Thank you. So I am Kristen Caldera. I am the current chair of the Central Nervous System Community. And I'm really excited. This is the first time we've done a journal club. Doctor, where are you? You're going away. Dr. Lahti, where are you? I'm here, I'm here. Oh, there you are. Sorry, you were underneath my chat function. Okay. So I just wanted to say a few things before I hand over the topic to both Dr. Lahti and Dr. Vanias or Caitlin on the screen here. I did want to say a thank you to the rest of the gang. We have several vice chairs that we work with and each one of us tries to keep you informed on FISFORM. We also try to come up with different educational activities and really promote that the CNS community, all that that encompasses is represented through AAPMNR. So this is a really nice opportunity for people who are interested in CNS and connecting with people that do this type of work can have support outside of the assembly as well. I mean, as we are tonight. We are going to be putting out some more information as well if you want to be more involved as a potential vice chair. So if you can remember, Dr. Lahti sent out a survey asking about what topics of interest people might have. And we have several other topics of interest, everything from talking about MS to TBI to functional improvements in patients with developmental disabilities. So keep your eyes open for that. And we always welcome feedback and new topics as well. If you happen to be in a great journal club or have a topic that you really want to learn more about or ask us to host, we're happy to do that as well. So with that, I'm going to hand over the screen to Dr. Lahti or Zanev, which is, I think it's actually kind of nice. We're all by first names here on the screen, which kind of makes it a little bit more personal. So thank you for being here again. And I will turn off my video during the presentation, but then please, everyone, you're welcome to turn on, show your faces so that we get to know you. Perfect. Thank you so much, Kristen. I really appreciate that. Again, I'm the educational chair of the CNS community, but I am not taking any credits. It's a team effort. I would thank Dan, one of the residents, as well as Caitlin, who helped me in shaping the PowerPoint as we are. Caitlin, we're going to be back and forth in the discussion. And again, I want to hear from the audience as well, what we are thinking about in terms of this article. So Joy, would you be able to put the slides on share, or do you want me to do that? Perfect. Caitlin's got them. There we go. Perfect. Phenomenal. Okay. So we're going to start first. Again, this is a journal club, which means that I would hope that somebody would have the time and energy to go through the journal. But again, it's more of a discussion and we have a rich experience from the audience that we would be happily listening to and get everybody's opinion on that. So Caitlin, do you want to take the lead? What would you prefer? Sure, I can lead. Okay. So thanks for the introductions, everybody. I am a PGY3 resident at the University of Wisconsin. So I have the pleasure of working with Dr. Caldera. So thanks to her and Dr. Alawadi who are co-presenting with me today. So the journal club article today is Physical Activity Programs, Surveillance and Fall Prevention in the Elderly. This was a systematic review that was published by a group out of Italy in medicine in 2019. Neither of us have any disclosures. So today we're gonna go over the article briefly, the design subjects and results. Then we'll have some discussion about what we thought of the research design, some of its limitations, some of its strengths, and then hopefully have some discussion about what its clinical relevance is and how we can use these ideas in practice for our elderly patients, neuro patients, and oftentimes the overlap of both. So to start with some background, as we all are probably familiar with, the United States and the world are aging with increasing numbers and proportion of people over the age of 65. And oftentimes aging is accompanied by frailty, sarcopenia, and consequences of this, such as increased falls, injuries, morbidity and mortality from that. And it is pretty well established that exercise can help slow or ameliorate some of these effects and reduce falls. But the dosing and the types of exercise that are the most effective to improve balance in older adults is less clear. And this was the niche that this group was looking to fill with this systematic review. So their objective was to identify which physical activity programs can significantly improve balance in older healthy adults based on a literature review. And their kind of secondary objective or thought was that these results could potentially be used to guide fall prevention programs in this population. So this was a systematic review of studies over the past 10 years. They searched the following electronic databases for the keywords of balance, exercise, elderly and training. And their inclusion criteria was the subjects had to be over 65 and without any disabling physical, neurologic or mental health conditions. And they also looked at the age of the person who was diagnosed with this mental illness, which we'll talk a little bit more about this later. Thank you. I'm just gonna concur to what Kaitlin said. Probably I would wanna hear everybody's thoughts later on on the age as well as the risk factors or any prior past medical history because these are very strong points for discussion. Sorry, Kaitlin, carry on, yeah. Yeah, and jump in whenever anybody has any questions So their initial search brought about 1300 results that went down to 112 after duplicates were removed. And then these results were screened and they excluded studies that didn't test the thing that they were looking for, which was specifically exercise in older adults. And then these full-text articles were assessed for eligibility, which was largely the age and the comorbidities or disabilities, leaving them with 22 articles and then went down to eight based on which ones had enough quantitative data or pre and post measures or a control group. That's how they went from essentially 1300 to eight studies and how they kind of screened these was still unclear after reviewing the article multiple times. So Dr. El-Owadi actually reached out to the authors to get a little bit more information on how they picked these eight studies. They didn't have a lot extra to say. They just said that the most common reasons for exclusion was age not over 65 for all participants. So some of them had an age cutoff of 60. They excluded any that had multiple interventions. So if they were doing exercise and nutrition or exercise and medication, and they excluded those that didn't have enough quantitative changes. So if they didn't report the baseline or post-intervention measures, or if they just said something vague, like there was a significant difference over the course of the intervention. So as we talked about, this led to eight RCTs that were included in the systematic review with a total of 200 total participants and a median age of 75 years of age. And the studies were pretty heterogeneous. There were study sizes from nine to 61 participants ranging from eight to 32 weeks. So they calculated the differences between the exercise groups and the control groups by using confidence intervals. And then they also, when the data was available, calculated the pre and post-intervention improvements. So overall, across the studies, balanced outcomes improved between 16 and 42%. And this was compared to the subjects before the intervention. In the control groups, there was a stabilization, but often a decline in balance measures over the study period, which made the difference between the intervention group and the control group even more dramatic. And the consensus was that all the studies evaluated did improve balance measures. And this is a wide range of interventions from the combination of resistance and aerobic exercise, aerobic exercise and balance-specific training, just specific balance training, and balance training with balance tools like the wobble board and the T-bow, which is similar to a wobble board. So I'm going to stop you here for a second, because again, I just want to elaborate on some of these studies, because some of them use resistance in aerobic exercises, as you mentioned, and the duration of intervention was six weeks, and they focused more on the static balance exercises. And again, there is a lot of, if you look at the article, there is a lot of back and forth between static and dynamic exercises. Just for the audience, the static exercise means you're putting the center of mass in one position and trying to optimize the patient's kind of, I would say, strengthening through that, versus dynamic is like you're changing the center of mass as the patient changes position and make the patient, or I would say the client, stronger using different positions throughout the exercise program. So you would see that back and forth. Some of other exercises, like I would say, they mentioned, and I'm not sure if I'm pronouncing it correctly or not, but Lourios, Rodriguez, and Garcia et al, they did a 14 kind of women in a 12 balance exercises for 60 seconds during rest, and they measured the Berg balance score, which is usually I use in my clinic most of the time in balance evaluation. There is a wobble board training that's used in attend elderly patients. Again, the sample sizes, this is something I would love to hear the audience thoughts on, as well as the sessions that they conducted for 30 minutes and the outcomes that they have measured in it that was mentioned in the article. There is aerobic step instability ball training, which was done by Donsky, and basically they used eight consecutive weeks. And again, I want to hear the duration comments from the audience. Was it too long? Was it too short for 18 reps? And as well as there was another exercise through adaptive physical activity and the Wii Fit training. And again, not that the Wii has any relation to what we are going through the artificial intelligence, but I want to hear the audience thoughts in the future, the role of artificial intelligence and physical exercises in the elderly. So these are the points I want to highlight for discussion. Just keep it at the back of your mind because I want to hear everybody's thoughts at the end. You can carry on Caitlin, sorry. So this is table one that outlines the eight studies that they reviewed in their systematic review. As you can see, this is a pretty heterogeneous group. So there's pretty wide age variation in the average ages for each of these studies. Like we talked about a wide range of intervention durations and a pretty wide range of exercise dose, essentially ranging from 10 minutes twice a week. So 20 minutes a week total to 90 minutes, three times a week or 270 minutes per week. And we're also comparing different balance assessments. A lot of them are one leg stance, which is a static balance measure, very balanced fit scale, but also there's the time up and go. Into NETI, which is kind of similar to a timed up and go with some extra balance challenges and there's a scoring system. So even with the outcome measures, we're looking at pretty different tests and all of the groups improved at least 16, 15, 16% over the course of treatments or intervention. And there was some of which a pretty dramatic decline in the control group, making the difference between them even more significant. So in the discussion, they outlined that there's a lot of different types of exercise that can improve balance. And I think it's been a long-term theme of like trying to figure out what the secret sauce of exercise is, or just like, so you can distill it down to the most effective in the shortest period of time. But that's really hard to do just because there's so many things that go into balance that has an aerobic component, a strength component, a neural component, that they're all go together and they're difficult to isolate which one is the most important. And this study pretty or highlights pretty well that there's not one single exercise modality that is superior to the others, but it's hard when you're comparing studies that are this different and have very different outcome measures to make a direct comparison against of different exercise modalities, which was their primary objective of this study. So we have some discussion questions starting with the study design. And when you're designing a systematic review, the question that you're asking is important. So I'm gonna start with like, is, was this a clinically important question or was this a useful meta-analysis to do? So we're gonna open the floor for discussion because I wanna hear the audience. We have a good gang here and I am pretty sure that we deal with a lot of similar kind of situations with our patients. So I would love to hear anybody chimes in and give me their input. I can go ahead and start. When I was reading this article when we chose it for CNS community in particular, and I said this to Zainab, I said, well, they specifically excluded people with disabilities and with, you know, central nervous system and cognitive issues. And so I said, do we, you know, do we really want to do this? Is this something that's going to be applicable to who we see? And she said, well, it's, it, yeah, it's a great starting point. But the other, the other part when, is it answering a clinically important question? I mean, I suppose if we're really looking for the one exercise that is better than all others to improve balance, I don't know if I really have that clinical question because of my varied patients with many different central nervous system areas that have been affected. And so I, I appreciated kind of that it was important to look at different types of interventions in this, this review, but for me, it wasn't as important that it, it found just one and I'm, and it didn't find just one. So that's what I was thinking. That's a great point. Yes. Any more thoughts? I want to hear more. I'm hungry to hear more. I don't know. Can you guys hear? Yes. Hi. I think thanks for presenting that super interesting. I guess I was interested in the, in the age selection too. You know what I mean? Because when we're thinking about elderly 75, 65, you know, we, it'd be helpful to know the older, older as well, but I thought it's so important and I'm so glad that we're looking at this. Yes. I'm going to concur because I mean, I've been looking at the American Geriatric Society and there has been a shift in the paradigm of defining elderly from 65 to 75. Again, we're still following the regular, well, kind of common senses of 65, but the American Geriatric Society is thinking about it. Again, among family positions, AFP or the American Academy of Family Physicians are still going through the 65, but there is a strong shift into moving to 75 as the age when you want to define the elderly. So thanks for raising that point. Yes. We can talk a little bit about the PRISMA guidelines because when they're, when they introduced the study, they said that the study was conducted utilizing PRISMA guidelines. And PRISMA's kind of way to quality control doing systematic reviews or meta-analysis. So it involves a pretty extensive checklist through each area from the rationale and objectives to the methods, how they're selecting these studies, how they're picking the inclusion and exclusion criteria. So they said that they were following it, but there are a few things, there are a few areas that seemed a little bit weaker, especially with how they were reporting bias. They didn't really address this very directly with if they were screening for bias in each study, if they were reporting whether there was an intention to treat or how much dropout there was. It's like any behavioral intervention is always a problem. And then any methods to explore causes of heterogeneity among the study results. So as we'll talk about in a little bit as well, it was a pretty diverse group of people across these different studies. So this is page one, and then there's page two. Similarly with results discussion, other information. We don't have to go through all of them, but we kind of talked about this before that they didn't do the best job with outlining exactly how they were selecting these studies, but they broadly say the inclusion and exclusion criteria, but it was still kind of hard to follow how they went from hundreds of studies to eight. And this is a pretty broad topic. And again, in their results, the bias and how they were accounting for differences in population. Another thing I wanted to highlight with the study design was, if you look at each study, they all had pretty variable individual objectives. So some of them really were trying to figure out what happens over time. Some of them were more like people who were trying to figure out what happens over time. Some of them were more like feasibility studies. So this one had a detraining component. It was also a bit confusing because in the introduction, they said that they could not live in a nursing home, but the wobble board study was people in an institution. This one was more of a feasibility where they were wondering if they could use equipment that could be found in a public park to influence balance in women over 65. Fallers versus risk of falling, which was also unclear. They were identifying people that were at risk of falling, so they were not perfectly healthy. And then comparing effectiveness of different protocols against each other. And again, community-based exercise programs. So all of these are pretty different, and these were all the individual objectives that were combined into the one systematic review that we have here. All right, we kind of already touched on this, but they used pretty strong language in the intro as being over 65 is elderly. And as we all see in practice, there is definitely some elderly 65-year-olds, and there's definitely some not elderly 65-year-olds. So we can talk about this a little bit more if anybody has thoughts about kind of what the age cutoff should be for studies like this. Yeah, what does the audience think? Do you think we having the age cutoff 65 is adequate, and what are we dealing in our world of disability or the patients where we are dealing with physical and mental challenges? Do you think 65 is adequate? Do you think we need to switch the gears in our profession? What are your thoughts? I think if you're looking at elderly, you have to pick some things. And I've also seen 55-year-olds that maybe don't look 55 either, look older or younger. So I think you have to pick something, and if that's kind of been where we've been thinking of 65, I guess I was okay with that number. I think 75 might miss a lot of people between 65 and 75 that I would be interested in seeing in this. And it sounds like they had to, sorry, they had to exclude some studies for being the cutoff of 60. Right, and in the chat box we have, I think elderly may be a combination of fact, like what does elderly mean, right? Combination of factors, age, comorbidities, compliance to recommendations, etc., not just a pure age. And they said, you know, if this is a study that's designed, you know, just to really answer those types of questions, you certainly could look at the comorbidity index as well, which not all of these had. All right, sorry, some of the answers popped up as well, but we wanted to talk about factors that limit the study generalizability, especially for the patients that we take care of. Sorry, some of the biggest answers kind of popped up, but. Yeah, I have a comment. The most important thing is to have a homogeneous population. That's the key thing. So the more you vary, the less likely you are to be able to explain your results. So age is one variable. Second is the initial level of function. So you may want to take a group of people who are functioning or who on a balanced test do poorly, and they may be the ones who do better. We don't know that. The other option is to take people at the other end of the spectrum who have good balance and see how they do with the same test, or they may require more challenging tests. But the bottom line, for whatever you're doing, you need a homogeneous population. And you, in analyzing the data, you then need to see if there is homogeneity in variance. And if there is no homogeneity in variance, then you can do a t-test with repeated measures. If there is some variance, then you need to consider, assuming that we have continual data as opposed to ordinal data or nominal data, then you can consider what's called the Welch's, W-E-L-C-H-apostrophe-S test. And that will help to normalize the data if there's questions about homogeneity and if there's variation in the number of subjects. You are phenomenal. You just brought me back to my residency days. We got to know this all yet for our research project. So, thank you. That was phenomenal. So, the question is not only for this, but there's a paucity of research amongst physiatrists. For the past few years, I have evaluated the research for the annual meeting. And traditionally, I'm looking at 30 to 40 abstracts. And of the abstracts, there's been about four studies, research studies, prospective studies. And of those, maybe one or two are randomized control. But this is not good for the profession. And I think part of the problem may be in the residency training programs, how much of an emphasis is there on doing research? That's number one. Number two is that we're not dealing – let me take a step back. So, 35 years ago, when I was the chief resident, some of you weren't even born. But when I was the chief resident, we would have grand rounds. And before the grand rounds, what I implemented was that each resident had to present an original research study that would then lead into their grand rounds. The residents rebelled. It was totally foreign to them. This was not something they wanted to do. And not being in academic medicine, I can't say what's going on in the residency programs. But what I can say is that there's a paucity of quality research coming out of physiatrists. And probably the good research is being published in other journals other than the Purple Journal. The other thing is that we're supposed to do a PIP, performance improvement project. Everybody's rebelling against that. However, if we, the profession, gave significant CMEs to those people who had their research project published, that would be more of an incentive for people to do research. So, just a few of my thoughts. And I hope you'll see my research projects, if they're accepted. I submitted two of them. They both deal with a comparison of males versus females for the acute effects of phenol nerve blocks. One is on the musculocutaneous nerve, and the other is on the obturator nerve. And if this is the central nervous system committee or group, we really need to see some work done with spasticity and nerve blocks. There's a lot of support for injections with botulinum toxin, because the pharmaceutical companies are supporting that. But there's nobody supporting research for the phenol or alcohol nerve blocks. Sorry, I went away from the topic, but it's all related. No, we appreciate your pills of wisdom. We really appreciate that. And we really needed to hear it. So, thank you. You're welcome. Yeah, it is a hard problem, because there's, like you mentioned, having a homogeneous population is like one of the most important parts of research, and ours is like, our patient populations are often not. And with small patient numbers, there's lots of challenges, but it's definitely a weakness of our field. So, the study or the subjects, we talked a little bit about excluding disability with kind of the effort of making a more consistent population. But each of these studies were conducted around the world. Brazil, Spain, Israel, Japan, Portugal, France, and China. So, each of these kind of brings their own cultural and geographic variability into it, and there were no U.S. studies. So, talking about the interventions, were the types of physical exercise analyzed adequate, and were there any types that were not included that maybe should have been? I thought that it was interesting that it was the very, very last paragraph that then reiterated what the current WHO recommendations are of 150 minutes of moderate intensity aerobic exercise a week, two to three days performing muscle strengthening exercises and three or more days practicing balance exercises has been recommended because some of these studies had 30 minutes once a week or 45 minutes once a week. But it's hard. I mean, this is a meta-analysis. It's a systematic review. So I understand that it's hard. I mean, I don't know, that would be very hard criteria to meet of consistent physical exercises. I did appreciate that there were some different exercises that people could do to improve balance. I guess I kind of talked about the dose too. And I kind of talked about the WHO. Got it. There were questions that I had reading it. Yeah. No, and I mean, a lot of people don't know what the WHO or the CDC exercise recommendations are. It's the 150 minutes of activity plus strength training plus balance for the elderly. And that's a lot. And there's only a couple of these interventions that actually met that. And it's hard because the WHO and the CDC exercise recommendations are just very broad, but they don't give you kind of a breakdown of what that would look like in practice or how to actually prescribe. Like prescribe this or something tangible to like talk to patients about what strength training, all your body looks like three times a week. We talked about this a little bit as well, about the difference between static and dynamic balance, and most of the outcome measures were static balance with single-leg stance, but some had dynamic components as well, and if static balance is a good proxy for falls, if this is something we should be measuring, or if we should be measuring falls, these things correlate. What does the audience think? What do you think the static balance versus the dynamic? I mean, I can personally think the dynamic would be more reliable, because most of our population would, for example, wake up in the middle of the night just to have that call of nature, and most of these falls happen at that time. So what does the audience think? I want to hear more. I would think that this has been looked at in the literature. Has anyone come across that or seen that in other studies that you've come across? I thought that they said in this article that it was related, but I didn't go and look at the citations. Yeah, that's what I kind of saw. Again, I didn't look at the literatures or dive into it. That's why I was hoping to hear back. I know someone in the chat said, I agree, I don't think multiples are occurring when patients are standing fully still and focusing on their balance. So dynamic exercises would be the more reliable. But again, I just want to hear more conversation. I want to hear the audience. So tell me more. You can always test both. There's probably a high correlation between the two. What I question, and I've not reviewed the literature, have you looked or are there any studies that look at people who are wearing shoes versus not wearing shoes or going barefoot? And walking, for example, a tandem gate and take people who have a known neuropathy versus those who don't. So just in my clinical practice, sometimes they'll come in and they'll say, oh, my father's having difficulty walking. And I say, let me see you walk. And he's perfect. There's no problem whatsoever. But if you give them a more challenging test, such as doing a tandem gate, then you may see an abnormality. Now take your shoes off and do the same tandem gate. Much better. So if that study has not been done, do it. And if you need guidance, contact me. I will definitely reach out. Thank you. Now, I'm speaking to my personal experience. Again, I deal a lot with concussion patients. So when I do gate eval, I do like the normal gate, the tandem walk, and then I ask them to close their eyes. And then if they can do all the three, the fourth one would be close your eyes, do a tandem walk, and spell the word world forward and backwards. I know that's a lot, but I do it. It's more of like testing their attention span along with their balance when their eyes close. I want to hear you folks if I'm doing too much or too little. Not too little, but if I'm doing it adequately. And I have a couple comments from the chat box as well. What about virtual training? I think I've read somewhere about this. And then a second comment is maybe static standing gives good information on core strength, which is important for preventing falls as well. It does stimulate dynamic balance training. So some good thoughts on all of those things that contribute to our balance, our walking, and even just how we're feeling in space. Another question is about how if these multiple outcome measures are reasonably to be directly compared across these studies, where a lot of them use single leg stands, but some of them had the more dynamic tests like Berg and Tinetti. I think for like the healthier patients, they probably correlate more. I think when you add neurologic injury or disease on top of it, then these things become more complicated. Like with retropulsion and dynamic spasticity. So I think for this population, it was okay, but still hard to make direct comparisons with different outcome measures when that's the only thing they tested. I guess in some ways it kind of simulates what we do at work too, right, because we have maybe one therapist who does one task and another therapist who does another task, or people come in and they have the, you know, we don't necessarily repeat all the tests in our visits. So sometimes we have to kind of say, is that the same as that? And I guess we sort of have to believe that it kind of is, you know, and hopefully that's true. But that's a great point, though. I think at the end of the day, you can't use different outcome measures and compare the same thing. But again, when you're trying to get a broad overview look or using a meta-analysis, it's just hard. It's not like you're just measuring a blood pressure and seeing if that changes with different interventions. So I think it's really hard. I don't think that they're all the same, but I think it was kind of what they had to look at. Yeah, totally. And so for something like TBI model systems, right, like we have like some, there are some measures that everyone gets. So if you're doing a study like that, then you could really compare, but there's still so much. There's going to be different, right, and who gave the test, who recorded it, you know, who. So anyway, I, as a clinician, I don't know. I don't know about the research stuff, but I know sometimes I really envy the people that look to see if blood pressure goes down or up. It's much more simple than our functional outcomes. Are there any other outcome measures that are helpful? I mean, you did talk about using the same ones. Are there any other balance evaluations or follow-up evaluations that anybody does? We tend to put a lot of faith in the Berg, so I hope it's a good one. That's what we do as well, so I concur. I think compliance would be a nice outcome to have as well. Yeah, no, that was a big gap. I didn't have access to all of them, but I looked at the text of a few of them. Compliance was right around the 60% mark, which is not terrible for behavioral interventions. But then the few that did the intention to treat analysis, there was no difference between them, between the groups. So that was definitely a big gap because adherence is one of the biggest challenges of any type of intervention like this. All right, we've talked about some limitations. Any others that we haven't covered yet? So, yeah, that's a good one. Disability exclusion. And at least in the US. There is a pretty large percentage of people over 65 that do report having at least one disability. And so as far as how generalizable it is population in general and especially the people that come to PM and our doctors. It's questionable. I guess kind of like a different way of thinking about it but like a lot of the falls I've had this winter have had nothing to do with balance right it's just like the environment of ice. And just if there's a way that I mean I know this is important and we want to do everything we can to get people as strong as we can but how do we environment so that they're also, you know, getting the rugs up getting the lights in the bathroom working you know have an autograph. It doesn't know it doesn't address that type of thing too. about direct comparisons already, relatively small sample sizes in a lot of these. All right, and we also have covered quite a bit of this. I'm curious if you have thoughts on kind of addressing balance deficits in people with or without neurologic deficits. Yeah, I would say even just vision changes, you know, a little bit of vision change, I mean, can be a huge thing. Yeah, I think of a balance is more like four components, the cognition, the vision, the hearing, and the proprioception. And I mean, as a CNS community, I know the proprioception is something that we deal with all the time with peripheral neuropathies, with spinal cord injuries or post-stroke kind of cognitive deficits on top of the neglect and proprioception. So it's definitely changing the game when it comes to patients with disabilities or physical challenges. I think we see that earlier on than the general normal population. And when you evaluate a patient with FALSE, the question you ask or the differential diagnosis in the back of your mind, is it like balance issue, vision, hearing, cognition? So that's where you evaluate the FALSE. It's a different wake-up compared to the population that we deal with compared to the general. That's what I would say. And I thought too, the point you made before about how you take care of people with concussions, like so many of the people I take care of already have had their fall and already have the injury. So that's different than primary. I guess if there's a primary French and a fall, we're kind of doing it. Oh, they already had this fall. How are we going to prevent more? So I don't know if that's the same thing or not. Maybe it is, but who knows? I also think with several neurologic diseases, we see progression. Not all, some are more static, but there can certainly be progression in multiple sclerosis and they can have all four of those areas affected that Zaina was talking about. But it does change and their needs change, not just for equipment, as their balance changes, as their strength, as their specificity is changing as well. So it is very, very challenging. I think you do a good job of like anticipatory guidance for people with progressive things too because that's what they're worried about and talking about like what is the next step if they get worse or like if they have a harder time transferring or harder time walking like before they actually need it. It's helpful and helpful to patients and families as well I think. We already talked about this a bit as well, but telling, giving people concrete advice can be hard for anybody. There was, I finally found the reference, but the number, number needed to treat for like exercise recommended counseling with physicians is like 12 versus the number needed to treat for like smoking cessation counseling is more like 50. But doctors don't often talk about exercise with patients. I mean, I think that PMNR doctors are better at it, but it's still hard to give people a concrete plan rather than just saying that they should just exercise more. There is another fantastic APMNR community called Exercise Physiatrists, I think. And that is who I was listening to their discussion and where they were going through the WHO recommendations. And one of the things that they talked about was writing it down and, you know, making people a little bit more accountable, like, oh, we had this discussion and I'm going to write it down. Just like you would write down, what's your diagnosis? What is your orthotic prescription? How often are they going to wear it? How long are they going to wear it? And just to write that down. And of course, we can start a prescription for that in clinic and then have the help from our therapists and our exercise groups. But I think maybe that might be a nice way to attack that. I like that. And is that help you to get kind of buy-in? Like, I might try to say, oh, I know you can't walk outside. I don't know why you can't walk outside, but I get you just told me you can't walk outside. So why don't you walk around your living room for 10 minutes every night? People first look at me like I'm crazy, but I feel like at some point they get that buy-in and then they might start walking outside. But I don't really, sometimes like repeating it may be help or something like that. After you write it down, I don't know. Yeah, I would say putting the SMART goals within the exercise. Like for example, if I'm dealing with somebody with a lot of comorbidities, I'll be like flat out saying, yeah, are you going to run a marathon? No, but is your goal to walk your dog for one or two blocks? Let's work on that. Let's start with that and then re-evaluate and assess your exercise goals. So it really depends on how much realistic they are. It depends on the circumstances around them and the resources they have. And also depends on we as exercise specialists and exercise prescribers. That's what sometimes I use to advocate for myself in a younger population, how much we can offer with using different strategies. And being familiar with community resources. I think it's helpful like senior center classes, where they can find like Tai Chi or find things to do with other people. So you can give them something like very concrete to look into. So somebody in the chat says, thank you Elisa, I do think the nice thing about this article is that it shows that any exercise or balance training in general is better than none. So that helps with counseling patients to just finding anything active they're interested in doing. I concur. Yeah, just finding what they're interested in, using that to keep them going and moving and yeah. Thank you. After reading this historic review, what other questions or areas of research should we want to know? Lots of things. Yeah, I think I'm still pretty curious, like does balance, having better balance, how many proof falls are we going to prevent there? And what about the rest of the falls? And some of that stuff that we can also do, you know, just a quick home eval, I don't know, we can do home evals, but like, how can we make the home safer? How can we make the environment safer? I wonder about that too. I'm looking about the question of exercise and balance in each of our CNS populations would be nice as well. And there is some, there's definitely some out there. But when I even think of, for instance, spinal cord injury, you know, are we talking about paraplegic, tetraplegic, which outcomes are we looking at? Are we looking at body mass? Are we looking at, you know, so there's a lot, there's so many factors, but we have to start somewhere. A few things we talked about was different modalities, correlating changes in static and dynamic balance with changes in reported falls, like that, if you improve your balance, can you reduce falls or are some falls inevitable, like we talked about? With increased aerobic capacity in itself is like to improve balance without the extra specific balance training or specific strength training and the virtual reality interventions that also have been brought up. I think everybody, floor is open for questions. I am curious if anybody has done any of the virtual reality interventions or knows of studies because I've had patients ask about it and it is a cool intervention. It's just the startup costs are hard if people want to do it on their own. I wonder, too, if it would depend a little bit on what population you're talking about. If we're looking at interventions in people that are 65 and older, they might not be as interested in working in virtual reality, whereas we have kids that that is absolutely how they want to exercise today. So it'll be interesting to see how some of these opportunities change as a technology becomes cheaper and be the populations that are used to working with technology already age. I would also like to just open up the floor, too, if anyone has any other topics that they think that they would like us to address in a journal article, if you think it was helpful, interesting, and you are welcome to communicate with us directly as well. We certainly don't have to do everything tonight. And I do thank everyone for coming. Unless anybody has any other comments, then we will let everyone get to bed, dinner, exercise, whatever you need to do. Thank you to Caitlin and to Zainab as well for stimulating the discussion and presenting the article and to all that came. Thank you. Thanks, everyone. Have a good evening.

journal club

CNS community

falls prevention

elderly adults

balance improvement

exercise modalities

study design

limitations

clinical relevance

future research