I didn't know I was actually the moderator for this, so I'm just going to jump right in and take control of it, and I'm now the moderator. My name is Joel Press, and welcome you all to the 2024 Passor Legacy Award and Lectureship and the presentation of the Scott and Adler 2023 Passor Musculoskeletal Research Grant Award findings. I do want to start this just for one second, because there's only a few of us in the room I think that knew Scott and Adler. Scott was amazing. Scott was a young physiatrist at Rutgers who I met when he was just starting, and this guy had the most incredible passion for musculoskeletal care and teaching and mentorship and research, and he was able to do everything. And it's wonderful that we have this award to honor and memorialize Scott, and I think the two honorees today just epitomize everything that Scott was. So I am very proud to be here today to present these awards and present the lectureship today. So I want to start by introducing Dr. Dan Herman, who is going to give us the 2023 Nadler Passor Musculoskeletal Research Grant Award's findings. So congratulations on your award, and thank you for your presentation. Well, findings is a bit much. You just get the money less than a year ago, and IRB approvals have actually only recently been obtained. So they turn these lectures around a little too quickly for research to really take place in a real-world setting, so I'm going to be talking a lot about the proposal and what we're planning to do and how we're moving forward. So I don't have any disclosures to make. So if I was to talk to you about the pathophysiology of a certain brain injury and I say there's an injury, there's microglial activation, there's astrocyte activation, you get inflammation that occurs from all of this, you have breakdown of the blood-brain barrier, you have mitochondrial dysfunction, and all of this ends up leading to cellular oxidation and cellular stress, dysfunction and even apoptosis. You would then have these neurocognitive deficits and performance deficits. You would be certainly excused if you thought that we were talking about the pathophysiology of concussion, but actually there's a lot of similarities with the pathophysiology from a neurological standpoint with COVID-19 and certainly with a lot of other neurodegenerative disorders, but when I was reading early in the pandemic about neurocognitive dysfunction and reading in terms of the background and what we were finding in terms of how this neurocognitive dysfunction was occurring and what the effects of COVID-19 were on the CNS, I kept on thinking to myself, wow, this would be right at home in concussion literature. So you may be asking yourself, what is a musculoskeletal guy like you, Dan, reading about the neurologic effects of COVID-19? Well, because the neurocognition is kind of a big effect on neuromuscular control and potentially on subsequent risk of injury. So when I talk about the effects of neurocognition and neuromuscular control and try to give a little bit of framework of what I'm talking about, when we're engaging in a neuromuscular task, from a neurocognitive standpoint, we have a stimulus detection where maybe if we think about this as like a running back, the running back is kind of responding or sensing internal cues, where their body is in space, external cues, maybe what the interface is with the ground, wet turf, dry turf, visual stimuli in terms of what's going on around them. They have to then discriminate with all that different stimuli coming in. They have to determine what's important for their motor control selection and what is not. A lot of players moving around them, but they have to say, okay, this is my pulling guard and I'm going to follow them and come off the right or the left side of it, depending on how they engage their block. They have to select a response, they have to select something to do, they have to select that motor control program, and then they have to implement it and they have to monitor what's going on with that motor control program and say, okay, we're going to make a little change here depending on how that's being implemented. All the while you have to do this very, very quickly in an athletic setting and you have to constantly do this in an iterative fashion. So any breakdown that may occur in any of these areas can affect how you execute your neuromuscular control pattern and potentially influence your risk of injury. And so we see this in athletes, where just dividing people who have kind of high-end neurocognitive performance and low-end neurocognitive performance. So these are people who have not had COVID, they're not people who have had any sort of injury, they're just straight, normal people who just kind of be a little bit high-end, a little bit lower-end in terms of how they test out in terms of neurocognitive performance. And you have them do just a standard athletic task, like a jump landing. So they stand on this 30-centimeter box, they jump forward to a target, and then immediately jump up for maximal height. And we have them do this while they're kind of receiving a signal from a TV monitor in front of them. So as they jump off this 30-centimeter box to their target, they'll get an arrow that either denotes left, right, or up. And if they get the one that goes to the left, then they'll jump up forward and to the left. If they get one to the right, similarly they'll jump forward and to the right. And if they get the one that is straight up, then they'll jump straight up and down. They won't move forward, they won't move left and right. So there's a decision that has to be made while they're in the air receiving this visual stimulus that they're either going to go left, right, or stay put. They have to go forward or stay put kind of at the initial landing target. And people who are on the low-end of neurocognitive performance compared to the people at high neurocognitive performance, they have much higher knee abduction angle, much higher knee abduction moments. And these two things have been shown to be predictive of ACL injury. This is just one of many studies that have been performed now. So we definitely see this then in a more pathological population. Again, these are kind of normal athletes. We see this in people who've had concussion. And there's certainly detriments on neuromuscular performance that are far beyond what the effects of neurocognition are. Certainly concussion influences a lot of different pathways and impairs motor cortical performance. And so we see these detriments in terms of neuromuscular performance. We have this jaunty fellow here, and he's going to walk around a target and come back just eight meters, nothing big. Maybe step over a little box or something like that along the way. And we see that people who have had a concussion have significant detriments in terms of their gait performance compared to people who have not had a concussion. So they clear that obstacle by a smaller margin. They have differences in medial lateral sway. And these effects are exacerbated by having a cognitive stressor. So doing things like serial sevens or spelling world backwards while they're walking, then that really magnifies the differences between the two. And perhaps most importantly with this, this is shown to be in effect at points in time well beyond what the clinical recovery is for concussions. So they meet return to play criteria and still you see well beyond that point they're still having deficits and differences in neuromuscular control. Does this affect injury risk? Yes. Actually several studies now have been performed. This is one of the first ones that we performed when I was at the University of Florida. And we had controls and in cases matched the cases to the controls. And they found that within 90 days of the return to play from concussion, the people who, this is, excuse me, this is again a University of Florida athlete, so high level athletes. Within 90 days of the return to play from concussion you had about 50% of them had had some sort of musculoskeletal injury risk. When taking into account the conditional factors and the matching, the odds ratio for having an injury was about three and a half which is pretty high. Again going into this idea that neuromuscular control deficits outlast return to play criteria, this is a survival curve analysis. So we have the overtime over this 90 day period. We have the controls. Here they have a linear decrement in terms of how many people are getting injured. And it's a linear relationship as you would expect if there's no kind of external effect. For the people who have had a concussion you may anticipate that they would have a higher risk of injury at the days closest to their return to play. And you would expect a curve that would probably be more like a log linear curve. But we don't see that. We don't see that the risk of injury improves the farther out that we get from the concussion. We actually see a linear relationship, a steeper slope, but a linear relationship. And so that begs the question is when does this actually stop? And there's actually data to show that for people who have had a concussion and you test them six, seven years later compared to people who have never had a concussion, they still have altered neuromuscular control. So this is where sort of the link that I had in seeing what the changes were from a central standpoint with COVID-19 on the brain and linking that to potentially what would be the impact in a neuromuscular control potentially injury risk. So what do we see in the admittedly very early and thin literature in terms of COVID-19 and the risk of having a musculoskeletal condition? There's a large study from the VA that looked across a wide range of different diagnoses across a wide range of systems and including musculoskeletal conditions and found that there was an elevated rate of presenting with musculoskeletal complaints after having COVID-19 compared to people who had not had COVID-19. Within athletes using the PAC-12 system, looking at the risk of injury pre-pandemic to post-pandemic, so after the hiatus of play, they found a much higher rate of non-contact injuries and non-acute injuries, so like tendinopathies and things like that, across several sports following that hiatus. And then within our own studies at the University of California, Davis, performed with one of our PEDS residents, we found that there was an increase of injuries following COVID-19, when we returned to play from COVID-19, compared to match controls. Now this is a little bit... Cutting it a little bit thin maybe, the P value is like .06 and we're getting another... Analyzing another year of data I think with additional power will probably find statistical significance. So anyway, there is some smoke in terms of whether or not there is an effect on neuromuscular control and hence this risk of subsequent injury. So our central hypotheses are that compared to subjects without a recent COVID-19 infection, individuals who have a post-acute sequelae of COVID-19 will demonstrate altered neuromuscular control and furthermore, that altered neuromuscular control will be related to how impaired their motor cortical physiology is. So a little bit about the methods. I'm kind of running through the methods here quickly, because I think actually the background I'm talking about is actually more interesting. So the subjects, again this is a pilot study, so only 15 and 15. We're really just kind of dipping our toes initially in the water to see what we find and where the interesting trends are. These are individuals with post-acute sequelae of COVID-19. Individuals who have had COVID-19, they continue to have symptoms at least three months later. These are non-hospitalized individuals and they have all these complaints, but a lot of them have completely normal testing and that's actually a criteria that we have. Normal EKGs, normal respiratory function, but some things off. They're continuing to have symptoms in terms of difficulty with concentration, difficulty with exercise, et cetera. Our controls will be age and sex matched and they can't have any musculoskeletal injury, surgery, or COVID-19 infection. In fact, we're limiting it to not even having an upper respiratory infection within the past six months. We're going to be kind of getting a flavor for who these people are and what their level of function is using different functional measures from the APTA. Also their symptom burden for long COVID and some promise measures in terms of their overall function. We'll also be assessing what their neurocognitive performance is like using a range of different tests. The ones I really want to kind of focus on are the ones that kind of incorporate a little bit of a motor control task. So finger tapping tasks, so that's just tapping with your finger left and right and then you repeat it while tapping one side while doing pronation supination on the other side. So sort of a motor interference task. And then the last one being the pursuit rotor task, if you've not seen this before, you're using the original one that was a big drum and it had a wand and you followed this circle as it was going around sort of like a record player and it was sensing the time that you were on target. Now we do this digitally and we do it with a mouse with your off hand and you put the cursor on a target that's going around in a circle and you vary the parameters in terms of how fast that circle is, how small the target is, et cetera. And they have trials to stay on target and you can see this tracing here with the variations where the person is off the target as they're going around. And this is something that, again, can be used for visual processing, the integration with the motor control function, and also motor learning. In terms of assessing their neuromuscular control, we go back to this jaunty fellow that we had walking the eight meters around a target and coming back, but instead this time they're going to be walking on a treadmill and we're going to be using three-dimensional biomechanics to assess their gait, particularly the main variable that we had as a part of the grant was looking at their knee flexion variability, which actually comes from a lot of the literature for things like stroke, Parkinson's, as being a really good variable to look at in terms of gait variability. But we'll also be looking at a lot of different measures, one of which I'll get to in a second. And then we'll also be assessing the motor cortical function using transcranial magnetic stimulation looking at both motor evoked responses and cortical sinus period. So looking at what their activation threshold is, how much it takes to recruit 50%, 100% the slope for that recruitment, and how long it takes in between stimulus to try to reactivate those, the motor cortex again. So again, results, this is something that we're, it's ongoing, but one of the things that I think is important to talk about in terms of what we ultimately might see down the road, again this is a pilot study, I don't want to get too broad-minded here, but it's possible that we see significant gait changes in individuals which may last a very long time. Again, going back to concussion, we're seeing six, seven years after concussion these people still have altered neuromuscular control. So there is potentially a sleeping giant here. Concussion, yeah, it's an epidemic in sports, but it's not like COVID, COVID's endemic. We're having not only COVID infections, repeated COVID infections, but more and more people are getting kind of this long-term effects, the PAXI, the post-acute sequelae of COVID. This if you don't know is the sleeping giant, it's in Connecticut, so anyway that's why this random rock features here. So what is the sleeping giant? Well it's not necessarily acute musculoskeletal injury if we're focusing on athletes. The sleeping giant is really what are the chronic changes and what chronic conditions will stem from those changes. Do people as they're walking have variability that changes, that alters their knee loading? Do they have changes in knee adduction moment that increases the risk of knee arthritis? So these sort of things that affect a broader swath of the population could be coming down the road as a long-term result of this epidemic and now endemic issue that we're facing. So a few acknowledgments. I want to acknowledge my collaborators, so Carolyn Patton who is just a fantastic biomechanist and just an expert in terms of neuromuscular control. And then Mark Adalovic who is in charge of the pulmonary clinic who does the post-COVID work and we're recruiting from his clinic. And then finally I wanted to acknowledge the foundation. Giving my little spiel for the foundation here, if you're not a donor please consider it. If you're early career they have programs which you can just donate 25 bucks a month, not a big deal. If you're earlier career or mid-career and you're just kind of getting into the spirit of donating, think about doing the Summit Club. It's $1,000 a year. There's a lot of work that can be done and it really relies on you. Thank you if you are a donor. It's greatly appreciated by everyone in the field because this work really does impact what we can do as physiatrists. So I'll end there. Oh, and I... Yeah, go ahead. Stepping on my own paws. And I just wanted to say I do have to leave after my presentation. I've already apologized to Stu. But just want to let you know just in case you think, ah, that's great, he just left after his presentation. So... No, if there's questions though, let's take some questions. Anybody? So, I'm sorry, maybe I'm interpreting your question differently, but what I think you're asking is like for athletes, you know, they obviously have a time off of play during which they're recovering from mono, they're recovering from flu, whatever. And then they come back to play and maybe they're deconditioned or just the wind's not in their sails yet and they have an increased risk of injury. Is that kind of what you're getting? Yeah. So, you know, there are some, there is one study that looked at high school athletes that, and they compared to kind of more general illness and they did not find in that particular study that there is increased risk of illness compared to, or excuse me, of injury compared to COVID-19. Larger study scale and they didn't really do the level of matching that I'd like to see. And so, you know, sometimes the effect can be hidden in the weeds a little bit. And again, it's early days. In general, if you're looking at, certainly if you're looking at concussion and comparing it to other injury risk or comparing it to other things where they would be away for a while, it does, the effect is in excess of what you would expect. Now whether or not that's true for COVID, who knows? And certainly there's all sorts of things here that are kind of playing into it. You know, what variant, right? Is the person vaccinated? What kind of symptoms did they have? Because there's a whole different set of symptom profiles where some people are highly cognitive. Other people are... You know, they have a lot of GI upset. Some people are very pulmonary, cardiopulmonary in terms of their symptom manifestation. So they're not all the same in terms of how they present. So there's so many things that we're still getting a handle on and that's actually one of the reasons why our IRB took a while to get taken care of is because every time we resubmit they're like, actually you should maybe think about this and there's like some new information coming out. So it's like this constant moving target, which even though we had our approval I think it still is a moving target. I mean we haven't really done a whole lot in this group. And we, I mean not just our group, but broadly in terms of sports medicine or people who are, you know, motor control experts, it's really quite early days. There are some small studies that have looked at gait in recreational athletes, small numbers, and have seen differences in their gait parameters, but that's not really getting at the question that you have and whether or not like looking at like individual control of, you know, small versus large muscle groups. I can tell you as an individual, I had COVID once, that I know of, and boy I tell you, when I went back to work, I couldn't type, whether that was a cognitive issue, whether it was, you know, motor control or some interface between the two, but I made errors all the time. It was very frustrating. For about three months I kept on making errors as I was typing. All right. Thank you so much. Thank you. Okay. It is my great pleasure today to introduce the 2024 PASOR Leadership Award. As you know, PASOR started in 1990 to advance the training of physiatrist in, or physiatry in musculoskeletal care. And it's fitting today to introduce this year's PASOR Leadership Award. As you know, PASOR started in 1990 to advance the training of physiatrist in, or physiatry in musculoskeletal care. And it's fitting today to introduce this year's awardee, Stuart Willick, who has dedicated his entire career to do exactly that, advanced training for physiatrist in musculoskeletal care. After graduating from a small, low-profile college in Boston called Harvard, he went to medical school at our Robert Wood Johnson Medical School and was an intern and resident at the University of Washington. I had the first pleasure of meeting Stuart when he interviewed for our fellowship in Chicago at RIC. I then had the pleasure of working with him every day as our fellow and as attending for his first year in practice after fellowship. And I remember many of the conversations we had about the importance of training high-quality fellows to go out and train more high-quality fellows, to go out and train more high-quality fellows, which is exactly what he did. He went to the University of Utah to train a generation of fellows, residents, medical students, and how to be an outstanding musculoskeletal physician. At the University of Utah, he is an adjunct professor in family and preventive medicine, adjunct professor in orthopedics, professor of physical medicine and rehabilitation, and an adjunct professor of physical therapy. He is a reviewer of multiple sports medicine journals, multiple-time winner of Teacher of the Year. He served numerous administrative positions, including VP of the Utah State Society of PM&R, the Chair of the Division of PM&R Resident Education Committee, Director of Musculoskeletal Rehabilitation, and Director of Medical Student Education. And in his free time, he's been a member of the Adaptive Bobsled and Skeleton Advisory Board, U.S. Speed Skating Medical Committee, Medical Director for the Snowbird Ski Clinic. His CV has three pages that are single-spaced of the sporting events covered. He has been a primary investigator and a co-PI on 17 research grants. He's mentored over 100. I stopped counting when it got to 100 because it looked like it was way over 100 at that point. Residents, fellows, medical students, and undergraduates. Has 70 peer-reviewed articles, 26 book chapters, hundreds of oral presentations, and lots of film and video and TV and all the other stuff, too. He's a member of too many organizations to name them all, but obviously very involved in the ACSM, the Olympic and Paralympic Committee, the AMSSM, and the U.S. Anti-Doping Agency Review Board. He has worked 11 different Olympic and Paralympic games, including two stints as medical director today. He's going to tell us a little bit today about his journey as a teacher and mentor and leader and really the role of disabled sports in neurorehabilitation. Stewart has shown incredible strength and resilience and fortitude and courage and tenacity in his career and overcoming a lot of obstacles recently. He is here today to send us a message about what we do every day and the importance of it, and I look very much forward to it. It is my immense pleasure to present the 2024 Password Leadership Award to my friend, my colleague, and one of my real heroes, Stewart Willick. Thank you. Thank you for that wonderful introduction Joel. I have many incredibly fond memories of my fellowship here at RIC. So many great stories, but unfortunately none that I can actually recount in a public setting. I was really caught off guard by this award for many reasons, and I'm truly honored. Many thanks to the awards committee, and infinite thanks to my family who have put up with my long work hours and many periods of travel. I had discussed potential topics for this talk with friends and colleagues. I usually prefer to talk about my own research. It would have also been easy for me to talk about Paralympic medicine in particular. But as I thought deeper about my career, how it was shaped by PASOR and PASOR's role within the Academy, some themes presented themselves that transcend my research and transcend my own career and have relevance to a larger proportion of our diverse Academy. I'm going to speak at the intersection of neurorehabilitation and sports medicine with a focus on a few themes, including how the Paralympics grew out of neurorehabilitation, the many critically important benefits of participation in sport for people with disabilities, the importance of understanding disorders of motor control in sports medicine, and how sport drives innovation of adaptive equipment. A full understanding of this intersection requires knowledge of the history of PASOR and the prehistory of the Paralympics. Please bear with me as we go back and then forward in time a bit. My understanding of these concepts comes from about 30 years of involvement in sports medicine. The first adaptive sports competition I ever covered was as a junior resident. It was a wheelchair rugby tournament in Seattle. I had no attending backup, no medical bag, and no formal training yet in sports medicine coverage. I am certain that I benefited from that event far more than the athletes who taught me simply from their expressions how fun, liberating, and social sports participation was for them. Now, having worked at eight Paralympic Games and three Olympic Games, along with other experiences, my appreciation for the role of sport in rehabilitation medicine is stronger than ever. My first games were in Sydney, 2000, when I was a member of the IOC Observer Program, a head of our games in Salt Lake City in 2002, during which time I was one of the polyclinic medical directors and head of sports medicine. During our games, I had the opportunity to work with longtime member of the IOC Medical Commission, Dr. Per Renstrom, on the emerging IOC Injury Surveillance System. Then, in the lead up to and during the Paralympic Games, I helped design and implement the first version of the IAPC Injury Surveillance System with Sir Nicholas Webber, a wonderful colleague and close friend who practices sports medicine in England and was a member of the medical committee of the International Paralympic Committee. Top right is a photo of me and Dr. Webber. Dr. Webber has been deeply committed to parasport for many decades. When he was a university student, he sustained an incomplete cervical spinal cord injury in a recreational rugby match. I will never forget when we talked right after he went sit skiing for the first time. Nick had this sublimely blissful, ecstatic expression on his face and told me, it was the most incredible feeling. It was so liberating. For the first time, I felt like I did before my injury. Because of my positions during the 2002 games, I was able to bring colleagues to Salt Lake City to work with the games, and we had the largest physiatric presence at any games up until that time, and maybe even up until this time. During the 2006 Torino Winter Paralympic Games, my primary role was as a researcher with the IPC Injury Surveillance System. Following structural changes within the IPC after the Torino Games, the medical committee had disbanded and I was asked to serve as IPC Medical Director for the Beijing 2008 Summer Paralympic Games. It's always gratifying to go to the games and sometimes see my patients at various games where they're competing as athletes. During the Vancouver 2010 Winter Olympic Games, I was the IPC liaison to the medical committees of both the IOC and the Vancouver organizing committees. I returned to Vancouver for the Paralympics as a member of the reformed IPC Medical Committee. I continued in that role during the London 2012 Summer Paralympic Games and the Sochi 2014 Winter Paralympics. Here's a photo of Wayne Derman and Martin Shwellness, the great South African sports medicine physicians and researchers. When they were not writing one of their several hundred research papers, they were playing practical jokes nearly constantly. If I recall correctly, this photo was taken after they made unsuccessful attempts to get Vladimir Putin, whose private box was very close by, to crack a smile at the gold medal hockey game, which Russia lost to the United States, won nothing. That was definitely a no-go on the smile. After taking a few games periods off, I returned to the role of IPC medical director for the Tokyo 2020 Summer Games, during which time I was once again embedded within the structure of the medical committees of the IOC and the organizing committee during the Olympic Games in order to become intimately familiar with and then help oversee the COVID mitigation plans during the Paralympic Games. That was seven straight weeks in Tokyo. Just about everyone in Salt Lake City is excited to have the games return in 2034. The picture on the right from last month is of the president and the CEO of the IOC alongside the president and vice president of health sciences at the University of Utah shortly after the formal awarding of the 2034 Winter Games to Salt Lake City. Alongside this announcement, the University of Utah has recently entered into a research collaboration with Université Côte d'Azur in Nice, France, as they will be our sister university ahead of their 2030 Winter Games. While I am not going to talk about my own research, I have been active in publishing on Paralympic, Olympic, and anti-doping topics highlighted in these three slides. I will take this opportunity to thank my many esteemed co-authors with a special commemoration of Dr. Jack Taunton, the great Canadian sports medicine physician who served as CMO of the Vancouver 2010 Olympic and Paralympic Games and attended eight Olympics overall. Jack passed away three weeks ago. My thoughts are with his wonderful family. Dr. Taunton was a giant in sports medicine, fairly referred to as the father of sports medicine in Canada. His story is also particularly relevant to this talk. I was fortunate to be able to spend a lot of time with Dr. Taunton during the Vancouver Games. A couple of little-known facts about Jack. He contracted polio at age seven and was also in a serious car accident as a teenager. Both resulted in motor impairments requiring extensive rehabilitation. He went on to train in emergency medicine and fell into sports medicine almost by accident when he started covering his daughter's field hockey teams. His own rehabilitation experiences as a youth allowed him to more keenly observe the subtle disorders of motor control that were leading to injuries in athletes, including himself during his completion of over 60 marathons. Indeed, Jack was an ER doc who thought like a physiatrist. Please allow me to now talk a little bit about my own early interests and then about my understanding of the history of PASOR. These developments are intertwined with a central theme I hope to convey, which is that in many ways I view the distinction between neurorehabilitation and musculoskeletal rehabilitation as a false dichotomy. I recall quite distinctly when I was interviewing at medical schools in 1989, I was asked on more than one occasion what I was interested in. The question seemed premature at that early stage, but it was still easy for me to reply that I was fascinated by the neurologic system and by the musculoskeletal system. Each interviewer's response was the same. They said, you can't be interested in those two fields. They're too disparate. Their responses were curious to me. I knew even at that early stage that the neurologic system and the musculoskeletal system are inexorably intertwined. They rely on each other during all the constant efferent and efferent neural volleys. I told my dad about these exchanges during the interviews. My dad was a really smart guy who had attended medical school at NYU in the mid-1950s at a time when NYU's Rusk Institute of Rehabilitation was among the few PM&R training programs in the country. My dad said to me, you know, there is a field that combines your two intellectual interests. It's called physical medicine and rehabilitation. Shortly after Dr. Cianca called me to let me know I had received the Passoral Legacy Award, I called my first mentors in sports medicine, both of whom were founding members of the Physiatric Association of Spine, Sports, and Occupational Rehabilitation, to ask about the motivation for starting and later dissolving Passor. I called Stan Herring, the grandfather of musculoskeletal rehabilitation in the U.S., and I called Joel Press. According to the Academy's website, Passor was formally recognized in 1993, but this was after several years of discussions and meetings. The motivations for starting Passor were to work toward getting representation within the Academy for those physiatrists who were practicing outpatient musculoskeletal medicine. Passor quickly grew to over 2,000 members, at that time about one-third of all physiatrists in the country. And some Passor members ultimately went on to hold leadership positions within the Academy, including Dr. Press, who was the Academy president in 2006-2007. Passor had accomplished its primary goal to the point that it was able to fold by 2008 when the Passor Legacy Award was established. The award is only one way that Passor's legacy lives on. The musculoskeletal branch of our field remains quite strong, perhaps even to the detriment of bread-and-butter rehab, which got me interested in PM&R in the first place. This year, while scores of senior residents apply for spine and sports fellowships, only 13 senior residents applied for spinal cord injury fellowships. 34 SCI fellowships did not fill last year and 21 positions did not fill this year. There are shortages in several other subspecialty areas of PM&R, such as pediatric rehabilitation. I hope our field can make sure we maintain good balance and excite young physiatrists to pursue subspecialty training in the more classic subfields of PM&R. I understand if that sounds hypocritical coming from a sports medicine physician, but there is concern about an increasing mismatch between clinical need and the availability of subspecialty trained physiatrists. Around the time of its founding, there were two early controversies within the nascent Passor group. First, there were arguments about what to call the new group. Some argued that because of the occupational component, there should also be a vocational component and a more reflective name would be the Physiatric Association of Spine, Sports, Occupational, and Vocational Rehabilitation, or Passover. Once cooler heads prevailed with that dispute, the founders moved on to a very real, serious controversy. A few of the founding members of Passor advocated for splitting off from the academy altogether, arguing that the musculoskeletal medicine that they practiced was too disparate from the inpatient rehabilitation that remains at the core of physiatry. Again, cooler heads prevailed. Doctors Herring and Press and others recognized that any schism between musculoskeletal medicine and neurologic rehabilitation would hurt all physiatrists. On most inpatient rehabilitation units, somewhere between 50% and 90% of inpatients will have some musculoskeletal issue affecting their rehab. This is, in fact, why the subfield of musculoskeletal rehabilitation began to grow in the first place. Through the 60s, 70s, and 80s, inpatient physiatrists started educating themselves about orthopedic issues so that they could take better care of their patients and not have to wait for their orthopedic colleagues to come and do a consult. And in parallel, my training in neurorehabilitation and amputee rehabilitation makes me a much better sports medicine physician and certainly a better Paralympic physician. In my sports medicine clinic at the University of Utah Orthopedic Center, we are always striving to improve athletes' neuromuscular control every day through exercise. Unfortunately, we still hear occasional chatter from some musculoskeletal physiatrists who hold on to the mistaken notion that a split from the academy is a good idea. But we are all involved in rehabilitation. We are all utilizing exercise to improve function. When I think about the pinnacle of function for individuals with impairments, I think about the Paralympic Games, which enables athletes with spinal cord injury, CP, limb loss, and other impairments to travel around the world, developing international friendships, and competing in sport at the highest level. I have heard many Paralympic athletes say, Doc, my injury is the best thing that ever happened to me. It opened up worlds of opportunities I would never have had otherwise. Now, the Paralympic Games did not actually grow out of sport. To understand the prehistory of the Paralympic Games, one must look back in time at the historical record of neurorehabilitation. The earliest reports of the benefits of exercise for individuals with physical impairments comes from ancient Buddhist text. There was a prominent Buddhist monk in the 8th century named Para-Atsu, who was an enlightened bamboo wheelchair user and wrote about the physical, mental, and social benefits of exercise for individuals with impairments. According to the ancient texts, Para-Atsu lived to the ripe old age of 104 before passing on to reincarnation for his next go-around. There was a long historical gap in the field until World War II, which brings us to the pioneering work of Sir Ludwig Guttmann. Dr. Guttmann was a German neurosurgeon who had escaped Nazi persecution and emigrated to England, where, at the request of the British government, he opened a spinal cord injury unit at Stoke Mandeville Hospital, 50 miles northwest of London, with a primary goal of taking care of injured soldiers returning home from the war. Dr. Guttmann quickly realized that the rehabilitation of his patients, mostly men in their 20s, would benefit not just from general inpatient rehabilitation but from a greater level of motivation to improve function through what Dr. Guttmann called rehabilitation sport. At about the same time, in the mid-'40s to late-'40s, on our side of the Atlantic, two monumental figures in the early history of our field in the United States were partnering to grow training programs, which were still few and far between. Our field's founder, Frank Cruzen, worked tirelessly to promote the field, and philanthropist Bernard Baruch donated millions of dollars to Jumpstart 12 training programs. As in England, motivation for establishing rehabilitation programs was driven, at least in part, by the needs of injured soldiers returning from Europe. Now, Dr. Cruzen's own clinical and research focus was in the area of modalities, such as short-wave diathermy, ultraviolet and infrared light therapy, and therapeutic ultrasound. When I was a junior resident at the University of Washington, I trained under Dr. Barbara De La Torre, who would later become chair at Johns Hopkins, and was herself a recipient of the Academy's Frank Cruzen Lifetime Achievement Award. Dr. De La Torre took us to what she called the Museum of Modalities to show off all of these old physical modality machines that were by then collecting dust in a closet, like so many other procedures that have come and gone. Dr. De La Torre was an ardent believer that exercise should be the first-line treatment in rehabilitation. Interestingly, 45 years prior to Passore's debate about splitting the field, early physiatrists in this country engaged in similar heated discourse about whether the field should be called physical medicine emphasizing the use of these physical modalities or rehabilitation medicine emphasizing medical rehabilitation and the use of exercise. Some argue that these should be two entirely separate fields. Kruzan advocated that these two branches would be stronger together writing, quote, "'Physical medicine and medical rehabilitation are closely interdigitated and it is apparent that it would be illogical for either physical medicine or medical rehabilitation to go its separate way.'" Fortunately, Kruzan's view held sway and the new field was formally named physical medicine rehabilitation. But the incorporation of sport into rehabilitation programs in the U.S. would lag behind England for some years. Back at Stoke Mandeville Hospital in England, Dr. Gutman introduced sport as an integral part of the rehabilitation program for his patients. He believed that by, quote, "'By restoring activity of mind and body, by instilling self-respect, self-discipline, a competitive spirit and comradeship, sport develops mental attitudes that are essential for social integration. The importance of recognizing that participation in sport provides benefits far beyond physical functioning cannot be overstated.'" Gutman's rehabilitation sport quickly evolved into recreational sport and as might be considered natural, the recreational sport quickly evolved into competitive sport. Here is a photo from Stoke Mandeville Hospital of young men playing wheelchair polo. Note the old wheelchair design with the casters in the back of the chair rather than in the front. Competitive spirit resulted in a wheelchair archery tournament held on the grounds of the hospital involving 16 World War II veterans, the first known organized sport competition for athletes with disabilities. Not coincidentally, the date was July 29th, 1948, the same date as opening ceremonies for the London 1948 Summer Olympic Games. The Stoke Mandeville Games became an annual event and grew to involve other sports. It became the International Stoke Mandeville Games in 1952 when four Dutch athletes crossed the channel and joined the fun. In 1960, the Stoke Mandeville Games were held in the same city as the Olympics for the first time, six days after the Olympic closing ceremonies. Four hundred athletes from 23 countries competed in 11 sports. Over the next two decades, the games grew in size and scope, adding additional disability categories and additional sports. The administrators of the Stoke Mandeville Games were increasingly in discussions with the IOC to more closely align their missions. In 1985, the IOC and the future IPC agreed to use the term Paralympic Games, having nothing to do with paraplegia, but rather that they were parallel to or alongside the Olympic Games. The International Paralympic Committee was not actually formed until 1989 and did not even have a permanent home until 2000 when they found cheap space in Bonn, Germany, which had a glut of office space after German reunification resulted in a move of West German political offices back to Berlin. The IPC understood that much more than elite sport was at stake. Perhaps even more importantly, elite sports serves as a platform to improve rehabilitation and promote disability advocacy around the world. This is clear in the IPC vision statement. Quote, to inspire and excite the world, the external result is our contribution to a better world for all people with a disability and the promotion of the Paralympic movement as a whole. Like Ludwig Guttmann, the IPC understood that sport can improve the lives of people with disabilities in many ways. Indeed, the Paralympic movement is truly about so much more than sport. It includes disability advocacy across a broad range of issues. On the medical side, there is abundant research from different parts of the world showing that people with disabilities are more likely to have chronic conditions such as obesity and cardiovascular disease. They are more likely to be socially isolated and less likely to be employed. And there is also abundant research that participation in sport and recreation improves cardiovascular health, mental health and self-esteem, social integration and employment status in people with disabilities. Through the end of the 20th century and continuing today, Paris Sport has continued to see very strong growth in participation and worldwide attention, along with continual transformation of adaptive sports equipment. The recently concluded Paris 2024 Summer Paralympic Games had 4,400 athletes from 170 countries. The Paralympic Games are televised worldwide with substantial social media attention and advertising revenue. They are the world's second largest sporting event in terms of athlete participation. This recognition helps the IPC move toward its goal of increasing disability awareness, acceptance and accessibility worldwide. Alongside the growth in scope and attention, the Paralympic Games have driven incredible advances in adaptive technology. Compare the track racing wheelchairs on the left with the modern track racing wheelchairs of today. There are specialized chairs for every sport, including fencing, tennis, hand cycling and rugby. This kiddo is running on modern prostheses. Who knows what he will be running on when he makes it to the Paralympics. At the Nielsen Rehabilitation Hospital at the University of Utah, an innovative team of physicians, engineers and patients are pushing the envelope of what is possible in sport and recreation for people with more complex disabilities and more significant impairments. With the vision of the head of our spinal cord injury service, Dr. Jeff Rosenbluth, they are manufacturing high-tech adaptive sports equipment that anyone can use. This is a video clip of a C4 vent-dependent quad with minimal left-hand function sailing with his mom. He is able to use both a joystick and sip-and-puff programmed specifically for him to independently operate the sailboat. And here is another C4 vent-dependent quad with minimal left-hand function operating the TetraSki with a joystick. The TetraSki, which can also be independently operated with sip-and-puff and was designed and is manufactured at the University of Utah, is now in adaptive recreation programs in many parts of the world. In this video, Dr. Rosenbluth is loosely holding the tether cord as a precaution only, but the athlete is operating the ski completely independently. There is even now a TetraSki race series called the Brian McKenna TetraSki Express with the national championships held each spring at Powder Mountain in Utah. Oops. Okay. On the right is the adaptive sports simulation lab at the Nielsen Rehabilitation Hospital where patients and athletes can practice using the equipment in a safe, warm, and dry environment before taking it out into the real world. And currently in development is EMG-activated adaptive equipment demonstrated here by one of our therapists, which can take advantage of any motor function whatsoever that an individual may have that will allow them to independently operate the new adaptive equipment. In the final five minutes, I will transition from talking from my perspective as an academic physiatrist and a sports administrator to my personal perspective as a dad. Close up and very personal, my son has further deepened my belief in the power of sport to empower people with disabilities. Dylan is a really fantastic guy, smart, funny, strong, adventurous, best friend to many, including myself. He graduated from Carleton College with high honors and a degree in physics. He turned down a PhD program in physics to ski, climb, and pursue all manner of adventure. He feels very lucky to have had the chance to work and ski at Alta Ski Area during the 2022-2023 winter season when Alta received a record snowfall of over 900 inches. A little more than a year ago, on September 26th, 2023, he and his climbing partner were on the approach to a climb in Little Cottonwood Canyon called The Thumb. Both were experienced by-the-book climbers with good safety judgment. Unfortunately, they encountered rockfall and Dylan took a direct hit from a refrigerator-sized boulder with an estimated weight of 10 tons. He was knocked about 60 feet down, steep, rocky terrain. He was about to go off a 100-foot cliff when he arrested on a narrow ledge because his climbing rope, which was still on his back, had snagged on a bush. He was life-flighted to the trauma center. His injuries were extensive and severe, including a T4-T5 dislocation with Asia A spinal cord injury, or as Dylan likes to call it, an A-plus spinal cord injury. He also very nearly lost his left hand due to a both-bone open forearm fracture, donating a 3-centimeter piece of his radius to the wilderness. One of the trauma surgeons told my wife that any one of a half-dozen of his injuries could have killed him. The two orthopedic surgeons who stabilized his spine, both of whom are friends of mine and one of whom is the department chair, called me separately right after the spine stabilization surgery. They both told me that Dylan had among the worst spine traumas they had ever seen. When they opened him up from the back, they could see his aorta. Early on in his course, Dylan used the term karmic balance to describe his situation. He knew he was incredibly unlucky to be in that particular location at that particular time, and he also knew how lucky he was on so many other accounts. I don't particularly like using the word miracle, but perhaps it is appropriate here. It's a miracle that he survived. It's a miracle that his brain is working. He seems to be as sharp as ever, and it is a miracle they didn't lose his left hand, thanks in part to the incredible work of the orthopedic surgeon who reconstructed his form. This is a 3D CT reconstruction of his form, and you can see the lacerated radial artery here. Fortunately, the vascular supply to his hand was ulnar dominant and the hand stayed perfused. We are forever grateful to the Wilderness Rescue Crew, the trauma team, the orthopedic team, and the rehab team that helped him regain function. Since discharge, Dylan has not been sitting around feeling sorry for himself. He has really been getting after it, in part driven by a very strong desire to regain full independence, and in part simply because he loves the adventures of life. Because of the left forearm injury, we weren't sure if he'd be able to climb again, but he's back at it. His surgical team cleared him to ski at six months post-injury. This video is from his fourth day on snow last April. Although it was hard for him to go from being one of the best skiers in the Wasatch to a first-time beginner, he was really ecstatic to be skiing again and can't wait to get back on snow in a few weeks. Dylan graduated, Dylan started graduate school in mechanical engineering this past summer. He is already designing and fabricating improved parts for his wheelchair and other adaptive gear. He has talked about ultimately going into this field, and he won the table tennis tournament last summer in the School of Engineering. Two months ago, Dylan and his girlfriend, Mara, who has stuck with him through all of this, drove up to Calgary to pick up his new adaptive mountain bike, a Bowhead RX. They camped on the way up and on the way back, sleeping in the back of his minivan, which we modified for just that purpose. The picture on the left is at the Bowhead factory. Dylan has a huge smile on his face because he got his new bike, and also because he got to nerd out for the day about adaptive technology with the company engineers. He has since been down to southern Utah to ride on the world-famous Slickrock. A week ago today, he did a 60-mile gravel race in Fruita, Colorado. The adaptive mountain bike technology is really amazing. It gives him access to a lot of the nearly 500 miles of mountain biking trails in the Salt Lake City and Park City area. He had also come up this steep, rocky section on this trail that's just a few miles from our home. Dylan wanted to join us here today and tell everyone in person how important recreation has been to him in the first 10 months since discharge from rehab. But unfortunately, circumstances would not allow him to come. Hopefully, the smile on his face in these pictures conveys how uplifting sport has been for him. He did ask that I pass along a few things. Life is harder after his injury, and there are lots of barriers. It's now harder to get in and out of bed, to get dressed, to get in and out of the car. Recreation, on the other hand, is pure fun and makes him feel normal. Being injured can also feel lonely. In most settings, he is the only person in a wheelchair. Recreating with other adaptive athletes provides a very comfortable community for him. He is happy to now have two friend groups from before and after his injury, and the two groups recreate and socialize together. Finally, and perhaps most importantly, Dylan knows that not everyone is as fortunate as he is. Because of my work, he personally knew Paralympic athletes before his injury and knew what was possible with a disability. Also, he is very grateful to have three phenomenal adaptive recreation programs in the Salt Lake City area. But he is all too aware that too many people do not have easy access to adaptive recreation. Our physiatric community is ideally qualified to promote adaptive recreation and sport for people with disabilities across the country and around the world. A few closing thoughts to summarize. The neurologic system and the musculoskeletal system cannot be considered separately. They are intertwined, working together for functional activities. Physical medicine and rehabilitation uniquely lies at the intersection of these two biological systems, taking advantage of the understanding of both in order to improve function. Training in neurologic rehabilitation provides a foundational understanding of more subtle disorders of motor control that lead to many sports injuries. And training in musculoskeletal medicine allows all physiatrists to take better care of their patients with the entire spectrum of physical disabilities. Participation in sport and recreation improves overall medical health, mental health, and physical fitness. Participation in sport and recreation improves overall medical health, mental health, self-esteem, social integration, and employability for people with disabilities, in addition to improving their mobility and ADLs. The Paralympic movement increases disability awareness, acceptance, and accessibility worldwide. And para-sport drives innovation and adaptive equipment, thereby improving accessibility for all, including individuals with more severe impairments. And we as physiatrists are uniquely trained to promote participation in sport and recreation for people with disabilities. And I certainly encourage everyone to get involved. Finally, what would Para-Atsu say? Well, Para-Atsu says, recreation frees the body from the bonds of paralysis, which in turn frees the mind. Thank you. I'm going to give him another hug. All right. Do we have any questions for Dr. Willick? You can see why I wanted him as a fellow, and you could see why I wanted him as a partner, and why I was sad when he left Chicago. And David Steinberg has him now in Utah. Any questions for Stuart? I mean, you can see the strength, the resilience that not only he has, but he's obviously begun into the next generation of his family, too. All right. Thank you. With that, we are adjourned. Thank you, Charles. Fantastic.

Passor Legacy Award

musculoskeletal

neurorehabilitation

COVID-19

sports medicine

Paralympic Games

adaptive sports

neuromuscular control

physiatric care

disabilities