Member May: Hot Topics in Performing Arts Medicine (1.25 CME)-Hot Topics in Performing Arts Medicine (1.25 CME) (enduring)

Hot Topics in Performing Arts Medicine (1.25 CME) (enduring)

Video Transcription

Hello, everyone. Hello from the East Coast. I'm not entirely sure where you all are, so the times are different.  My name is Tracy Espiritu McKay. I am the current chair of the Performing Arts Medicine Community with AAPMNR.  I'm so glad to have all of you join us. We have an incredible panel of speakers here for you today.  For those of you who were at the annual assembly in New Orleans, we're actually repeating the lectures that we had then because it was supposed to get recorded, but it didn't.  So we have the opportunity to present it again for all of you. You may have heard these lectures. That's okay. Refreshers are always cool.  We've got a bunch of great topics. If you aren't familiar with them, we'll be talking about the art of treating artists,  caring for the breakdancer, which is really great considering that the Olympics are coming up and we'll be seeing breakdance.  We have ballroom dance medicine for the physiatrist, ergonomic evaluations of the musicians, concussion management of the performing artist,  shockwave therapy for the performing artist, and PRP for the treatment of dancers in particular.  We will have a 10-minute Q&A session at the end of this, so if you have any questions, please try to hold onto them. I promise that we will have time to cover that at the very end.  Let's see. What am I missing? I'm seeing lots of familiar faces here, lots of people just signing on.  Thank you again for joining us, but I think it's safe to start, so I'm going to stop showing my face.  I'm going to mute myself, and I'm going to have Dr. Popoli introduce himself and his presentation, and we'll start with him.  Great. Thank you. Let me bring my screen up. I've been told I'm boring because I repeat myself, but apparently that's cool now, so that's great.  Let's see. Okay, so thank you for having me. I'm David Popoli from Wake Forest University School of Medicine,  and I'll be talking about the art of treating artists, specifically lessons that I've learned in clinic. I have no disclosures or financial contracts of interest.  As a brief outline, I'll start with an introduction with some numbers for those of you that are numbers people.  I'll also go through how language matters when taking the history as well as understanding the context of injury,  both within the history as well as the physical exam, talk about how precision is key, as well as briefly touching on equipment assessment.  And as we talk about sort of how to start treating your patient, how and why it's important to engage your patient in shared investment.  So by the numbers, dancers, musicians, performing artists in general are definitely injured at fairly high rates,  and the overwhelming majority of these are overuse injury, which kind of begs the question. We have a lot of people getting injured. We know they're going to get injured.  How are we as a medical community doing? Unfortunately, at least from dancer studies, it appears that we could be doing better.  About 80 percent of dancers say that their health care provider doesn't understand them, and about 43 percent say they're given unhelpful advice.  For those of you in the audience, you already know this is going to be stop dancing. It's the audience selection for the unhelpful advice that is given.  I'd like to frame this a little bit in the case of history. This was a patient that I saw, 17-year-old elite level female ballet dancer with knee pain.  I won't read all of this to you, but basically it sounds like it's not really a mystery case.  I'll use this case as a reference for where you can add on to a history or add on to a physical exam in terms of how you can treat.  The first thing is to be curious, really to strive for connection with your patient. One of the best ways to do that is learn the vocabulary.  This may seem pretty basic, but actually not knowing can be your friend. Performing artists really like to teach their doctors.  If you don't know something, the question is an opportunity to build a relationship with your patient. This actually happened with the patient that I saw.  She said that she had told an outside provider that it hurt when she did plie, and that she had gotten sort of a vacant stare and was told to stop dancing for two weeks.  Obviously, there was some service recovery here. Her body language also looked very closed off.  She looked pretty unsettled in the chair, which brings us to the second point, which is to be conscious.  Performing artists, in general, it's important to be mindful when you're around, to be very present in the room, because they are very finely attuned to nonverbal communication.  For a dancer, this is just a nonverbal cue they're going to get from their partner to do something.  For a musician, it's going to be a very subtle hand wave from the conductor to do something.  We, as their physicians, are saying a lot more than we think, so we do have to be very cautious.  It seems kind of odd, but there's actually really good psychology literature to tell us that when we communicate with our patients,  when they come in in terms of the reception we give them, how we mirror their body language,  and what we do in terms of eye contact, that really helps enhance that encounter and make them trust us. As we're taking that history, then it's also important to be complete.  I don't need to tell you, as a physiatrist, that it is important that you delve into the social history and be very granular in detail about BH35,  because a lot of these are going to be about modifiable risk factors. Asking about things like training hours, nutrition, sleep, lowering surface equipment,  tempo changes for an artist, an instrument as a performing artist, because these are going to help us as we go through evaluating the situation.  For this patient, her hours were already kind of a problem, as you can see up here, not a lot of load cycling,  but those last three bullet points, that's really your opportunity to be curious. What is a standard warm-up? What that really meant was, I don't really do a warm-up.  What do missed meals mean, and then making them up? This meant that she was really kind of trying to make up meals on the weekend,  indicating she had a caloric deficit, and sculpting was trying to lose five pounds prior to performances, which we all kind of agree, these are not ideal.  So if you've not taken that opportunity to be curious, it's a completely different experience. Next is to be collaborative.  Again, as physiatrists, this is kind of our MO, but really it's your opportunity, as you're taking this complete history, who else needs to be involved?  Very clearly, physical therapy, nutrition. You may need to get a point-shoe fitter on board if this is going to be one of your valet answers.  You may need to talk to this person's instructor. You need to talk to psych. It's important because working as a team does matter.  There's a number of studies that show that when you engage a team when taking care of a performing artist, that there's reduced time missed.  And this was a good study looking at advanced companies who were actually reducing days missed as well as reducing work time.  It's also important to work as a team when it comes to the physical examination. Static strength, static testing is not enough.  So really looking through strength, flexibility, and biomechanics. And that PT that may be co-located with you in the clinic,  that's another set of eyes to do dynamic testing and observation, as well as to assess muscular endurance.  Now, you're not likely to get that dancer or that musician to play for 20, 30 minutes or dance for 30 minutes and see what happens.  So this is your opportunity to bring technology into the clinic. What does it look like before you got hurt, when you were starting to feel? What do you look like now?  What's happening with your performance quality? And you can usually get the performing artists to film themselves, and so this is a great opportunity to use that tool.  Performance assessments also include assessment equipment. So for this dancer, it would have been a point shoe. For someone else, it might be looking at their instrument,  might be looking at a bow, might be looking at what's going on. And so it's important to not discount the equipment. Thankfully for her, it wasn't an equipment problem.  She actually looked better in her nickel eye than she did in her hanger. As we're moving, and we've gathered all this information,  we want to think about how we're going to treat this patient. It's really important. This is probably the one that took the longest to learn its position.  So treatment is a performance enhancement for three parts. They really don't want to stop, so I have to be able to add something for them. So in addition to being complete,  you may have to get a little bit creative to get the dancer or the performing artists on board about why they need to be engaging in this physical therapy or this treatment program,  and giving them something where they feel like they're going to be better as an artist at the end of this. It's also an opportunity to introduce cross-training.  Just as an example, I mean, these may be very appropriate stretches for someone having knee pain, but that's not going to resonate very much,  so why don't we do something like this where it feels a little bit more  performance support for you. For our case update, this dancer did very well. She's actually now dancing professionally. So the five Cs of working with the dancer,  those that you would like little snippets, being curious, asking lots of questions, being conscious, mindful of your presence, being complete, both in the history and the exam,  and that may require being collaborative, having a team, and then lastly, being constructive, so it feels like there is a real benefit to this person.  Thank you, Dr. Popoli. Next up, we have Dr. Rubesh.  Okay, I'm getting ready to share my screen.  Here we go. Okay. I need to go to presenter mode. How's that look, Tracy? Looks great. Okay. All right, we'll get started. So I'm Dr. Melody Rubish.  I'm director of primary care sports medicine at Rothman Orthopedics, New York. I'm going to speak on musculoskeletal care of the break dancers,  or as I like to say, when breakers break down, because why not be cute and clever? I have no disclosures. I do have to say that I have given this lecture before,  and it's been in combination with two physical therapists who are awesome, Jen Janowski and Kelly Barton-Schneider. Jen is in Chicago, and Kelly is in L.A.,  but will be moving to Carolinas soon. And we have two Olympians already qualified for the Paris Olympics, Sunny, Grace Choi, and Victor, B-boy Victor,  are already qualified. We just completed an Olympic qualifying series in Shanghai where we have two B-boys and two B-girls who are in the mix.  Our B-girl placed fourth, and our two B-boys placed fifth and sixth. So we do have a good opportunity to possibly qualify two more Olympians. This was our pool from the fall.  And just a quick breaking background as it originated in the 1970s  in the Bronx. And the term breaking comes from the breaks in the music. And I'm going to skip through these, but breaking terminology,  be aware that a B-boy and B-girl is how they like to call themselves. A crew is a team of breakers who compete or a social relationship,  and a battle is a competition between crews or between people. Crashing is falling out of a move, and if you call somebody out, you're just challenging another breaker.  And a set is a choreographed sequence of moves, which in competition is actually something that we have to be careful with  because that can be marked down because everything is judged. So just to go through some quick terminology, top rock, up rock,  and freestyle, the go down footwork and down rock, freezes, transitions,  power moves, tricks, flips, and breaking should be qualified as a contact and collision sport, and in fact, we do qualify it as a contact or high-risk sport in the USOPC.  It's when you purposefully collide or hit the ground with force, routinely make contact with each other or inanimate objects,  and usually with less force than a full collision sport. So this is El Nino. This is Alex. He's up in Boston with Lauren.  So these are not his injuries, but this is just I have these videos playing to give you an idea of what to expect  and what you can kind of understand some of the injuries that happen. Chronic instabilities, joint hyperextension, patellar dislocation,  ankle instability, radiculopathies, both cervical or lumbar, peripheral nerve entrapments, particularly ulnar nerve or median nerve,  fracture and nonunit if they go back too quickly, tendinopathies from overuse, spondylopathies or spondylolisthesis, and muscle strains and tears and concussions.  And now he's finishing up his thing. Okay, so this is Sunny Choi. She's just showing some practice. Basic training in gymnastics is helpful, headstands, handstands, cartwheels.  That teaches you sort of how to fall. There's also a history of prior injury or experience level. These are all intrinsic injury risk factors.  Flexibility and stability are important, in addition to proprioception and vestibular acuity, similar to circus artists. This is Jeffreau Rad. He placed fifth in the recent OQS.  And as you can notice, he threw down on asphalt. I'm just going to take a glass of water. These are often done – sometimes the flooring isn't great.  You can't predict other breakers' moves. Sometimes they crash into you. Flooring, equipment, lighting, socioeconomic barriers, and rehearsal space.  A lot of times these breakers are going in. They're going around their other jobs. They're having to get in what they can.  They're taking what people will give them in terms of free personal training and all of that, so safety can be an issue. So there is an issue with bracing and breaking.  There was a study that studied 40 professionals and 104 amateur breakers. And a lot of them wear bandages, either on their wrists or their elbows, head protection and knee bandages.  These are becoming more frequent. They suggest that protective gear is usually something worn after an injury, but not necessarily as a preventive measure.  I will say that at the Olympic level, they are realizing with the level that they're having to train at that they're trying to be preventive.  They have access to a little bit more money and equipment and medical professionals. But they do still try to hide their bandages a lot or their tape.  They like to kind of keep things. They don't want people to know what their risks are. And then I'm going to skip this one. By dance style, though,  Shea Odrafetimi conducted a web-based survey over a six-month period, and they had 232 responses about reported injuries.  And they found that breakers had a higher incidence of injury between other hip-hop genres like poppers, lockers, and new schoolers. So this is B-Boy Morris.  He's no longer in the pool, but he's a really, really great breaker and a really strong guy. So there was a good study about the musculoskeletal injuries in break dancers,  and this is less than 10 years old. A lot of wrist, a lot of finger, a lot of knee, shoulder, lumbar, spine, elbow. And you can see there's a lot of injuries here.  Wrist and finger is over 60%, knee over 60%. So if you're seeing two breakers, you're likely going to see all of those things.  And the most common injuries tend to be not as egregious, sprain, strain, tendonitis. Dislocation fractures are less common.  And I show this picture because, honestly, when I travel with the team, you just have so little time, and you have to be careful in limiting their range of motion.  So a lot of this is just tape. I just end up taping them together as long as it's safe to do so. But you have to decide when to compete, when not to compete, how to modify,  and how do you prevent this from happening again. So we're going to talk about the head spin hole, neck sprains, break dancers, bursitis, back.  And let's see, the head spin is spinning while in a headstand due to chronic inflammation from repetitive head spins.  So this was a great case study that actually was – you can see the callus. If you see my arrow here, this is a callus that formed on top of the skull  from this person continuously spinning on his head. So this has been developed. These are hats that people wear. And you can usually tell if somebody is going to throw this down  because they wear hats. They'll put their hat on, or that you know that they're going to do something on their knees because they'll put their knee pads on underneath their pants,  something like that. This is logistics. She placed fourth in the most recent OQS, so she is not yet qualified for the Olympics.  I wanted to show this video because she does a lot of dance. She's very artistic, and she really battles the person across from her.  I won't be able to show all of this because she just goes to town on this lady telling her to watch her. So that's the person she's battling.  You can see how she's spinning on her head, on her back. She's using her arms and her legs to propel her. Here she is with a flare. You can see just a lot of head movements,  and then she just decides to hold it on her head. I'm going to keep moving. You'll have more. So lower back injuries because I want to respect the next people's time.  Commonly injured location, so repetitive nature. Victor here, he's already qualified for the Olympics. He was the first American to qualify for the Olympics.  A lot of holds on the head, a lot of jumping, a lot of landing on the head. Okay, with that, I'm just going to quickly run through.  There's a lot of upper extremity stuff, as you could see, but we are really experts at taking care of these upper extremity injuries, particularly the neuropathies.  So we're really great at knowing is this cubital tunnel syndrome, is this cervical radiculopathy. The main thing is know when to tell somebody not to battle.  If it's not safe for them or others to continue, that's still the case. And I have references available if you'd like to reach out to me. This is my contact information.  And I'm going to stop sharing my screen. Thank you. Dr. Davenport, you're up next. Let me get my screen share going.  Should be good. All right. Everyone see that? Okay. Perfect. Okay. Moving on. So we're going  to go through some culture of ballroom dance and styles, review some literature and talk about  culture specific medical issues. So when someone comes into your office and says they do ballroom,  that is a very wide variety of options there. So we have international, which stays in hold,  American, which is coming off of international, but comes out of hold for our classic styles.  And within that we have standard and Latin for international styles and American smooth and  rhythm. And then going into can you hear me? Okay. I think someone's not on mute. So, and then going  through the competition circuit, we also have a lot of dance styles that are outside the competition  circuit outside these styles as well. So just like we're good at as physiatrists, it's very  important to find out exactly which style or styles people are competing in. And most people compete in more than one. And then we'll additionally do non-competition social styles  on this side as well. And then for divisions and levels, we have amateur couple, like my husband and  I will go to amateur couple, but a lot of times amateur couple can be very people who are like  very serious. If you're familiar with like dancing with the stars, people who are going to be pros  will start out as amateur couple and then go into their professional couple when they kind of age  into our go through the competition ranks into professional. And then pro-am is a very big scene  in the US. So if you have someone who comes into your office and they're 65 years old, and they're  like, I'm a very high level dancer. And you're like, huh, it's probably on the pro-am scene as  the amateur dancer, more commonly women. And actually one of the more competitive age groups  is your 55 to 65, kind of the empty nester group, but maybe having some disposable income. So it can  be quite expensive where they pay a professional to take them out on the floor. And then they start  out, we all started in bronze, move into silver, gold, and then open is considered the highest level.  It's divided by age groups and there are different ways to win a competition, either by quantity of  competing multiple rounds. And they're called rounds each time you go out on the floor versus  quality, which is more winning a scholarship or championship round. The culture is very much a  competition culture, unlike a lot of dance styles, such as ballet, which is a performance, go to a  theater. This is more of a competition. And so the results are valued more than like a cabaret or  showcase type culture within the dance sport. And higher experience has been shown in studies to  correlate with higher rankings. And people come into this from a very international style. So a  lot of international and American style pros have come from Russia, England, Italy tend to be very  common countries. There really isn't a season. It's a very year round type sport and it can be  very financially lucrative for the pros, especially in the American scene. So we get a lot of people  who will win their competitions at their level internationally, and then come to America as pros.  And so it's very important when you're asking them to not dance that you understand that they get paid to be this professional and that can be a huge financial burden.  It tends to be very gendered. So what a male ballroom dancer is expected to do and their injury patterns is often very different than a female ballroom dancer. And that goes through  styles. And there's a very clear lead and follow. We don't call it male or female, woman or man.  It's called a lead and follow. However, the man is expected to be the lead and the woman is expected  to be a follow. And everyone who knows me can understand how that went in my first class.  But technically I'm a follow. I know, shocking to everyone. But they have very different injury  patterns. In terms of equipment, it's very universally tan, shiny, slick tear. This is  me and my husband in our kit. The women tend to be more in elaborate dresses, but actually it's  very satisfying to me that it takes my husband way longer to put on his kit. And it tends to  be much more uncomfortable for him. And that gives me great joy since I have to follow him around.  So we do work with more extreme shoes though with our get up. And the posture for the more Latin  culture tends to have a lot more mobility within the posture. So we have to look for when someone  is a standing posture, they actually reduce their curvature within their spine. And they've shown  just straight standing posture, especially for Latin dancers have the less amount of curvature  and yet more mobility when moved through that. So that's something that we see within our data,  but looking at barm dance culture, the body type, my female coach, who's my husband's pro partner  and likes to say barm is a vein sport. So it matters how you look. And so you tend to, when we look at data compared to other dance styles, they tend to be taller, slightly less  musculature and slightly greater adiposity compared to ballet and contemporary standard dancers,  which is more your international styles tend to have more ectomorphy as well as more height.  And Latin, it tend to be slightly shorter and more curvy and they're in more mesomorphic features.  In terms of fitness at cardiovascular, it is considered a heavy energy expenditure with a  higher aerobic cardiovascular capacity. And it's more aerobic compared to other styles of dance,  such as ballet and contemporary. And based on what kind of dance you're doing, it can have more cardiovascular requirements and the last dances tend to be your more cardio dances.  And so they like to torture all of us of putting those at the last. You also have a higher balance  correlating with higher international rankings in the medical literature. So these are some  things that are very important to ask about in our clinic is asking about their balance, asking  about their cardiovascular cross-training. There tends to be less substance use, but that being  said, there also is less knowledge about anti-doping laws and they've worked for many years  to try to also get ballroom and dance sport in the international Olympics. And so that will be  something that will be important for us if that happens. Red S tends to be less of a concern in  the dance sport culture compared to other forms of dance, but obviously we do still want to pay  attention to this. Asymmetries are of huge importance of dance sport is a very asymmetrical dance style. A lot of dance styles, you do everything right and left. This is not the  case in dance sport. It tends to be a left lead, left side, left this. I have to frame toward my  left to try to frame for my right. I can't even think about it. So these are extremely important  when we're looking at injury patterns. We do have similar injury patterns compared to other genres,  which have similar injury concerns, such as overuse, fatigue, and repetitive movements. More common in women than men, but both very common. And then standard female dancers have  a little bit more neck pain compared to male dancers, but male dancers have more back pain compared to female dancers. Lower limb, like most forms of dance is the highest.  Some things we have to worry about is floor craft. It's not considered a contact sport, but I've never been in a competition where I haven't run into someone. So it's very common  that we run into people. It's not a choreographed floor craft. It's part of what you're judged on.  The positioning tends to be more in parallel rather than turned out. So if someone's transitioning  from one dance style to another, and you do worry about, especially in my social dancers, shoulder positioning, because in social dance, you don't know who your partner may be,  and they may crank on your shoulder. For other insights, we need to look at their Latin position,  showing them a lot of times they're putting a lot of bunion force and then working on their  knee hyperextension. So some things that we want to ask, and we can share these slides to ask about  them, is exactly what they're doing within their season and talking about what kind of coaching  they're doing. So with that, I'm going to move on to our next realm and stop sharing and move on to our next speaker. Thank you. Dr. Lee, you are up next.  Everybody can see that okay, right? Yes. All right. So this is a modification of what I've done for the APM&R last time. I know I have about eight minutes.  So what I did was I just kind of shortened it to see if I could convey to everybody that what I'm going to share today isn't really like rocket science.  It's not very hard if you're a physiatrist.  But we can really provide simple solutions for musicians who come in and see you with simple complaints that nobody can problem solve for them.  So I'm just going to share a few solutions that my patients have shown me or my patient and I worked it out in my clinic at our performing arts medicine clinic here in Texas.  I have zero disclosures. Most of the photos and videos here are taken by myself. So this is a case of a young oboe player. And if you can take a look at this person's thumb.  And you can see that this person showed up with a cheap complaint of just a thumb pain at the distal end. And really was playing a lot, 20 plus hours, lots of stress in her life.  And really no other issues. So physical exam and everything really pretty much normal. And pretty much have just one complaint.  So our solutions here was just adding a cushioning support for that thumb rest and providing more surface area for that IEP at the thumb.  And really this resolved this patient's complaint. Was able to play 15 plus hours, no problem. When she was hitting more than 20 hours, there were still other issues.  But at least this one problem was solved just by one singular change in her instrument.  One thing that I wanted to just point out, if you're doing something like this, even if you add a thumb pad, there could be an issue.  So if you can see that this person is hyperextending the distal end of the thumb. So you can try to think about other products out there commercially to try to mitigate for this.  And there's many, many, many options.  If you ever go into this area of instrument modifications, there are many, many commercial products that you can go into and talk to your instrumentalist patients and discuss it.  Try different products out in your office or with their teacher, if they have a teacher. This is another example that I wanted to show you.  35-year-old, a little more mature and more seasoned player.  35-year-old player. And so this person was also playing about 15 hours. There's a hypothenar pain here. I don't know if you're able to see that.  Do you see that left fifth digit there? And she was having a lot of that ADM-related pain.  And so what she was doing was that she was extending that she was hyper-AV ducting the fifth digit quite a bit and causing a lot of that AVM spasms.  And so really only thing we did was to extend that shape of the key, added a little bit of a little addition of clay or like a tag at the end of that key.  And so that her fifth digit could reach it a lot easier. And so that was just really one thing that we changed. And she was able to, we were able to eliminate that ADM spasm.  There are a few other examples. This is a classical guitar player who came to see me, had already been seeing an OT from my, you know,  he was already trying to problem solve some of the degenerative joint disease that he was experiencing in his hands and instability of the IPs due to the degenerative joint disease.  And he's already has the splints made by her, his OT in his fingers.  The problem was this was working very, very well, except when he was trying to bar, he couldn't really bar with this splint on.  So what we did in our office is that we use KT tape or any other tape to try to replicate the splint that his OT created.  And just with that simple addition, we were able to, he was able to bar, no problem. And he was quite happy with the solution.  Now, this is not forever, obviously, but he could wear the splint when he doesn't have to bar.  And then when he does have to play more difficult pieces with a bar, he can try to tape his fingers to mitigate for the instability and the pain.  This is another example that I want to show you just simple straightforward issue. This is a saxophonist who had instability of his MCP. I think you can see it probably.  You can see the hyper extension that's created. And what he did was he actually had a 3D printer at home.  So I asked him to create this. My fellow and I both asked him to just see if we can support his hand a little bit better. I unfortunately don't have the after photo.  I forgot to take a picture of it.  But he was able to stabilize his MCP a little bit better without having the MCP collapse into extension as much, just by adding this piece to his instrument.  So that's another example. These are some commercial options for people who need a little more support with their instrument. So I just wanted to give you some pictures.  If you want to start, if you have any instrumentalist patients coming in and complaining of some of these instability related issues or hyper overused type of issues.  There are some commercially available stability support like an ergo bow or ergo trombone, like something like this where they actually wear a harness around them.  And then guitar rest, where you know if they have a foot rest, they're quite uneven with their posture.  But then if you're able to convince your classical guitarist to use a rest, you're able to create more of an ergonomic posture. And that's it, really.  And I have one minute to spare. Thank you so much. Dr. Paschule, you are up now.  Okay, great. Hi, everyone. I'm super excited to be here. And we're going to be talking very quickly about concussion management and the performing artists. I have no disclosures.  Here's our three very, very quickly learned objectives for today. We're just going to talk about sort of important pieces for recognizing concussions with performing artists.  Very briefly touch on some of the changes that were made last year and opportunities for all of us to sort of improve education with performers. These are just some headlines taken.  We see this a lot in our theater performers. And that's sort of where it's made its way into the news. But it does happen in all genres.  And these are two cases that I saw in the last probably year, year and a half.  And this is one of my favorite examples. I saw this in a ballroom dance competition. It wasn't older male in a ballroom dance competition.  Like Dr. Davenport was saying, they do collide and sometimes people fall because of that.  And then one of my young ballet dancers actually went flying off the chair during Nutcracker and landed with her head right on the floor.  So both of these, you know, we did eval them and pull them from competition at that point and their performance. I think everyone here is probably familiar with this.  But these are just a few new things that were added in terms of the 11 now become 13Rs of sport-related concussion management.  And we're going to sort of touch on the ones that are bolded throughout this talk.  So when we're talking about sport-related concussion in general, so not specific to performers, these are the numbers we have from the CDC in terms of epidemiology.  Most of these are occurring in collision sports. Obviously, I think a lot of us in sports, we see this in, you know, football and soccer. But what do we know about performing arts?  It's not super well researched, but there is some data out there.  So if we take just sort of all comers of dancers in all genres, the lifetime prevalence is, you know, 3 to 24%, kind of a wide range there.  If we look just at theater performers and personnel, that jumps up quite a bit to about 67% lifetime prevalence of a head impact and 10% prevalence of a concussion diagnosis, probably being underdiagnosed.  And then if we look at stunt performers, that jumps up to an 80% lifetime prevalence. That's very high, but I think it definitely makes sense that that would be the highest.  There was an interesting study that came out of the Cirque du Soleil group. They actually did a retrospective analysis.  They looked at 18,000 reported injuries in 1,300 performers more or less, and they actually lumped concussion in with head and neck.  So it was actually pretty low prevalence, which was really nice to see. How does this happen? Well, a lot of different ways.  There's lifts, there's falling stage sets, there's contact or collision with a performer or with the floor, like one of the cases I showed earlier.  You know, they have very large head pieces and costume pieces sometimes. So it really can be very varied.  You know, I think the problem in general with concussion is just a lack of recognition, and this is very exacerbated in our performing arts population.  You know, it's definitely underreported, I would say, because a lot of dancers, performers, either they don't want to report it or they don't know to report it.  You know, there's really this incentive to sort of hide symptoms, especially when we talk about like our freelance or our gig-based performers.  And, you know, sort of the flip side of that is if they do report it, who are they reporting it to?  A lot of our performers don't have regular access to a health care provider, you know, or maybe, you know, like I'm there for performances, but we're not there in the studio, we're not there during rehearsal.  And so, you know, we have to sort of educate them on how to come forward and who to come forward to.  One thing that came out of the Amsterdam consensus guidelines was talking about the CRT-6, which is this. I'm not going to go through it.  It's not a tool for diagnosing concussion, but it can be helpful in having non-clinical people recognize someone needing to get evaluated for a concussion.  So I think just kind of educating that this exists and letting more people know about it is a start.  I think, again, I'm kind of preaching the choir, but everyone here knows that if you suspect a concussion, you're sort of yanking that athlete.  They should be no same-day return to dance performance, competition, anything after a suspected concussion.  But we do know from the literature that a lot of dancers will sort of continue to dance after a potential concussion or even while they have symptoms.  And we just know that this delays their recovery, and so we really want to get them referred to a health care provider. In terms of the new tools that we have, we have the SCAT-6.  It can be used up to seven days post-injury, but we now know the clinical utility sort of decreases after the first three days,  and so they've gone ahead and created the SCOTE-6, which is sort of a more multimodal clinical assessment we can do in the office.  Really need to be educating the performers but also the artistic staff on kind of the recovery and rehab that is expected.  There is this pressure to return quickly, especially if there's a performance coming up,  and so that definitely people want to sort of falsely report their symptoms to get back quicker.  And just special considerations for performing artists, things that we don't really think about maybe with other athletes,  but if they have to get back to rehearsals and they have a really high cognitive load of memorizing lines or they're learning new choreography  or they're going to be on stage for a performance and there's going to be bright stage lights, there's going to be very loud sound, maybe some special effects.  So really sort of take that into consideration. They should be really asymptomatic by that point.  And these are just kind of the updated recommendations from the Amsterdam guidelines. We're no longer saying for years now and should not be saying in bed,  they should be kind of getting up and about and we want them to start this subsymptom threshold aerobic exercise,  usually around two days later and getting people into cervical vestibular rehab if they have that subtype of a concussion.  These are the new guidelines for return to sport. It's not dance specific, obviously. So how do we take this and translate that to performing arts?  This is a paper I would encourage you all to look at. The references are at the end, but they did this before the new guidelines came out.  But I think a lot of it carries over really talking about how we can get them in back to a barre class early.  That's non-contact light aerobic exercise and sort of have them maybe marking choreography and then kind of gradually improving as their symptoms come down.  They need to be getting to stage four. That's our contact reintroduction.  So, you know, they really shouldn't be doing anything where they could collide with another performer before that.  But I think we still have some ways to go for this. These are my references. And thank you.  Thank you, Dr. Pasquale. And up next, we have Dr. Elson. I want to also thank everybody so far who have been so considerate of your time and all the other presenters.  So, Dr. Elson, take it away.  All right. Let me get my screen up.  You guys are not seeing my PowerPoint yet, are you? No.  It's not giving me that. Oh, there we go. No, it's OK. Back there. There we are. Perfect.  So I am very excited that so many of you guys are here today. So thank you for joining us on an evening after work. And I'm happy to get a chance, an opportunity  to go through this again with everybody here.  So we're going to go through a quick case study. And I think that what I really want to highlight with using Shockwave for the Performing  Artist is that Shockwave is becoming the new tool that we can all use, but to not forget what it is to be a physiatrist and kind of think  about Shockwave as another tool in our belt, but not necessarily the first tool that we're going to bring out. This is the first patient that I used, or the first dancer  that I used Shockwave on. And this was a 23-year-old elite ballet male dancer who'd already been seen by several other physicians, which  I think is pretty common in a typical physiatry practice with deep, achy, gluteal pain. He'd already had NSAIDs. He'd already had a hip injection.  But interestingly, he had had a sports hernia repair that hadn't been completely rehabbed before this. And when we actually started watching him move,  it was really interesting that he was hypermobile and he was doing that typical grabbing his glutes and holding on for dear life to try to stabilize his pelvis.  And he had some positive neural tension signs. He had a lot of muscle tightness, a lot of increased tissue density in the muscles surrounding the pelvic girdle,  and a lot of trigger points.  And the first thing that we did was get involved with his physical therapist and really working on improving his hypermobility and his transverse abdominus recruitment,  and functionally working on his core stability with gyrotonics and trigger point injections. And kind of going back, our diagnosis at this point was ischial femoral impingement.  Tried all the normal stuff, but things were just not getting better. So what else can we do at this point?  So his imaging was negative. Sometimes by the time we did all these extra,  when we really rehabilitated him, we're left in that left ischial region. And so at that point, we kind of ran out of other things to do,  and now I had this new tool, this radial shockwave device. And we were just having a hard time breaking some of those myofascial pain components  and some of his neuromuscular patterning. So we added radial shockwave to our plan, targeting both the gluteal muscles as well as the TFL and his adductors.  And we're able, within two visits, after we had done all the other rehab, to really get things going.  So when do we think about using shockwave for performing artists? We know that performing artists develop a lot of pathologies along the kinetic chain.  Their injuries tend to be more chronic and overuse or misuse symptoms. They can't really afford to take time off. And we frequently will see things like stress fractures,  tendinopathies, myofascial pain, and especially in our musicians or our dancers, the small joint arthritis.  There's two main types of shockwave that you'll see. So the pictures A, B, and C here are from a focus shockwave device. And that device is the kind that was used originally  to break up kidney stones. And so that one has a little bit more focused energy and tends to be, there's several different types of shockwave, but that tends to be the piezoelectric  or electromagnetic magnetic type. The radial shockwave is the type that you're going to see more commonly. So chiropractors, a lot of physical therapists will also use this one.  And so this is mostly pressure waves. And in fact, I had a patient that came in who has been getting shockwave on their horses and wanted to get it done.  The vet was going to do it on them as well, and they decided maybe they should come to a human doctor to get it done. And so when we think about these two different devices,  there are two main types of pressure waves. So this is the focus shockwave one, which is really a much higher level of energy that's released,  and it creates a much larger negative pressure wave. So this negative pressure wave causes little air bubbles to be released. And on our next slide,  I'll show you what happens with those little air bubbles. The radial pressure waves are much lower and lower energy. And so therefore safer to use on multiple areas of the body.  This is a very busy slide with a lot of different chemicals that have been shown to be released with shockwave. So we know that it can increase tenosites, releases.  We think that some of the pain modulation might happen at the level of the C-fibers. But what does this actually mean? How does it really work?  Well, so number one, we're looking for pain relief. This can happen along a couple of different mechanisms, but one of those is hyperstimulation.  So we kind of think about exhausting the molecules that sense pain. And very often when someone will leave your clinic, they'll feel a lot better. They'll have an immediate relief.  We actually counsel people to not go and go run a marathon or go do more than they would normally do.  We also think that some of the longer term effects happen because of vascularization. We help increase blood flow to a region. We know that protein biosynthesis occurs,  and this is how we can lead to tendon healing. And the cell proliferation works on those measures as well.  For people with calcific tendinopathy, this has been really helpful for destruction of calcium deposits. And interestingly, I've had improvements  with both the radial and the focus devices for this, both with rotator cuff and gluteal tendinopathies.  The difficulty with interpreting the literature is that there are so many studies out there and it's like comparing apples to oranges. So what doses are being used?  How many impulses do you use? What is the frequency of the impulses? What type of wave are you using? How many sessions do you treat? How frequently do you treat?  How do you find the area? Do you use gel? Do you not use gel?  And should anesthesia be used? And so there's a lot of different things that you need to look at. So when you're thinking about whether or not  the study was done well or how you interpret it, you really wanna be considering all of these options.  I think one of the important things to think about is that clinical focusing. So during the test, or during a treatment, you can actually reproduce the patient's symptoms  and that helps get a lot of buy-in.  I have a couple slides on some of the RCTs and meta-analyses that have been done that look at common symptoms in dancers, so including Achilles tendinopathies.  And also evidence for plantar fasciitis, another very common symptom in a lot of, especially in my older dancers and fellow dancers.  But at the end of the day, what's really important for treating our performing artists? Having a non-invasive procedure that helps actually promote healing  in addition to just helping their temporary symptoms.  Something that's part of the comprehensive program, it doesn't negate anything else that we've already done. It doesn't mean that they do not have to do physical therapy  but it is a procedure that allows for the performing arts to not have to take time off. And so I've particularly found this useful for small joint arthritis in my musicians  and for tendinopathies and other myofascial pain syndromes in both musicians and dancers.  I'm happy to take any questions later on. Thanks for being here.  Thank you. All right. Now for me to share my screen to talk about PRP.  Sharing screen.  All right.  I think you all can see it. If somebody can give me a thumbs up.  All right.  Thank you. Okay. So we're going to talk about PRP. Let me stop my timer and reset it. Beautiful. Okay. So we're going to go through a case study here talking about PRP.  I know a lot of the people on this Zoom call are familiar with PRP already but just in case we have early residents and possibly some med students, I don't know if there are,  we can talk about that as well. So we're going to talk about a 28 year old musical theater performer that I had come in. She was talking about left foot pain  that began after running in some heavy Doc Marten boots. It was in the ball of her foot. She didn't think anything of it. It hadn't healed for two months.  She denied prior trauma of the area  and it was just achy and dull and she couldn't really dance because she couldn't go on releve and she couldn't wear her heels as a musical theater performer.  She tried meloxicam and she was referred to physical therapy. She had some issues there. These are the findings, decreased FHL flexibility. Again, releve was painful.  Grand plie was painful as you can imagine because of the positioning of the foot as well. So we had the running diagnosis of sesamoiditis versus an FHL tendinopathy.  Whoops.  All right. So we did some imaging and if you can see here where that yellow arrow is pointing, you can see some cortical irregularity  and some fragmentation of the tibial sesamoid along,  sorry, no, that's the fibular, sorry. That's the proximal margin of the fibular sesamoid.  All right, so in physical therapy, their goal was obviously to get her back to dance and to be in heels and on point.  After a whole bunch of interventions, she had some improvements in her range of motion, but really it was still pretty irritable. And after six sessions, six weeks with,  you know, her home exercise program, she really wasn't doing too well.  When you're seeing somebody with sesamoiditis, of course you wanna think also about like sesamoid pads and modifications to shoe wear and not just PT.  So we got an MRI because after six plus weeks of physician-directed treatment, she wasn't better. And you could see osteonecrosis of the fibular sesamoid there.  That bone should be appearing bright white like the other bones that you see on that MRI, but it's pretty black.  So what is sesamoiditis? What is a sesamoid? It's a small bone within a tendon or muscle that is near a joint surface. And it really acts as a pulley.  It's an ossification center that helps as a pulley to alleviate stress on the tendon or muscle that is attached to it. And osteonecrosis, also known as avascular necrosis,  is death of bone tissue because it's not receiving blood supply with all the nutrients. And then that leads to tiny breaks in the bone and eventual bone collapse.  So what is PRP? PRP is autologous plasma with a really high concentration of platelets, higher than whole blood. You spin it down using a centrifuge  and these platelets contain our natural, innate growth factors. So tumor growth factor, beta-1, all of this stuff.  And really you have two types of it. You've got leukocyte poor versus leukocyte rich. Leukocyte rich is where there's a ton of neutrophils in it.  And it's a pro-inflammatory approach to the platelets.  And then you also have neutrophil poor, which is not inflammatory. And there are a ton of papers that tell you what you should be using and what you shouldn't. It's a mixed bag.  But anyway, those are the two main types that we typically look at. That is the centrifuge there.  So how does PRP work? Now, what you're doing is you're supplying a super physiological amount of these growth factors and you're pretty much inducing irritation and injury.  And you're doing this in tissues that have a really low healing potential.  You've got your, back to med school, you've got the cytokines that are involved in these pathways of healing with inflammation, cellular proliferation, tissue remodeling,  and neovascularization. That chart there on the right is showing you that in those first 10 to 14 days, that's really the time of inflammation and acute injury.  And people are in a lot of pain during this time, especially after having just received their PRP. But this is similar to how a wound heals in those first seven to 14 days,  that's when the inflammation is highest. So then you have the cells proliferating, and then as the collagen kicks in, that black dotted line,  then you have the remodeling of the tissue and hopefully better healing.  So what's the clinical rationale for using PRP in this particular patient or anybody with a chronic injury?  She had failed non-operative treatments, we had tried offloading and that didn't work. And then we had said, all right, well, if that's not gonna work,  what else can we do at this point? So we had her see an orthopedic surgeon and that person pretty much said not to do it. There are complications, especially hallux valgus or varus,  there are cock-up deformities depending on which sesamoids removed. And if you have a dancer that's gonna be in a heel, then that's not something you want  or even somebody dancing on point. So there's limited literature regarding PRP for avascular necrosis, particularly of a sesamoid.  We talked about what AVN is and how you are applying the PRP to improve the blood supply.  So with her in particular, we use leukocyte-rich PRP.  Two minutes here. So conclusion, something to think about when you are dealing with performers in general, the good majority of them don't have a legitimate insurance plan.  It's usually bare bones, bare minimum. So with PRP, it's typically not covered by insurance anyway so out-of-pocket costs are pretty high. They vary based off of institution.  I know where I work right now at NYU, it's 9.50 for a unilateral one location, one joint.  Then you have to think about their rehab and recovery status post receiving PRP. This is different than shockwave, what Dr. Elson was talking about previously.  So if they're in season, you're not gonna wanna do PRP.  Some other things to consider in these last few seconds is that PRP is a nontraditional treatment. There are increasing reports of success.  There are case reports and so many studies coming out. But in this particular patient, we had used leukocyte-rich PRP with immobilization with a return to physical therapy  and she had a pretty good effect for the non-surgical management of her sesamoid ADN. She did follow up about a year later with her pain that returned.  Prior to that, she was back in class, back in auditions. Last I checked, she's still having issues being in her heels and taking class, but I think she's come to terms with it now  a little bit more and she knows what to expect. She's a little bit more accepting of her injury, but I don't think she's doing it again because it was really painful.  But that is that. Thank you. Stop sharing.  All right. So thank you for that. We have 15 minutes to have a Q&A session  for any of our speakers. You know, again, I want to thank all of our speakers for spending time with us tonight, sharing their expertise.  I continue to learn from all of you. It's really incredible.  So actually to start off this Q&A session,  I want everyone to just reintroduce themselves, names, what institution or practice you are at. And then I actually have a question for Dr. Lee,  but I'm going to go in order of who I see on my screen. So Dr. Davenport, I'll let you go first. I'm Dr. Kathleen Davenport. I'm at HSS Florida as the doctor of physiatry  and I'm the medical director of the HSS Performing Arts Medicine Collaborative.  I'm Dr. Pasculli.  Hi, everyone. I'm Rosa Pasculli. I'm down in Atlanta at Emory.  And Dr. Elson.  Hi, I'm Lauren Elson. I'm the director of Dance Medicine and Performing Arts Medicine at Mass General Brigham and Spalding.  Dr. Lee.  Hi, I'm Lee. I work at UNTL Science Center. I run the Performance Medicine Fellowship here and also now co-director for Performance Division at our institution.  Dr. Rubish.  Hi, I'm Dr. Melody Rubish. I'm in New York City at Rothman Orthopedics and I'm the director of Primary Care Sports Medicine.  Dr. Popoli.  David Popoli at Wake Forest University. The director of Performing Arts Medicine at our institution.  And I'm Tracy Espiritu McKay over at NYU Rusk and the Harkness Center for Dance Injuries. So again, thanks for joining us, everyone. Dr. Lee, my question for you.  How do you know, so you were talking about modifications of that first player.  How do you know when it's an issue of technique versus actually having to modify their instrument? Yeah, so this is, I think Dr. Popoli talked about this.  Having a team is really important. So fortunately we have a very good relationship with,  you know, so this was a collegiate musician that I saw. And so I closely work with the music teacher and the professor. So we actually start there.  Like we talk about technique first and we talk about, you know, practice habits. We talk about all the other things first. And then we start to think,  okay, like you still have these issues. And then we start to think, okay, I'm seeing this when you play, does your teacher see this?  And then we start to think about what can we mod here? And we also have to work with the person who would mod it for her. So we have to talk to the instrument person.  So it's a really big, much of a team effort. That's the same with like everybody else too. So, you know, the one that I, the guitar player that we talked about,  so he and his OT and myself, and then we're all kind of talking all at the same time. Sometimes we do like a call together or, so collegiate musician is pretty easy to do that,  but professional musician can be a little bit challenging. Some of the string players, I know the luthiers that everybody goes to in this area.  So I just kind of call the luthier up and be like, hey, you know, can we change this or that? And during AAPMNR, our session, I did talk about our sort of like  viola violin setup clinic that one of the viola professors do in this area. So sometimes we work with her to try to have different setups for like the chin rest and shoulder rest.  We look at it, we take pictures and sort of just like any other athlete, we try to do it similarly, you know, try to see if we can work with the teachers  and if there's therapists or OTs and PTs involved, we try to talk to them.  Thank you. Dr. Elson, quick question for you before I start scanning the chat for further questions. When you are treating calcifications for a shoulder and hip stuff,  are you doing focused or radial?  So right now I'm doing focused for the calcifications. However, before we had a focus machine, I did use the radial and had pretty good success. So I don't know that it's better.  I know our volume has gone up when we started offering the focus, but I've had a couple of complete resolutions of calcific tendinopathies with the radial too.  Cool. All right, so we have a question from Emily here.  You mentioned insurance difficulties in this patient population. What is your best suggestion for patients whose insurance is not accepted  by dance performing arts trained therapists?  You know, I'm actually going to direct this question to Dr. Rubish because I think technically she's the only one that's in private practice for all of us.  So that'd be interesting to hear. Yeah, you know, it really depends. If it's workers' compensation, sometimes if it's a show that has a lot of money, they'll bankroll it.  Or a company that is well-funded, they'll have donors that have money set aside for this sort of thing, because they know that these are high-level athletes  that sometimes have to do things that insurance isn't going to pay for. A lot of times, you know, we have the privilege of living in New York,  and so people do have a little bit more disposable income,  even those who are, you know, working three gigs to work in their company. So I do find that a lot of people will do a dancer discount or something to try to do that,  as long as, I would recommend if you do that, make sure that they're still valuing the care. Sometimes I think all of us are always willing to do what we can for this population,  but sometimes you want to make sure that they're not devaluing the devaluing that you're doing. I don't know if you've noticed anything.  I see David and I see Dr. Popoli and Dr. Davenport nodding and Tracy hiding behind her hand.  So I don't know if that helps answer the question, but I find that, you know, we still have to be honest with them about what the research is showing.  So I try not to make assumptions about who can and can't afford something and make sure I have the same conversations with everybody  and let them know we'll work within what they can do and what their time allows.  I have the benefit of working at the Harkness Center for Dance Injuries in New York City, where we have financial assistance for those who don't have insurance.  And all our therapists are pretty much well-versed in treating performing artists.  Dr. Lee is down in Texas, and I'm sure she has access to therapists at her Performing Arts Center. So I think if you have the ability to be in these big cities,  you have access to things like this if your insurance doesn't cover it.  I want to just make sure I get more questions in in our remaining seven to eight minutes. So Ricardo has a question there for Dr. Elson.  Hi, thanks everyone for this wonderful talk. Dr. Elson, I had a question. Have you used Tenex for those calcified tendinitis and everything like that?  I've just been having some experience in some patients, and I just was wondering your experience on that. Yeah, that's a great question.  And Tenex is a great tool that has research behind it. It's covered by insurance most of the time. And I think it's a very good option for some of these calcific tendinopathies.  I would say that the only time I would ever try shockwave first is if we're limited and how much time someone can take off for recovery. So, because you can't, I mean,  if you're, Tenex is like a micro microsurgery. So you're gonna be out for a little bit longer. But otherwise, especially if, I was gonna say, especially if cost is an issue,  but we actually just lost our ability to do Tenex because of insurance coding issues. So, and I don't know if other places are experiencing that too.  And I think that's gonna be a little ripple effect for a bit. So the private practices are somehow still doing it, but for some reason within the academic centers,  if it's not being done in an OR, I don't know the details. So if it's being done in an OR, that's fine.  So financial insurance will pay for it if they spend dozens and dozens of dollars on it, but not for the doing it in the clinic.  But otherwise, yes, Tenex is great.  Thank you.  Any other remaining questions in our last five minutes?  And just as a reminder to everyone, the community board is always available and open to all of you with questions. All of us are getting notifications  when something gets posted and we're a great community. Physiatrists, we love working with each other. So, you know, networking is our thing.  Thank you for organizing Dr. Espiritu. You're welcome.  And we should probably give props to Dr. Elson, the OG.  Very happy to see you guys all here.  You're in great hands, Tracy.  Thank you.

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