Just to give you a very quick overview, we have little highlights and tidbits from the performing arts medicine world, kind of a combination of introductions as well as current topics within performing arts medicine. And with that, I am going to turn you over to our first speaker, who's going to be presenting on the prevalence of pain and management of common musculoskeletal injuries in musicians. So we'll start with Jeremy Stanek. So Jeremy is a former professional trumpet player who is now a sports medicine trained physiatrist at Stanford where he is currently building their performing arts medicine program. All right, everybody hear me okay? All right. Are we good? All right. So thank you very much, Lauren. It's a pleasure to be with all of you this evening. I'm gonna try to go through this fairly quickly but still give everybody some good information. So I have no disclosures. When we are looking at pain amongst our musicians, let's start with the pros because most of the studies have been done looking at our professional musicians. Even though that's where most of the studies have been done, a recent review actually only found only 109 articles looking at medical issues in the pros and that's across all genres. Now, some of the pro studies have looked at fairly large cohorts, probably the most significant of which was done by Fishbein back in 1988. That's kind of our landmark study. Looked at a little over 2000 musicians and found that about a third of them had at least four or more what would be considered severe problems. There was another study that was done by Bronwyn Ackerman I believe it was in 2012, was looking at different professional organizations throughout Australia, showed that there was quite a much larger prevalence of pain with about 80% of Australian professional musicians had some kind of a pain or playing related musculoskeletal issue. Most common sites by far were back, right upper extremity and the neck. And you're gonna see some similarities as we go throughout the entire presentation. There was a German study done a few years ago by Gesenzer looked at publicly funded orchestras and that included radio symphonies, stage symphony orchestras, theater as well as opera orchestras. They had almost 750 participants in that study, 490 of which showed that they had chronic pain which they reported as being at least three months or longer. Over half of them reported having a quote permanent type of pain as well. They reported back pain more than any other area followed by the shoulder and then the neck. So similar to the previous studies that were done in the other countries. With this particular study of those with pain 17% reported having medical treatment, about 11% of those folks use medications of some sort about 7% use relaxation techniques such as yoga, Feldenkrais, Alexander technique, things like that. There were a smaller number of people who reported trying to either avoid the pain somehow or just flat out trying to ignore the pain. 70% of those people attributed their pain directly to playing their instrument. So a lot of people are getting pain and they associate that with their primary instrument. In this study, less than half reported knowing of any medical facilities that specifically provided care to musicians. So we physicians have some work to do on that front. And in that study, only 13% of the people that had some kind of a medical issue actually saw an arts medicine specialist. There was another study done fairly recently in the United Kingdom. Show that 86% of British professional musicians had pain within the last 12 months of the study. Again, with the most common sites being the neck, low back, as well as the shoulder. With this particular study, it was anywhere from one in 10 to one in five people reported having a quote, disabling pain at one of those sites. So you can kind of see that there's, not just a significant amount of people with pain but it seems like they're having a lot of pain that severely interrupts their ability to do what they like to do and their job in some cases. So we've talked a bit about the pros. How about our college students? And this is kind of a picture of what a typical college practice room looks like. So most of your collegiate musicians are going to spend a lot of time in a teeny tiny room just like this. I did a fairly large study a couple of years ago looking at prevalence of pain in college students. It was a two year study. Here are the numbers from the first year of that study. In that study, out of those thousand people, we found that over two thirds of college students experienced some kind of playing related pain. Most of them having pain both during and immediately after they get done singing or playing their instrument. Of those 75% with pain reported that the pain does affect their ability to play or sing, which was about half of all of the people who took the study. Over half of all musicians who experienced pain felt like they were being held back as a musician because of their pain. So this is really having a big impact on their lives. Just a little over a year ago, I repeated this study with a colleague of mine at one of the top US music schools. We actually found it at that particular institution, the prevalence was much higher. It was actually around 80% of those folks were having pain. When we look at stratifying pain, depending upon where the person ranks, like are they an undergraduate? Are they a graduate student or a professor? You can see that there are some differences here. So their pain does kind of decrease as you get farther along in your career. Now, why that happens, we could speculate at this point, but you have to wonder, do the younger players who have a lot of pain just quit playing? And so that's why the numbers start to dwindle or decrease as you get farther along in your career. When you compare these findings to some of the studies that involve the professional musicians, it tells us, okay, there are probably still some questions that we need to try to answer. Up to now, as far as I know, nobody has really studied how many aspiring pro musicians have actually changed their career plans just because they had some kind of an injury or some kind of pain associated with their performing. When we look at what types of instrumentalists or vocalists get pain, break it down into primary instrument or primary voice, woodwind players by far experience more pain than their counterparts, with 83% of woodwind players experiencing pain. And most significant out of that were flute and piccolo players, 93% of whom experience pain when they are playing. Interestingly, over half of all instrumentalists experience pain. And although fewer vocalists proportionally experience pain, it's still almost at 50%. So a pretty good chunk of people. When we look at the common sites of pain in our collegiate musicians, it's fairly similar to what you see in the pros with lower back and upper back being by far the most common. Actually, it's a little less than half of college musicians also with performance-related pain reported having the exact same kind of pain whenever they are doing daily non-musical tasks. So say shoulder pain or forearm pain whenever they're opening a jar, typing on a computer, doing things like that. When we look at whom do these people approach whenever they have some kind of a problem, it's not very surprising that the first choice of the person that they go to is their primary instrument teacher. But you have to remember that most primary teachers have zero medical training whatsoever. So are they getting the best recommendations? Maybe, maybe not. The kind of thing that really I think hit home with me was that the second most popular choice all across the board was for people to not seek help from anybody. And that's where I think we have a problem that we can really try to address. Even among teachers, about 41% of teachers who get some kind of an issue will go seek help from a medical provider. However, the second most popular choice is to not see anybody at all. And sadly, out of all of those musicians who do seek help from somebody, only about half of them are actually satisfied with the results that they receive from seeing that person. When we look at the different types of treatments that musicians are using, a good amount of them will decrease their personal practice time or change their playing technique. About a third of musicians will do nothing different. Treatments other than rest and changing their technique, as you can see, are pretty varied. But most of them will rely upon insets or use ice and heat to help their pain. And you have to remember that injuries can happen to anybody. It doesn't matter where they are in their career. And you can see by these previous numbers that it really happens all over the board. When we look at the types of injuries that are out there, some of these things kind of are common sense, like your musculoskeletal injuries, because you have a lot of musicians who are doing repetitive use, so they're gonna get tendinopathies and things of that nature. Brass players are always pushing a big chunk of metal against their face, so that kind of goes without saying. You will hear about some other examples of specific injuries from some of the other speakers coming up a little bit later. As we go down the line, I think a lot of people don't think about eye issues, but as you can see by this picture, eye issues do happen in trumpet players. Psychiatric, I think that's something that a lot of people don't give enough emphasis to, or at least think about it a lot. When we're looking at musicians who come into our clinic, you have to think they're under a lot of stress, they may have nervousness, performance anxiety, body image disorders, self-esteem issues, and you really have to think about that when you're treating the performer as a whole. The ACSM has proven that low levels of self-esteem and sensation, or sensation seeking rather, has been associated with a greater risk of depression, anxiety, negative physical symptoms, all of which can impede performance of the musician. Stress consistently demonstrates a relationship with both injury and ability to rehabilitate from an injury. And there's also a fear of re-injury amongst all performers. And there is a strong correlation of musicians between their self-identity and how they're playing with their instrument. When we look at some of the contributors to injury, these are gonna be regardless of where they are in their level of training or if they're a professional. Equipment is a huge thing. For example, look at this little kid with this tuba. This tuba is obviously way too big for this kid. So some adjustments need to be made, whether it's changing how he's approaching the instrument or maybe the instrument size itself. All of these other things, posture, technique, these are things that you can evaluate in your clinic. When we think about joint laxity, as you can see from that picture on the right-hand side, it's not just your athletes that you see who can get joint pain from excess laxity. Your musicians are also really susceptible to getting injury for the exact same reasons. Other things, time playing, warming up. When we look at time playing, you really have to think about everything in that regard. It's not just their individual practice time, but also all the time that they spend in rehearsals and concerts. All of that adds up together. A lot of people forget to add up how much time they're actually making music on a daily basis. And importantly, both fatigue and injury are related to time spent on the activity in an exponential manner. Warming up, musicians are pretty notorious for not warming up properly or not taking enough time to warm up. And that can really be a big factor in leading to an injury. When we think about the repertoire or the type of music they're playing, are they trying to play something that's way too advanced for them at that time? Because less skilled musicians are more susceptible to pain and injury. What are the performance conditions that they're in? Are they playing outside in freezing weather? Are they in really hot weather outside? Are they playing in a cramped space? These are all factors you have to take into account. And what do they do outside of making music? Musicians are just as easy to go out and do recreational activities that can lead to an injury that may prevent them or at least inhibit their ability to play their instrument. When we look at our collegiate musicians, there are a few other things that they have to really think about. A lot of collegiate musicians are in multiple ensembles. And so that really adds up to the amount of time they're playing on a daily basis. And when we look at the amount of time they're playing, unlike our NCAA athletes, collegiate musicians don't have any kind of regulation as far as how much time they have to take off or how much time they can practice in a given day or a given week. Also, these collegiate musicians are dependent upon playing in a certain number of ensembles to maintain their scholarships as well as their grades. And so there can really be a lot of stress and a lot of factors that are pushing against those musicians to always keep playing and not take time off if they do get an injury. Also, especially if they're at a smaller school, they may not have enough personnel to get a substitute or fill in for them, or even have someone who is good enough to come in and play that part for any performances. So they're not only kind of having to think about themselves but think about, am I letting my ensemble down and letting my colleagues down if I can't play this part or if I have to try to take time off? And then another thing to think about are all of our teachers that are out there. A lot of teachers like to do a lot of modeling whenever they are in lessons with other students. And so they usually don't think about adding that up into the amount of time that they're playing on a given day or on a given week. And so even modeling to other students can really add up a lot and can make you more susceptible to injury. So some other folks are gonna be talking about some of the other injuries. This was just kind of a brief overview of some of the factors that can lead to that and kind of what the prevalence is just to get the mind going. Here are my references. Thank you all very much for letting me be here and take part, and we'll send it back to Dr. Elson for the next round. Thank you, Jeremy. All right, next up, we have Dr. Scott Homer. So Scott is a physiatrist specializing in the management of hands and upper extremity, musculoskeletal and nerve disorders at Brigham and Women's Hospital and Spalding Rehabilitation. He particularly loves to help musicians and others to help participating in activities that they love. Hello. So I'm going to talk about getting the diagnosis right. It's really important, and that's something that was mentioned in the previous talk that sometimes musicians are not going to the right source in order to make sure they have the right diagnosis. So I'm gonna talk a little bit about that. So musicians are not going to the right source in order to make sure they have the right diagnosis. So they may get advice that's not necessarily the appropriate advice if they have the diagnosis wrong. For instance, a lot of people pass around the diagnosis of carpal tunnel, and if that's the right diagnosis, then they can do the appropriate things, but sometimes they have hand pain and then they refer to it as carpal tunnel. So it's important to get it right. So we're gonna talk about some of the things that I've learned in my practice of how do I differentiate between different diagnoses. So first case is a 45-year-old woman who's a violist, presents with intermittent numbness in the whole hand. So it's bad in the right hand, but starting to have some on the left as well. And when asked about it, she also mentions at night, she gets some hand pain as well. She also notices that when she plays for about 15 minutes, it starts to get tingly in the hand. So this is something that should certainly bring to mind the possibility of carpal tunnel. Now, it's important when trying to diagnose a nerve entrapment to think about the distribution of the sensory nerves of that nerve and being able to differentiate. And it's important to ask which fingers are involved. So with carpal tunnel, it's the radial most digits, including part of the ring finger and the sensory branch in the palm, while theoretically useful, doesn't tend to be as useful clinically, as well as the muscle innervation to the thenar muscles. So it's important to ask specifically whether the patient is having any numbness and tingling or tingling pain. If someone just has wrist pain, they don't have carpal tunnel syndrome and it's time to move on looking for another diagnosis. Someone describes their hand falling asleep, that's classic. The thing that can be tricky about it is people don't always have the perfectly anatomic symptoms. And so it may be, they may describe it as being in the whole hand, which would include the pinky, which is not anatomically supposed to be from the median nerve, or it may just be a couple of fingers and that may be confusing. They may also have some symptoms going up the forearm. As was mentioned previously, musicians also have other activities that's important to remember that. So if they ride a bike or use the keyboard a lot, these things can bring out issues that non-musicians have that musicians can get as well. So leaning on the handlebars can bring out carpal tunnel symptoms actually more commonly than it brings out an ulnar nerve symptoms. Another thing is people can describe clumsiness in the use of the hand or the fingers, and that can really come out in playing an instrument. And as much as this has been able to be elucidated, it's typically more of the sensory impairment that results in the clumsiness rather than actual weakness in most cases. And in more advanced cases, it's important to take note of whether the patient is having constant numbness or if they're also having actual weakness in the thenar muscles. Once you get to that stage where the numbness is there 24 seven and it doesn't go away even with rest, then you're starting to approach the possibility that even if you got surgery, you may not get 100% recovery. And so you don't wanna put it off too long, which some people do because of fear. It's important to distinguish from other possible diagnoses. So someone who maybe has diabetes or someone who doesn't have polyneuropathy, it's not that hard to distinguish it. So even if they have it in both hands, if you just ask about their feet, if they're not having any symptoms in the feet, then it's not a length dependent polyneuropathy. This can also be delineated with further testing. Another thing that comes up a lot is, could it be coming from a pinched nerve in the neck? Well, important questions to ask are, does the neck position ever affect the symptoms? If you lean your neck to the side, does that tend to bring it out? Does it involve the dorsal aspect or the back of the hand or the forearm, or is it mostly the palmar side? Ridiculopathy often includes some of the dorsal or entirely dorsal part of the hand and into the forearm, which is not the case with carpal tunnel. And if it's bilateral, it's not likely to be a ridiculopathy because bilateral ridiculopathy, especially in the same distribution would be rare unless there was a particular neck injury. But bilateral carpal tunnel is very common. And then thoracic outlet symptom is something that comes up a lot. And a lot of people have different opinions about this. I would say, taking a step back, thoracic outlet is a very hard thing to prove. And so I think it's more useful to zero in on the more provable diagnoses such as carpal tunnel or ulnar neuropathy or even ridiculopathy and rule those out. If it's none of those, then thinking about thoracic outlet makes a little bit more sense. Thoracic outlet would typically be in the pinky and not so much carpal tunnel. So it wouldn't typically be a carpal tunnel mimic as much. If your approach to the presumed thoracic outlet is trying physical therapy, well, you really haven't lost much. If you're thinking about surgery, you should be very cautious. So on the exam, you try to really do what you can to delineate one thing from the other. So if you feel the thumb or the index finger and compare it to the pinky finger and ask if there's any difference, that can be a little bit easier for someone to tell you versus just asking if they feel things 100%. And you can test the thumb abduction and opposition strength. Sometimes people think they see atrophy and it may not be, especially if they have CMC arthritis. But if a person appears to have atrophy, then they ought to also have some abduction strength. And if they don't, then the atrophy may not be real. A very useful test is combining the carpal compression test with the wrist flexion test, which has been shown to have much better sensitivity and specificity compared to either test alone or with Tinel. So that's an example of that. Here's an example of thenar atrophy. One thing that's becoming much more common in practice now is a diagnostic ultrasound. And if you're on the fence of whether or not you need further testing, in the past, it would have been like, okay, well, should I order an EMG? Well, that's expensive and it hurts. If you have ultrasound right in your office, you can just check. You can check for nerve swelling at the wrist. And there are various cutoffs out in the literature. I've chosen to use cutoff of 12 square millimeters. And you can also check the ratio with the forum. And it sort of depends on how sensitive versus specific you wanna be, what your chosen ratio is gonna be. It could also be really helpful when people have a hard time describing their symptoms or whether you're concerned that they may have some type of inflammatory synovitis or a cyst. Or if the electrodiagnostic studies were confusing because there was peripheral neuropathy kind of slowing everything down, you can actually check with the ultrasound to see if there's focal swelling. Or in the case of someone who's already had carpal tunnel surgery and they're having recurrent symptoms, you can take a look what's going on there. So here's an example of an enlarged nerve on the top and a normal nerve on the bottom. And then on the right side is the long axis of the normal at top and the abnormal thickened nerve on the bottom. So when should you get an EMG instead of using the ultrasound? Well, a lot of times you really don't need it. If you're comfortable, you see this condition often. It's clinically straightforward. It really doesn't necessarily change what you're gonna do very much. But when the cases are unclear, as I said before, people have a hard time describing which fingers are involved or have a hard time describing whether they're having pain or numbness and distinguishing from other conditions. Now, even though it can be helpful in many cases, it's also important to remember that EMG is not particularly sensitive for mild radiculopathy and it's not particularly sensitive for mild ulnaropathy. So if you get the EMG and it doesn't show either of those conditions, it really doesn't rule them out. So you end up falling back on your clinical evaluation. And if someone is really reluctant to have surgery and they wanna wait, well, you may wanna get an EMG just to see how bad it is. If it's mild, you may let them wait versus if it's severe, you may encourage them a little more strongly to go ahead and get surgery. Initial treatment can start with activity modification. So if someone gets symptoms only when they play, then you try to get a sense of how long they play until they start to get the symptoms. Of course, you're also gonna look at the posture and the ergonomics and the amount of tension they're playing with and all those things that you would do for every musician. It may be that by improving those factors, you get rid of the symptoms, but it may be also that every time they play 15 minutes, they start to get symptoms. And in which case, if you have them take a break before that and they're not continually aggravating the nerve. Also wearing splints at night can be very helpful because people tend to bend their wrists while they sleep. Steroid injection is not a permanent solution, but can help delay surgery, can help illuminate the cases when you're having a hard time deciding which nerve is compressed. And in some cases, it can last a good deal of time. If people are doing everything they can that's non-surgical and it continues to bother them, especially if they want to get it taken care of, it's reasonable to proceed with the surgery. If they are having permanent sensory loss, you really wanna advise them that if they wait too long, they may not get 100% recovery. So I think, although there are a lot of great things we could talk about, we have limited time and so we can stop there. But I just wanna emphasize the importance of getting the right diagnosis. And somebody who has only discussed it with their teacher, or maybe in some cases, their primary care, if they don't have a lot of experience with this sort of thing, people can go on for months or years with the wrong diagnosis. People go on for a long time with a treatable condition that they're not treating because they don't understand what it is or they're afraid of the treatment and sending them to someone who really understands these things and becoming that person yourself, you can really do a really valuable service to these patients. Thank you so much, Scott. We're going to transition now to Dr. Yun Lee. And before we do that, I just wanna welcome those of you who have since joined us. And also to remind everyone that if you would have any questions, please put them into the chat. And when we start our Q&A panel and panel discussion, I will start with those questions. Okay, I'm gonna introduce Dr. Lee. She is an assistant professor at UNT Health Center, Health Science Center. And she has the pleasure of working with performers in the Dallas-Fort Worth area. And is very excited to be joining this group of physiatrists today to talk about performing arts medicine. Hello, everybody. So I will try to talk very fast as much as I can to talk about focal dystonia, musician's cramp. During last year's community day, we had a lot of questions about focal dystonia. So this year we decided to dive into this topic a little bit more. I think physiatrists may be one of the first physicians to see these patients with focal dystonia. And I think physiatrists are also probably one of the most qualified to be the leader of a treatment team to help musicians recover from this really serious condition that often crushes their career. I have no disclosures. Just briefly, historical perspective. Many say Gower's description of tetanoid chorea of a patient with Wilson's disease was one of the earliest attempt to describe dystonia. Later in 1911, Oppenheim also described dystonia as muscular deformance. Apparently at this time, many physicians thought focal dystonia had psychiatric origin. We have a more comprehensive definition now. The current definition of dystonia is movement disorder characterized by sustained or intermittent muscle contraction causing abnormal, often repetitive movements, postures, or both. So focal dystonia is dystonia of a single body part and it's many different forms. So of course, as physiatrists, we're very familiar with cervical dystonia, by far the most common focal dystonia we see. And some neurology texts also filed busbar spasm and oral mandibular, lingual, pharyngeal, laryngeal dystonia under umbrella of cervical dystonia as well. Of course, we see oral mandibular and sort of that oral dystonia in performers who use speech and voice, such as singers, teachers, preachers, or lecturers like myself. But I'm going to focus more on instrumentalists today. The musician's dystonia or musician's cramp is a task specific disorder. So the patients must perform a specific type of movement of their art form to show you the signs of dystonia. For instrumentalists, symptoms will present itself as muscular incoordination or loss of voluntary motor control, extensively trained movements while the musician is playing the instrument. This is really disabling and it's devastating and sometimes terminates musician's career. So prevalence of focal dystonia, including writer's cramp, busbar spasm, cervical dystonia is about 30 out of 100,000 patients. So if you are looking at Dr. Alton Muller's 2000, I believe, three paper, he is one of the mostly studying focal dystonia experts. He is over at Hanover, Germany. He says about 1% of professional musicians are affected. So focal dystonia is really rare and we won't really see dystonia very often in our offices. But keep in mind, compared to other occupations such as call for writing, musicians are at a higher risk to develop this disease. So let's talk about the features of focal dystonia. The symptom onset is about mid thirties, although this is really variable. The youngest patient I saw was about 18 years old pianist. Unfortunately, many of these musicians exhibit symptoms around the age of mid twenties to mid thirties, which is sort of like right at the highest of their careers, which makes things so much sadder. More males are affected than females. There's no pain. However, there can be some muscle aches from prolonged spasms. Lack of pain should help you distinguish from repetitive strain injuries or plane-related musculoskeletal disorders. Patients will tell you about subtle loss of control, lack of precision, fingers curling, irregularity as trills, fingers sticking on keys or strings, involuntary flexion of the fingers or bowing thumb if you're seeing a string player, and the impairment of control of embouchure, which is what we call correct application of lips, facial muscles, and tongue playing wind or horn instruments in certain registers. So focal dystonia is overwhelmingly affecting classical musicians compared to jazz musicians, for example, which is, I think, super interesting to me. I'll talk about it a little bit later about this. And then many musicians think that their problem is due to like a technical problem or lack of practice. So they start to practice more, which makes their symptoms worse. This picture, of course, is a famous pianist, Leon Fleischer. He suffered from vocal dystonia. And in one of his many interviews, reflecting back to the beginning of his disease, he said he was desolate, his life fell apart. I think this quote tells us your patient's state of mind when they come to see you for the possible diagnosis of this disease. And I think it is really our responsibility to help them see that although it's really difficult, there are some treatment options available for them. So it wouldn't be a dystonia talk without any videos. So I'm gonna show you some examples, starting with piano and guitar. Ideally, you should be seeing these patients in your office, but of course your patients can bring piano into your office. So I sometimes ask them to bring like a video of them playing. This is all from YouTube. Let's listen to this pianist. ♪♪ Did you see it? I think so. This is a really good example of a dystonic keyboard right hand. Of course, right hand is more affected in pianists, but this video is not really typical because patient's second digit seems to be more affected as opposed to sort of more common digit three to five. Also, you see bilateral hands. Now, um, for guitarists, right hand is more. Did you see how symptoms worked? So, but many think that focal dystonia patients may have a genetic disposition that is amassed by intrinsic and extrinsic triggering factors. So intrinsic triggering factors seems to be perfectionism, anxiety, need for control, as well as reduced inhibition, altered sensory motor integration. So the theory of reduced inhibition in the sensory motor system as a cause of focal dystonia has been around for quite some time now. This has been shown by transcranial magnetic stimulation, and this abnormal cortical inhibition is seen in both hemispheres, interestingly enough, even though most patients have unilateral symptoms. And so kind of a reason why many think that there are more generalized or genetic reasons why they would have this disease. Ultrasensory perception theory also has been suggested by many because patients start to show symptoms of focal dystonia after injury, trauma, and overuse. Extrinsically triggering factors are determined by nature of the musician's discipline. So for example, classical musicians are more affected, like I was saying before, and jazz musicians less so. Even if they're affected, jazz musicians are sometimes able to change the passage that trigger their dystonia, or they somehow improv out of these dystonic postures, which is fascinating. Another example of intrinsic triggers can be demonstrated by the fact that violinists would have more issues with their left hand, their fingering hand, with a greater load in work, while the guitarist will have the right hand that's more affected, where they have more workload there. So we've seen our patients, and we've diagnosed them, and then we had difficult conversation of this diagnosis already. Now what do we do, right? First we need a multidisciplinary team. If the patient does not have a neurology specializing in movement disorders, I usually start with a referral. We also need help from psychologists, PTs, and OTs who are familiar with focal dystonia musicians. Although not very commonly used, you could start oral medications like Artane or Baclofen or Phenethoin. If you're one of those physiatrists who have a very robust spasticity management practice, toxins can be really an enormous tool for these patients. One thing to keep in mind is first, observe the patients when they play. This is crucial. Secondly, examining what is the primary dystonic movements and separating out some of the compensatory movements. This is kind of difficult, actually. We have to observe them play multiple times on several occasions, making sure that we inject the primary dystonic muscles with toxins. Some studies say that toxins are better for forearm muscles, not as effective for dystonic embouchures or upper limb region. There are a few specific rehab strategies. I think I'm kind of running out of time, so I'll just briefly talk about sort of the umbrella theory. So, a lot of PTs and OTs kind of utilize multiple different types of rehab where they constrain the either affected fingers or unaffected fingers with splints and keeping them and putting them through therapies where they train motor speed, motor strength, and different stages of sensory discrimination. One thing for sure is that I spent a ton of time talking about lifestyle changes. The type A personalities, I don't know if you understand musicians, but they are very type A. They're perfectionists and the constant need for practice has to change. We talk a lot about sleep, diet, exercise, not staying in their studio for like six to eight hours in a whole, time practicing. We try really hard to convince them we need to help their brain to recover, and these are lifestyle changes that is necessary for their brain. I also counsel a ton about mindfulness and body awareness, and at the end of the day, the treatment needs to be tailored to individual patients. It is really a long journey for you and your patients. In summary, although difficult, focal dystonia is treatable, brain is plastic, and it is important for our musician patients to know that this diagnosis is not what we call kiss of death. It is a learned disorder, so your brain can unlearn it. I think we need to be that cheerleader for our patients so they can stay optimistic. They go back to playing, and some play even better because they have gone through this painstaking hours of understanding their playing habits, and they really put in the work to increase their body awareness. Because we don't really have a silver bullet treatment for dystonia, we and our patients really need to stay optimistic and open to different treatment options, and we need to help them stay resilient through the recovery process. And finally, for the same reasons, we should be willing to try everything, as recovery takes a year or sometimes longer, and the recovery is really not that linear. Thank you for your attention. Thank you so much, Dr. Lee. All right, now we are going to switch gears a little bit and have a couple of short talks in the dance world before we get to our question and answer and panel discussion. And really, one of the big things that we wanted with this session was to allow for time for networking, because really that's what these community sessions are about. Next I'd like to introduce Dr. David Popoli. He is a sports and performing arts medicine physician at Wake Forest Baptist Hospital and also works closely with Wake Forest School of Medicine to provide musculoskeletal education. Thank you, Dr. Elson. I will bring up my screen. So I'm going to switch gears a little bit. I'll be talking about injections and dancers. This is the who, what, where, why, when, and how. I do not have any financial or conflict of interest disclosures. I will tell you, though, that I have a cat who likes to be involved in video teleconferencing. So if she appears, I apologize in advance. My other disclosure is this is not intended to be a comprehensive literature review, nor is it intended to be a specific expert talk about the way that you should treat your patient. Really, what I'm hoping to do with this presentation is go through some interesting pieces of medical literature in an effort to spark discussion. I know there's a lot of people on this event, and so I'm really hoping to spark discussion and welcome your comments and questions. I'd also like to see how you all might feel about ways that we can either improve care or improve the quality of the research that we're doing. The first major thing we need to talk about is who is the dancer, and how is this different than a different athlete? Unfortunately, there's really a paucity of evidence when it comes to injection therapies and dancers. In fact, if you put the terms injection and dancers into PubMed, you only get about 25 hits. So unfortunately, we're a little bit reliant on parallels to other athletes and trying to generalize that information to treat dancers. There definitely are some parallels. Dancers have extreme loads they place on their body. They have massive psychological loads, physical loads. They're different, however, because their biomechanics are different. The way they load their bodies are different. The other big difference here is that dance is predominantly a female-dominated sport. So if you look it up, it's anywhere, depending on which study you're reading, up to 80% of dancers are female-dominated. 80% of dancers are women. In this study that I'm going to just point to with my cursor here, there is some suggestion based on some of the physiology that the biomarkers for tendon injury in women are different than the biomarkers for tendon injury in men. So these studies that are predominantly male, is that really generalizable over to the female population of dancers? The other issue with medical literature is often there's age cutoffs. A lot of the studies will cut off people under the age of 18. And dancers as a group, many of them are 18 or under. In fact, most dancers have retired by the time they're in their mid to early 20s. And so this creates a problem with generalizing the material that we read about. It also brings up thoughts about skeletal maturity and tendinous maturity as we look through some of the injectates that we use. What specifically are we using? This study that was published in PMNR in 2019 brings up some concern about local anesthetic. So I think a lot of us use, if we're not using exclusively local anesthetic, we're often combining it with something else. This is your lidocaine, rapivacaine, bupivacaine. And unfortunately, it does seem as though some of those medications are directly chondrotoxic. And in fact, it's inversely proportional to cost. So lidocaine, which is the cheapest, seems to be the most chondrotoxic, followed by bupivacaine and then rapivacaine. This study by Whitaker goes one step further. And unfortunately, there is some concern that corticosteroid injection, when combined with local anesthetic, can actually increase chondrotoxicity. The information about corticosteroid injection overall is pretty broad. I think the literature has been very mixed about how effective it is for treating pain or improving function. But certainly, I'd love to hear what people's thoughts are about corticosteroid injections. Hyaluronic acid, also in its derivatives, certainly coming around. And prolotherapy, which is sort of interesting, had kind of been in the background for some time and is now making quite a bit of resurgence, perhaps because of this concern for chondrotoxicity. I think most of us, though, are probably most familiar and most excited about PRP and stem cell as being regenerative therapies, something to kind of be able to heal that unhealed injury Unfortunately, with PRP, and this is not to say that PRP doesn't work, but there's a lot of heterogeneity in the studies about PRP. And part of that is derived by how do you do the injection? Is it ultrasound guided? Is it leukocyte rich? Is it leukocyte poor? Are you using a lytic agent? Is it combined with physical therapy afterwards? So I'd like to point to two of these studies, the YAN study and the CHEM study, that actually ended up showing exactly opposite things. Both are high-concentration drugs. Both are high-quality studies. But the YAN study says leukocyte poor, PRP is the way to go. The CHEM study says leukocyte rich. So I guess as a provider thinking about doing PRP, make sure that you have a good understanding of the protocol and sort of be cognizant that there are a lot of differences in the way that PRP is performed. Stem cell therapy is very similar in terms of lots of heterogeneity in the literature. I would like to hear people's opinions and thoughts about Botox. So I think Botox is another one of these materials that's making its way back into practice. I've seen people been using Botox in terms of treating muscle inhibitions in people who have had chronic pain, and that seems to be actually quite beneficial. With dancers, where are we doing these injections? So you can pick your favorite target. There are lots of them. So there's the spine, both intraarticular and then either an intralaminar or transforaminal epidural. Certainly joints are injection targets. For dancers, one of the more interesting and I guess more dancer-specific target is that first MTP. But like other athletes, we're also talking about hip, knee, ankle, et cetera. I think in dancers, I wouldn't say more than other athletes, but definitely the vast majority of the injections that I have done in dancers have been tendon sheath. And again, this is going to be largely based in the lower extremity. But one of the places that's sort of unique too is the plantar fascia. And the only other athlete group that I see commonly mentioned with respect to plantar fascia injections are runners. So that's another distinguishing factor for dancers. When you're considering working with a dancer and possibly doing injection therapies, this is probably the most important question, which is why are you doing the injection? Is it going to be a sole therapy? Is it based on trying to reduce pain? Are you looking to improve function? And is it going to be combined with other therapies? If you're just doing an injection to try to get someone over the hump and through their performance season, that's one thing. But if you're looking to have that dancer-derived long-term benefit, certainly something else. I'd like to point you all to this study. This is actually quite a good study, JBJS, looking at the minimum clinically important difference. And it finds that actually how we define minimally clinically important difference is actually very challenging and very diverse within the literature. So one of the things that I would offer to you all as part of this networking conference is what do you feel like is a minimally clinically important difference? Because as we're reading through literature, our tendency is to go right for the statistics and say, hey, listen, that looks like a statistically significant difference in pain or a statistically significant difference in function. But is it clinically important and is it clinically relevant? When are you doing the injections themselves? So I think one can make a case for any of these. Again, if you're doing the injection with the intent of getting a dancer through his or her season, this I will point to you actually is in the Journal of Dance, Medicine, and Science. This was a dance-specific study. Unfortunately, it is rather small. This was only a 19-person study. But it did show that 18 of the 19 dancers were able to go back to dance and 13 of those 18 within six months. So there is some benefit, perhaps, of being able to do an in-season injection. One could also make an argument, and I'd like to hear people's thoughts on this, of whether there's a reason to do injections in the off-season. So particularly if you're intending to combine your injection therapy with a tailored and specific rehab program, there might be benefit in waiting until you've got that block of time in order to then pursue rehab after the injection. Chronicity comes up a lot. So I hear questions from dancers, how long should I wait to get an injection? Should it be six months that I have pain? Should I have tried other things? The answer, unfortunately, there doesn't seem to be a great answer or at least nothing overwhelming. There does seem to be at least some suggestion within some of the meta-analyses that are out there that if you're doing injections inside of six months, maybe those don't, there's less support to say that that's the right time to do the injection and perhaps waiting and trying to see if people can get through other therapies first. The last big element is how we do the injections themselves. Certainly landmark guided injections are possible, although with some of the biologics, one could make an argument than going more for ultrasound guidance and looking for specific findings to inject might be important. I would say that there's some challenge here though because all this dance this study from BJSM says that a lot of dancers have abnormal ultrasounds at baseline so it becomes challenging if you're looking for specific ultrasound findings and redo the injection but a lot of those dancers already had those ultrasound findings even in the absence of necessarily having pain. You're in a little bit of a quandary. I would say there's lots of evidence that suggests the accuracy of injections when performing ultrasound guidance is much superior. I'm sure there'll be conflicting thoughts from the panel here and from the audience but I would encourage people definitely to be thinking about using protocols particularly if you're going to go for an orthobiologic and combining those with therapy. Thank you. Thank you so much Dr. Popley. We're going to do a transition now into what's all on our minds which is having our performing artists return to performing arts in the time of COVID. When we were restructuring the talk going from three hours down to an hour and a half and trying to figure out how are we going to cram so many topics and excited to try to put something that's a little bit new and a little bit different and hopefully can spark some discussion and see where people are at with this as well. I don't have any disclosures. Before we get started I just want to do a quick poll so you should be seeing a poll pop up on your screen right now and I want to know if you are seeing dancers what type of dancers are you seeing? Are they children, professionals, pre-professionals, adult students and then wherever you are in this country or maybe even now that we're virtual internationally what are your dancers doing? So are they 100% virtual right now? Are they actually back into the studios? I'll give you guys a few seconds to get these out. So right now we're at about a quarter of you have voted. So right now it looks like we're trending with most people taking care of the children adolescent dancers with a handful of older pre-professional and college conservatory as well and really a mix right now. You know several people are still virtual right now but also several are in the studio without precautions. All right this is a particularly important topic right now as physiatrists are now being seen as the go-to's for dance medicine or trying to become the go-to's for dance medicine. We want people to come to us and ask us these questions as we become the team physicians for companies. Very briefly we're going to talk about the toll of COVID-19 on dancers and then some logistics in terms of returning to the studio and current performance realities and then also just so you have some resources if you need to refer back to these things later. In general dancers careers are extremely uncertain. If they're not like physicians where once you get into med school and you put all that time in it's likely you're going to have a job. With a dancer they can train their entire life they can make it to the top one injury and that's the end of their job. Also many dancers work within the gig economy so if there's no gigs happening there there is no nothing to work for. In general there is less money in the arts so when when money is strapped those are the first things to go. Dancers also really have a very strong identity within their profession as well as their very often their social network within this profession. For the professional dancers there are particular challenges going on right now that that actors equity or the actors union which is designed to protect dancers right now has several stipulations which make it so the dancers and actors can't perform without certain standards which is great for the dancers however what's been happening in this field is that very a lot of theaters are sidestepping this and hiring non-equity or non-union performing artists so this is hurting both the non-union performing artists and that they're working in unsafe conditions and also the union artists are not getting work. Also within this you know it's different than with musicians so you know whereas a musician might not be able to perform during this time and they might not be able to practice with their groups they are able to practice full out whereas dancers can't unless they happen to have a dance studio within their house there's going to be decreased space different floors so if they're a tap dancer they need a particular floor if they're going to be jumping they need to have a sprung floor and also many of them do cross-train with either Pilates reformers or other types of weights or props and at least at the beginning of COVID weren't able to practice with partnering. One thing to recognize is that guidelines are always changing I know that within Massachusetts starting on Friday we actually regressed a little bit but we have general recommendations and most of what I'm going to be presenting is from the papers put out by Dance USA Task Force on Dancer Health so these provide some good guidelines for recommendations in terms of dancer safety. At the beginning with phase one and phase two it was recommended really only virtual practice but as we've been able to progress while certain public facilities are closed we have been able to get dancers back within bubbles or pods and we'll talk a little bit more about that and I'll talk also a little about the different phases of a dance class and how those can be adapted. Within the dance companies there are a lot of ways to regulate who is entering the facility and it has been recommended to at least have the dancers attest to not having any symptoms. Also recommended are potential temperature checks which we know don't really catch the asymptomatic or early carriers and also screening for increased fatigue which is great theoretically but if you ask a dancer if they have increased fatigue when they're getting back to the studio I think you'd be hard-pressed to find one who doesn't have increased fatigue. It is really important that anyone with any kind of symptom self-isolate until it can be confirmed whether or not they have it. For dancers that are going to be in the studio for the full day it is recommended to consider twice daily symptom checks. Also was recommended to possibly check the oxygen saturation as that may decrease before other findings. Again this is not scientifically proven yet but may be a good screening tool. To keep all of our dancers safe we really need to have everyone be treated as an asymptomatic carrier and there are different ways that this can be done. For example especially for dance studios it's important that the dancers not really utilize the waiting rooms and lobbies for socialization as they might have before so they can wait outside or in the car before class. If the classes are spaced out then dancers can enter and exit the studios a little bit more spaced out. Gone are the days where we would all peek through the door and watch the class before us. We encourage dancers to come dressed and to wear their street clothes on top of their dance clothes so that they're not using the dressing rooms. Within the bathrooms certain stalls can be taped off to decrease the capacity. I know that for some dance companies they have the dancers put their belongings at the bar and within the dance studio the bar section is sectioned off every six feet so the dancer's items are six feet apart they're dancing six feet apart and then also for floor work you can tape out grids on the floor to maintain distance. At least for phase three it's recommended not to do what's called across the floor work so within several different types of dance class dancers move across the floor and typically it would be done one dancer after another or one group after another. So a way that could be that this could be gotten around is to have two different groups standing next to each other and then have one group go and then the other group the other go. It's really important that dancers wear masks. All the major dance companies that are rehearsing now do this. Dancers need a new mask or a clean mask every day and wet masks do need to be replaced. If the dancer needs to take off a mask they need to move away so they're at least eight feet from the dancer next to them. We also know that we need to work on decreasing tactile transmission so having enough hand sanitizer around is necessary and there are also you can find the CDC guidelines for decontaminating the bars and doorways and other high touch surfaces. Typically in a dance class an instructor would be giving tactile cues so these will have to be minimized during this time and it is recommended that the floor be cleaned every day but if you have dancers that are doing a lot of floor work then the floor should really be cleaned in between classes or in between rehearsals. Some of you are lucky enough to live in places where you can open the windows all year round or at least now. In New England we are moving into the time of year when this is not possible so figuring out what types of filters you have are they high enough capacity to turn around the air as frequently as you need to. Classes can again be spread out. If you have live musicians having shields up to separate the musicians can be helpful and another thing to think about is singing and projecting have been correlated with with virus spread so decreasing the music volume so teachers don't have to shout over it can can be preventative as well. There are different ways of isolating the dancers and I know that for several of the studios that I work with here especially the higher level groups have made different pods of dancers so the kids perform or rehearse in groups of six to ten. Even the professional dance companies are doing this the ones that have a ton of money are just like the NBA and having a bubble and living and residing together but for those of them who can't do that then that there are pods of six to ten dancers that that meet together every day and for them there are actually social contracts they have to their partners actually have to sign these contracts as well or anybody else that they're living with so it can get quite complicated but it's very important so that there isn't an outbreak within a company. This does impact who the dancers can be partnered with it does have an effect on the choreography. When the dancers are coming back into the studio it's important to recognize that you know although this might not be an actual injury a lot of them are not going to be in the same shape that they were in March before this happened so the ramp up should really be expected to take place over three to six weeks. Masks are very important but people can't go from not wearing a mask and to wearing masks all of a sudden so we want to give them time for the accustomization and also make sure that people are hydrating and sleeping when they haven't actually had to get up and work every day switching back onto a morning schedule can be challenging and there are more specific guidelines for these in the papers but so we can in the interest of time so we can move on to the discussion I'll put these out here but generally for baseline conditioning it's recommended the dancers actually try to do two to three hours of movement every day and for the professional dancers trying to get three to five modified classes per week ideally with from their company class. You can get creative with cross training with weights with cardio and there's good evidence from the Australian ballet that calf strength is significantly related to foot and ankle injuries and so they recommend doing up to 30 working up to 35 single leg elevations in parallel per leg daily and then for in season working dancers this goes down to 25. And we have good recommendations here that have been put together for us by the DanceUSA task force and getting into the new performance realities and most of the companies here in Boston are getting creative with their zoom videos there are some live streaming events outdoor performances were happening but now we're actually getting into virtual seasons with several of our dance companies. And I just want to put this out there there have been several super spreader events without masks we know that at the beginning of the pandemic within South Korea and the ballroom dance community there was a significant amount of spread and then more recently just last month there was a spin studio in Ontario that was doing everything right they were following all the protocols everybody had to wear masks in and out the bikes were more than six feet apart they reduced their capacity they would clean the studio in between every class and despite all of that they had more than 50 primary cases from the studio and over 80 secondary cases total so yes masks are necessary. There are great resources both for staying in shape the mental health component as I mentioned before DanceUSA has the resource papers out there the International Association for Dance Medicine and Science has great mental health resources Performing Arts Medical Association Actors Fund within the Boston Dance Alliance we had a whole month of virtual programming for dancer health and wellness during COVID as well as the Actors Union has good information as well. All right now we get to move into the fun stuff all right a couple more questions for those of you who are here can you please let us know if you are a student resident fellow attending this will help us answer questions and design our our Q&A session. Excellent okay we have a big mix of everything perfect. All right and then next we have all right so is performing arts medicine a significant part of your practice something a small part something that you would like to get into or just something that you're hearing about but not really sure about? Perfect. Okay, so now I have the honor of introducing you to the panel. So I'm going to stop my screen share and I will ask our panelists, I'll call on them one by one to give you a quick rundown on who they are and what they're doing within performing arts medicine and then we will go from there. So I'm going to have Kathleen start. Hi, thanks so much. I'm Dr. Kathleen Davenport. I'm at HSS, Florida Hospital for Special Surgery, Florida. I'm the company physician for Miami City Ballet. I'm on the board of directors for the International Association of Dance Medicine and Science. And I'm the co-chair of the Dance USA Task Force on Dancer Health. Thank you. All right, next we have Matthew Gerson. Matthew, I think you're over here. Hi, as I'm unmuted, but I'm Matthew Gerson. I'm in Seattle, Washington. I work with a network of physical therapists and other professionals in town. We created a group called Seattle Dance and Performing Arts Medicine, where we have a free clinic that we run for injured dancers and performing artists. I'm also on the board for the International Association for Dance Medicine and Science and I'm happy to be here and part of the panel. Thank you. Next we have Dr. Sajid Surge. Everybody starts a little dark in here. I'm Saj Surve. I'm the co-director of the Texas Center for Performing Arts Health at the University of North Texas in Dallas Fort Worth area. I'm also the program director of the only Performing Arts Medicine Fellowship in the world, the first and only. So if you're interested in specialized training in Performing Arts Medicine, please let me know. It's a one-year fellowship. I'm also the medical director for the Texas Ballet Theater in Dallas Fort Worth, as well as the UNT College of Music, UNT College of Dance, TCU College of Dance and the Fort Worth Opera. Thank you. Next, Dr. Scott Homer. Hi, I'm Scott Homer. As mentioned, I'm a psychiatrist with hand and body disorders. And so we just ended up for extremely so that I could have the expertise. And as you may know, there's no, well, there is a fellowship, but in order to, you know, particularly especially the non-surgical hand, there's no fellowship for that. And so now I have the privilege of working at the Brigham and Women's Musician Injury Clinic and, you know, working at Spalding and teaching residents about that. So hand and upper extremity questions, happy to answer. Next, Dr. Yain Lee. Hello, everybody. So like mentioned earlier, my name is Yain. I work for UNT Health Science Center at Texas College of Osteopathic Medicine along with Dr. Survey. I take care of performers in Dallas-Fort Worth region with Texas Center for Performing Arts Health. Big part of my practice is seeing the local professional musicians, music educators. I do a ton of education for DFW music community. I also see young dancers and cover Dr. Survey when he can't cover Texas Ballet Theater, TCU Dance and the Opera. Thank you. Next, Dr. David Popoli. Hey everyone, David Popoli. I am at Wake Forest Baptist Health. I'm the Medical Director for the Performing Arts Program at Wake Forest Baptist. I'm also the Chair of the Medical Committee for International Association of Dance Medicine and Science. And I'm the Medical Director for Musculoskeletal Education for the Wake Forest School of Medicine. And Dr. Jeremy Stanek. Hey everybody, I'm Jeremy Stanek. I am just about to start my third year at Stanford University. I'm attending here in the San Francisco Bay Area. I treat musicians and dancers of all ages. I like to focus a lot on educating and health prevention of injuries with our collegiate musicians as well as dancers. So it's a slowly growing practice, just starting to work on building a performing arts program here at Stanford. So I appreciate everybody's interest. Everybody who's here today and thank you for letting me be a part of this. Hi everyone, I'm Lauren Olson and I'm the Director of Dance Medicine at Spalding. And we take care of several of the smaller dance companies and adaptive dance companies in the Boston area. I'm also on the Board of Directors for the International Association of Dance Medicine and Science and involved with Dance USA Task Force on Dance Health and on the Programming Committee for the Performing Arts Medical Association. So we're gonna get into a couple of the questions in just a minute. Before we do that, I'd like to have Dr. Servais just kind of quickly give us a rundown in what you guys are doing for the musicians and COVID and how people are getting back to playing in person. Sure, yeah. So I'm one of, as I mentioned, I take care of the UNT College of Music. And so with them, we've had to make a lot of modifications in order to allow them to continue to practice and perform. They've removed, they've eliminated all large ensembles. So anything over 20 people. And then the biggest performance spaces that they have have now been reserved for ensembles that are in that sort of 10 to 20 range, allowing them to socially distance. They've also had to do a lot of modifications to the instruments themselves, including covers on any bells or openings to the instruments and special mouthpiece guards for the woodwinds and masks with slits in them to allow for decreasing the spread of particles from the mouth and airway. When it comes to voice, voice is really still quite limited just because of a lot of the data that's out there in terms of spread. So a lot of the voice work has really been relegated more to just individual work, solo work. And they've been experimenting at UNT with some of the technology. So there's some tech out there, including Zoom. There's some modifications you can make to Zoom and there's also other software that you can use that'll allow you to keep low latencies so that you can play with one another in reasonable time through an internet connection. And although that tends to break down once you have more than five or six people sharing a connection, but for smaller ensembles, quartets, quintets, trios, they've been trying to do as much work in smaller groups as they can. And then a lot of the lessons that they've been doing have been largely tele, so virtual in terms of using these low latency technologies. NASM, the National Association for Schools of Medicine, Schools of Music, sorry, I'm on the medical side. National Association for Schools of Music, sorry, published guidelines on how to play and make modifications as well for the collegiate level. And those also extend down to the high school and middle school levels as well. Most high schools and middle schools are allowing most folks to participate virtually if they choose. And if they are choosing to rehearse in person, they're doing all the same things that the college is doing in terms of requiring distance, fabric over the bells, masks and everything else as far as that's concerned. Thank you. We have a question for Dr. Lee. Would you mind discussing a little more of your experience with the use of botulinum toxin on these, on vocal dystonians and musicians? Yeah, oh, of course. So I don't do the toxin injections myself. I mostly work with either the movement specialist who's a neurologist normally, or a physiatrist who I would prefer, somebody who's very experienced. So a lot of times when you first diagnose these patients, the diagnosis itself is very impactful. And going through the treatment process and treatment options, in my experience, Botox injection isn't really the first thing that they jump to, especially the musicians. They do a ton of research by themselves. And already when they come and see me, they have a suspicion in their brain that they might have vocal dystonia. And so when I talk about treatment options and then when I get into Botox injections, they sort of say, hey, can I try other things? And then once during that time of rehab, PT, OT, a bunch of other things, we hook them up with a spasticity management specialist or a movement specialist. And then we start to kind of go down that route of tone management toxin injections. Injections themselves aren't any different what you would be training at. I think, are you in practice or are you training? But most of the time, it's not any different from any other injections that we do for the upper limb. I think units vary from 100 units to 200 units. And it's kind of a trial and error. And it has to be based on really, really good history and very, very good and careful physical exam. Like I was saying earlier, to make sure that you're isolating the dystonic muscles from the non-dystonic muscles, that's crucial. Sometimes I've had some musicians panicking because the weakness of the fingers. And so I think that there's gotta be a bit of a TLC with your patients with vocal dystonia. I think that the logistics of doing the injections themselves wouldn't be any different from your normal sort of good physiatric care spasticity management. Hope that answered your question. Thank you. Next, I have a question for Dr. Grierson. Can you talk to us a little bit about your clinic and how during this time things may or may not have changed with seeing the dancers in your community? Sure, right now, so the clinic that we have, the free clinic for dancers is a really fun interdisciplinary, multidisciplinary clinic where we have physical therapists, sometimes occupational therapists, sometimes chiropractor, massage therapist, of course, the physician. And we sort of all team up and work to, in teams of five or six and treat each of the performers who come. And unfortunately, because of coronavirus, it's been very difficult for us to continue that type of model. We have tried to transition some of that to the Zoom environment, but it is frustrating because it's just, it's harder to get a good exam. It's harder to really see what's going on biomechanically with people. I will say a lot of the dancers, I also, in addition to the free clinic, my day job is a physiatrist and I have a sports medicine clinic. And there are people who do come into the clinic in person. And just like any of our clinics right now, we're limiting people in the lobby, everybody's wearing masks. But actually it's interesting because some of the professional companies, they all sort of have a contract with each other of like what types of environments they're gonna go into. And in terms of risk reduction, thinking of each other as a community in terms of risk assessment, because some of the smaller companies are like five or six people or sometimes seven or eight. And so they have sort of different concerns compared to a bigger ballet company, which might be 30 to 100 people, depending on bringing all the trainees. And so we've been able to see people one-on-one in clinic, but it's been harder to do some of our multidisciplinary programs unless it's on Zoom. But we're hopeful with some of the data, you know, in terms of vaccines and all that, you know, it's probably going to be another, you know, six months to a year to 18 months before we get all that stuff going back together. So it's sad. We want to do everything in person, but we're trying to keep the community safe. So. Thank you. And next, I have a similar question for Dr. Davenport with your role within the dance company. How much is the dance company, I guess, coming to you and also heeding your advice for navigating this time? And then also wanted to put in a plug for your podcast, if there's anything you'd like to share with us about that. Thank you. Not my podcast. It's Kathleen Bauer, who's the physical therapist for Miami City Ballet. She does the Dance Docs podcast, but I'm one of her frequent contributors there. And we've talked a lot about COVID returning to the studio and different things that we were not expecting to podcast on this year, as most of us were not expecting to do things this year. So for my role as the company position for Miami City Ballet, and also with the Dance USA Task Force, we've had conversations from other dance companies on what they're doing. And thank you for that review, Lauren, on talking about that. Overall, I think people are trying to do their best, you know, with everything and people are coming to me. I would say the silver lining that I think many people on this call have noted is the telehealth options. And so I've been able to do a lot with telehealth, similar to what Matthew said with his companies, we're trying to do less of the onsite clinics that I've been doing for them and more telehealth options for them. And it is very handy to have someone like a physical therapist who I can really trust on site, who can run them through their physical exam while I'm talking through what I want them to see. And that's been a really great way to do some of that multidisciplinary work while still maintaining social distance. So that's been one of our adaptations that's been successful for our team. And then Miami City Ballet, like many companies, are doing outside performances, and we're trying to keep them as safe as possible with that work. Thank you so much. I see a couple of questions here first from some students. And so I'm going to kind of lump them together and give our panelists a chance to weigh in, especially our fellowship directors. They asked if anyone is willing to share advice regarding pursuing a career in performing arts medicine, as well as how important is your experience as a musician, performer, or dancer going into performing arts medicine and to incorporate that into residency training. And so before I open this up to the panelists, if the panelists are okay with it, if you can all go ahead and put your email addresses, if you're okay with people reaching out to you, in the chat box. And then that way, for those of you who are looking to have a little bit more one-on-one discussion, I think that can be helpful, because we could talk forever on this. And I also want to make sure that if anybody else does have questions, feel free to send in your questions. I just want to make sure we get those answered, too. So does anyone want to start tackling that? I can start off with that. Dr. Davenport and I actually ended up training together back in residency. And our strategy was to find someone who was an expert in the field and just sort of stalk them a little bit. So we went online, found their email address, and begged them to let us do a rotation with them. And it's getting to the point that that was over 10 years ago. Now I'm feeling old. But there are more people out there now doing this work, and it's exciting to see that there are more and more clinics out there that are calling themselves performing arts medicine clinics. And so I would definitely reach out to anyone in any of these clinics. Hopefully, it's not always the case that there's one close by where you live, but hopefully one in a similar three or four-state radius. But there's always opportunities to work with those people and shadow them. But if there's not, then my recommendation would be to also just reach out to some of the physical therapists in your community. Find people who are also interested in this. Start your own little journal club in the area where you're working. And over time, that will sort of grow. That will sort of blossom. You will find like-minded individuals. You will start to be able to bounce ideas off of each other. And in the beginning, none of us started out as a performing arts medicine specialist. That's not what any of us ever started. I don't think. People can correct me. But you have to start slow, and it builds and becomes part of your practice to the point to where then you wake up one day, and you're like, wow, this is like a big part of what I'm doing. I'm really excited, and I don't even know how I got here. But there are lots of people I would network, and there are some great organizations out there like Performing Arts Medicine Association, IADAMS, where you can meet people. And people in this field love mentoring because there's not enough people out there who do what we do. If I could tack on to that. I think answering sort of the second half of that question about your own personal experience as a performer, I think you definitely need to draw from what you know. You know, having that lived experience is so incredibly valuable when dealing with, you know, the performing arts population, just because you have a shared language and an ability to communicate with fellow performers who are of the same, you know, background as yourself. And I would say that the majority of people who do this type of work tend to be people who come from that community. So it's the dancers who go on to do dance medicine. It's the musicians who go on to do music medicine. You know, I mean, it's the idea of a sort of all-encompassing performing arts specialist who takes care of all performing artists is a relatively new concept. You know, it tends to be the singers taking care of the singers, and theater people taking care of the theater people, and so on and so forth. So, you know, I think it's definitely draw from your own experiences because it's so valuable, and I just want to add that. And I will say from, to go off of that, and thank you for adding that, that, you know, when people getting into sports medicine ask, like, good and bad things, pitfalls I see on there about sports medicine, I always say sports medicine really works if you're going to be there anyway. Like, if you're going to be at Friday Night Lights, being at the high school football game on the sideline for three hours, you're going to be very happy if you're going to be there anyway. And that is why we tend to see people who are in the industry or in that community anyway. I'm going to be at Miami City Ballet whether I'm backstage or in the audience, and so I'm very happy giving up my entire weekend and giving up my Friday night to Miami City Ballet and to see four different shows in the weekend, and I think that's an amazing weekend because I would want to be there anyway. And so I think that you're going to be very happy with your career choice if you're participating in things that you would want to participate in anyway, because it's a lot of nights, it's a lot of weekends, it's a lot of Sunday night at 8 30. We're here because we love it and we're passionate about it, but this is our lives. Like, Matthew and I and Lauren with the Adams board have been on weekend calls for two months straight, and we are still here because we love it. But I think if you're getting into it for other reasons that you're not passionate about it, I think you have to really wonder why, you know, are you going to be there anyway? So I don't think you have to be a professional dancer to do dance medicine, but I think you're going to be much, much happier if you're going to want to be at the dance performance anyway, whatever that looks like to you. Yeah, kind of piggybacking off of what Saj said, I think I'm probably one of the few people that went into physiatry specifically because I knew that would give me the training to do performing arts medicine. Having been a pro trumpet player before I went into medicine, I use my skills and knowledge as a trumpet player all the time whenever I'm treating any kind of performer, whether it's a dancer or it's a musician. Especially with the musicians, I think one that makes me a better clinician because I know the mechanics and the biomechanics that go into playing all of those instruments. So overall, I think it makes me a better diagnostician and clinician in general and figuring out is it something technically that they're doing with their instrument that's putting them into that position that makes them at increased risk for injury or causes injury in the first place. And then I also think that really also kind of puts the patient at ease too and gives them a little bit more confidence in my skill set because I'm able to communicate with them in musical terms that they understand. I'm not using fancy medical terms that they don't understand. I'm able to communicate in their language and we can have a good two-way conversation on what's probably going on and how we can make some changes or adjustments to fix the problem that's happening in the first place. With regard to dance medicine, I really had zero experience with dance medicine at all before I went into medicine at all. And you know, physiatry is the best specialty that there is and it allows us to have this great community. We can meet other people just like we are in this community group right now. There are other organizations like the Performing Arts Medicine Association, iADAMS as well, where we non-dancers can learn as much as possible from all of these amazing people like we have here today so that I can become a better dance medicine provider and I can learn a lot more and be a better provider to all of those dancers also. Sorry, you can go ahead, Scott. Okay, thanks. So I was a jazz drummer in college and had issues with pain in my wrists and you know, after having had multiple different diagnoses and a frustrating course, what I knew is that I wanted to know everything there was to know about the hand and arm in the medical, in the mainstream medical profession. And you know, so I just, you know, that field tends to be dominated by hand surgeons. And so even though I knew I didn't want to be a surgeon, I ended up spending thousands of hours with the hand surgeons because they're the ones who dominate the field, you know, and trying to know everything that they know about it and then adding that to, you know, what is known from sports medicine, from physiatry, and then, you know, adjunctive specialties to try to add that in. You know, it was something where there wasn't an existing fellowship, but by seeking out and spending time with people, you can sort of put together your own fellowship of sorts and get the training that you need, because the bottom line is you need to be comfortable doing, you know, what you're going to be doing and you got to seek out the expertise that exists. So I did do a short fellowship of sports and spine to add to, you know, skills with ultrasound, ultrasound-guided injections, PRP, and those things like that. You just have to go out and get the expertise. And so, you know, you may think, oh, I need to go to this one particular school or this one particular residence to your fellowship. And you may have the luxury of doing that, but you may not. But even if you don't, you can still find the resources around you. And then the other thing I did was go shadow at different performing arts clinics in San Francisco, in Boston, in New York, and, you know, email them and see if you can, and you go out and spend time with them. It's a little harder during COVID, but, you know, you can cobble together what you need to know to do what you want to do. I just wanted to add that I was the prime example of somebody just looked for someone, and I was lucky enough to know Dr. Servais from medical school and just kind of stalked him. And that's just kind of how I ended up where I was, where I ended up. And having the PM&R education was a really great fertile soil to build whatever I have now to take care of our patients. But I'll say that having the musician background is very helpful. Not to, you know, everybody talks about the biomechanics and the language and all of that, but also the culture of practice, auditions, failures of auditions, playing at multiple different ensembles, teaching, you know, you always have to teach, and then being really poor, because if you don't play, you don't get paid. These kind of things is really helpful to take care of the mind and the spirit of your patients. So that's my two cents. of segue into that. I think this goes along with the other things that we were just talking about. You know, as physiatrists, we are good at leading interdisciplinary teams. This is what we do is we bring people together. And I'm not sure about my colleagues, but I think I am a better clinician overall because of all the physical therapists that I have worked with because they have taught me to look for things. My physical exam, my residents always say, how did you learn that physical exam? Well, that's actually a physical dance medicine, physical therapist exam that now all my patients get. And I think if we show that respect and learn and have that ability to learn from each other, I think other people are happy to work with us. I mean, there's going to be politics in everything that we do, but when we go in with an open mind, we can learn a lot. And now we do have these performing arts fellowships coming up thanks to some of the pioneers that are here. But for those of us who are not old, but older, you know, when we were creating our own fellowships, it was basically going to the orthopedic surgeons, going to the neurologist, going to the people who were taking care of the dancers, and then using our physiatric skills to create a comprehensive oversight and putting that all into one place. If other people have, for those of you who are working in the interdisciplinary clinics, want to add to that. No, I agree. I think it's about putting together your team. You know, it's just finding who is, what's the expertise around you and who can you draw from. And if you don't have it, trying to recruit those people down near you somewhere so that they can be a part of your team. So yeah, it's just a matter of, you know, trying to figure it out. And I think it's getting easier day by day as more and more people are getting involved in this field and it's starting to grow a little bit more. So I think, you know, a fellowship like we put together couldn't have existed, you know, five years ago, just because the pieces weren't in place to be able to do something like that. So it took a lot of concerted effort to get, to assemble the right people and the right team to be able to put something like that together. So it takes, you know, mindful effort to move it in that direction. We are over our allotted time, but welcome any last minute questions that you guys may have. And then also to put in a plug for the Performing Arts Medicine Phys Forum. So this is really a place for us to ask each other questions, to reach out. I don't know if students have access to that. So if you don't, feel free to email us. But this is a great place for us to network and ask our questions. And then also this community day was definitely cut short and a little bit different than we had originally planned. But if there are topics that you're interested in either hearing about or presenting in the future, please let us know. And yeah, we welcome as many people here as possible. Can I say one more thing, Dr. Ellison? It's Dr. Servais' birthday today. Happy birthday. Happy birthday. Dr. Servais, thanks for making us a part of your birthday. We really appreciate it. Wouldn't have it any other way. any parting words that they would like to like to give? I'm sure that I speak for myself as well as the other panels that we're happy to hear from you. I see Dr. Servais has the fellowship information in the chat. So please make sure that if you're interested, I almost want to go back and do the fellowship. So, oh, there's a great question here about performing arts medicine education opportunities outside AAPMNR. Yes, there are tons. So in fact, for the, at least for the International Association of Dance Medicine and Science, if you join, you have access to this year's annual symposium, which just finished, but those links will be up for the next year. And then the Performing Arts Medical Association also has the, has their annual conference as well as a lot of great resources. Both of those organizations have a journal affiliated with them. The Performing Arts Medicine Association has a certification program. So, so lots of, and there are other smaller organizations as well, but those I think are the two go-tos, especially, well, I think well, nationally and internationally for, for education. Oh, and then the Harkness Center for Dance Injuries in New York City does have a whole online, online class courses that you can take. Thank you all for being here. And I'm looking forward to hopefully think of crossing you guys in person next year.

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