical marijuana? So the difference between association and causation that was drilled into us as medical students and should continue in our daily decision-making, certainly holds true here. So, and interestingly, just last week, I did have a spinal cord injured female ask me specifically about the effects of medical marijuana on fertility. And I just gave her that description that I just put forth to you. So especially since spinal cord injured patients tend to be of childbearing age for a good chunk of the population, I think it's worthy of discussion as part of that extended conversation. So. Jeff, that might be one-sided, so. Yeah, I'll add to that. I think when I talk to, and I'll especially use the second part, the female patient, we know that, well, the CDB1 receptor is especially lipophilic. So we're talking about cannabinoid receptors. And we know that the THC crosses a placenta and also goes into breast milk. So I think you have to be very careful when talking to a pregnant, a female that's in years of pregnancy or viability that wants to become pregnant or may not, and may become pregnant, that THC does cross the placenta. In studies, we know that it does affect the prefrontal cortex. We know it affects the limbic system in rats. We know it affects hippocampal size, learning, and memory. We know it affects the amygdala, which is your fear and stress responses. And we know all this occurs as well as limbic connectivity. So if this, you know, I think about this, if this was my daughter and I have a six-year-old and I'll put my own family member in, I would not be recommending at this time THC or THC-based products when they're in years of pregnancy or want to become pregnant. To that end, we know that, you know, I think causation, I appreciate, it's really hard to do double-blind placebo-controlled trials in anybody when it comes to THC for lots of different reasons. Number one, people know when they take THC and they don't. Other is it's a schedule one drug. So it's hard to get the approval for those studies. But that being said, I think that we can at least say there's an association between that it may be unsafe in pregnancy. That being said, I think one study that I do always like to quote is one in Colorado where we have the recreational and medicinal. So they had secret shoppers call 400 dispensaries and say, should I use medicinal marijuana for morning sickness? And out of that, 69% recommended marijuana for the treatment of morning sickness. And 31.8% recommended calling a healthcare professional without prompting of the secret shopper. So I think you have to be really careful when discussing in pregnancy. I think you have to understand that there may be side effects both short-term and long-term to the developing fetus and also in school, cognition, memory, anxiety, fear responses. And, you know, I think we all as good parents want to give our child the best chance in the world to succeed. At this point, I just claim with good faith and good understanding, recommended. So I'm going to stop us there. So we have time for questions. And I know we could get, like I said, we could go on forever about this, but I thank you. And to the audience, this is downloadable. They have both presentations and I've looked at them both. They're really nice to be able to access. So Jeff, John's Jeff, too many Jeffs. There are a couple of exo questions and a couple of, I think if we can't get to them all, we could probably relay those to the experts and have them answer offline. Yeah, I want to be respectful of time for the session. I know folks have other virtual places to go, but we can go back to the exoskeletal group for just a minute, Chad and Matt. I was looking at a couple of the questions and I want to tie two of them together. There's a question about effects on functional outcomes when exoskeletal systems are applied during inpatient rehab. And then a subsequent question that says, can you say with certainty that those who trained with the exoskeleton had overall better outcomes in terms of achieving independence at the wheelchair level and had fewer secondary complications, ER visits, UTIs, et cetera? So how certain are we really that this is doing what we would want it to do if we're utilizing it during the IRF initial stay? Yeah, I'll take a first crack at it and Matt, go ahead and fill in the gaps here. I guess, Jeff, I'm not certain if I'm supposed to be pro because it's going to be hard for me to say with a tremendous amount of certainty that the evidence is in that exoskeletons are officially the way to go. I think there's some anecdotal data, some retrospective data maybe, and some small trials, but it's far from clear at this point, either in terms of functional outcomes as well as some of the secondary kinds of issues that were brought up in that question. So Matt, do you have something you'd add to that? Yeah, not really. I mean, I would say that I think the studies that show some benefit are done in the outpatient setting. And probably had a lot more sessions than could fit into an inpatient stay. Great, and one more I want to pull out here, and that is how would you justify exoskeleton training for patients whose insurance won't cover those as an outpatient? They won't really have access beyond the IRF stay. And then associated with that is how do you justify then kind of selecting patients for use of this device based on insurance during the IRF stay, if that's one of the decision points? Yeah, I think I tend to think of the exoskeleton as a tool. So it's one of a handful of gait training tools. And so I'm not necessarily looking for insurance to approve specifically the use of an exoskeleton. If gait training is indicated, then the therapist and the physician recommending gait training as necessary for care, then we have at our disposal a variety of tools. And one of which would be the exoskeleton. I guess that's kind of how I think of it in terms of justifying its use. And then within those tools, some are gonna be appropriate for walking at the parallel bars. Some are gonna be appropriate for walking in a body weight support treadmill training system. Some might be appropriate for walking in an exoskeleton. But that's sort of how I view it clinically and am able to sort of justify based on their clinical presentation and level of appropriateness. Great. And Matt, unless you have something else to chime in on there, I wanna give the last three minutes here to Rita and Mike and Jeff. Do you wanna pull out a couple of questions, Rita? Sure, I'm trying to combine a few. It looks like there were a couple regarding people who were using opioids and looking at medical marijuana. Do you trade them off and or do you use them concomitantly at the same time? How do you manage that? And then have we seen any overdoses during the pandemic time on these drugs used together? So as highlighted, I think you need to go to your individual states cert qualifying conditions. In some states, opiate use disorder by itself is a qualifying condition. There is some societal level data to suggest that adding medical marijuana to your state may have an effect on opiate utilization. If that opiate is coming from a medical provider, it doesn't have effects on things like heroin or fentanyl-based heroin or fentanyl-based products. There is certainly concern with anyone on opiates also taking another CNS affecting medication. Having said that, it's pretty darn hard to overdose with marijuana by itself in isolation. The people could get sick, they could get nauseous and can be hospitalized for that, but you're not gonna get things like respiratory depression with medical marijuana in isolation. Jeff, you wanna? Sure, real quick, I would just add, and that's a great point. Yeah, I think that you will discuss the effects of medical marijuana or medicinal marijuana and with opioids, but I think most patients tend to do them at the same time. Being realistic, I have seen an increase in hospitalizations, not only during the epidemic, but in the hospitalization. Not only during the epidemic, but I think there's good, if you look on Colorado's website, it said that there's a hospital in Central Colorado that saw a 2000% increase in emergency room due to marijuana overdose or poisoning ever since 2015, when recreational became legal. So there's lots of evidence out there that shows that recreational slash medicinal marijuana, and I know that is not the same thing, but just for the sake of time, there's a lot more use of the EMS system, poison control calls, as well as emergency room and ICU bed use. So that's just to add. And then your pain reduction that we see, and I know we're short on time. Well, it was approved on a very small reduction in pain and pain use. So I always discuss what pain reduction are you looking for? And then when they start utilizing medical marijuana, we see either on a BAS or another scale, are we hitting our goals? I think anytime you start an opioid or medical marijuana, you really want to psychologically make sure they're doing okay. And also are you hitting the goals that you want to achieve? So those are two points. And Dominique asked a question. It's in Mike's slides for the interaction. So I think that's all we have. Jeff and Mike, thank you so much for my point, counterpoint, and I'll turn it back to Dr. Jeff Johns. We are at the top of the hour. Thank you all, Mike, Jeff, Chad, Matt, especially Rita for your co-moderation of this session. Thanks for pulling this all together. This has been an excellent discussion. Thank you all for your comments and questions in the chat. And I hope you enjoy the rest of your virtual conference. Thank you. Thank you guys. Thanks everybody.

exoskeletal ambulation devices

initial inpatient rehabilitation

spinal cord injury

medical marijuana

safety

feasibility

psychological impact

business aspects

potential benefits

risks