Welcome to Community Session Part Two. We're very happy to have you all here. Tonight we have a great program for you. As you know, Part One was dedicated to Performing Arts Medicine 101. And tonight we have some more intricate topics and hopefully we'd like to spark a lot of discussion. So we're gonna start off with Dr. Scott Homer with his talk, Predictive Processing, a theoretical framework for addressing symptoms that don't fit the classic diagnostic expectations. Hello, everyone. Thanks for being here. So gonna be talking about the model mentioned and specifically applying it to use-limiting conditions and thinking about what we know and what we don't know and ways that some exciting new neuroscience research can help us advance into a better understanding and a better clinical care for these conditions. So we've all heard that beauty is in the eye of the beholder but that's not the only thing that is in the eye of the beholder. Many aspects of our experience, if not all, can be considered to be coming from our own construction of experience. Now, for me, the core problem that I want to address is that we have many musicians coming into clinic with prolonged pain that seems to exceed the traditional diagnostic boundaries and can be challenging to treat. I'm gonna start off with a brief case. 18-year-old violinist comes in with persistent and worsening upper extremity pain that's relatively diffuse, required her to cut back significantly on playing time and required her to drop multiple courses. And she's worried about her ability to continue down this path. What would be the diagnosis she would typically receive? Well, typically it would be focused on some kind of tendonitis or myofascial pain syndrome, something musculoskeletal. A lot of patients have some common questions in these scenarios. For instance, why is it lasting this long if my prior injuries didn't last so long? Is it tissue injury? And if so, which tissue is it? Is it muscle or could it be a nerve condition? What's the diagnosis? Well, it's not uncommon for musician pain to spread beyond traditional diagnostic boundaries. And how do we even know exactly which tissue is involved when the areas seem to spread over multiple different kinds of tissue? Another common question patients often have is how much to rest or how much to keep using the limb. So rest has been a mainstay of treatment for a very long time and continues to be. Yet there are many thoughts about whether or not rest is overuse. And how much rest is the right amount? Find this a very challenging question to answer. Many also claim that pain can be the result of weak muscles and so we need to strengthen. But how much strength is the necessary minimum in order to avoid injury? I'm not sure that we have answered this question too precisely. Should I pursue my pain and can a person even do that? In many cases, I don't think they can. But how would you even know if you're doing that whether you're causing harm or not? Taking another step back, conceptually, is pain really the most useful concept for these scenarios? Could we focus on other things? For instance, what about the behavior or the activity? How much the person is actually using it? And besides pain, are there any other sensations that are going on when the patient tries to play that? Could be getting ignored. If we think about behavior, there may be more determinants to whether or not one continues playing besides pain itself. For instance, what about beliefs around pain and injury? If you focus on solving the pain but you don't address the beliefs, is it possible that you might continue to have problems? And how one goes about playing the instrument, whether their pain and or other factors lead them to change attention and timing, whether or not they're playing at all is a different question from how they're playing. Experience is an attempt to take a step back from focusing just on pain. Is it possible that we and the broader culture around pain leads patients to focus on that rather than having a broad, more nuanced awareness of their bodies and the healthy sensations that are also going on? For instance, could you have a more positive focus on the healthy sensations that are going on? And do we even have a good vocabulary for this that we agree on? I think it's wise to consider the full pathways and not just the peripheral musculoskeletal anatomy and not even just the peripheral neuroanatomy. Where does pain occur at the site of injury? Many times we think this way. The traditional model, this is the way we talk. The pain is in my wrist, the pain is in my forearm. But if we take a step back, we know that that pain is formed in the brain. And even the traditional neuroanatomy model is focused on the way that pain signals travel from the periphery to the brain. But more recent neuroscience research is demonstrating more top-down origins of pain and a more complete picture of what's going on in the brain, including predictive processes. So if we come back to the case of this violinist, now that we're thinking a little more broadly, what is the most complete illustration you can provide of the anatomical structures operative in this condition? Well, you can think back to your neuroanatomy classes, you can think back to your pathways. But even beyond that, I wanna highlight the point that brain anatomy is also anatomy. And when things are happening in the brain that are part of our experience, they are relevant. They shouldn't be sidelined into some separate category. Of recent interest in neuroscience research is a network called the interceptive network that spans the areas that are written here. And we're gonna get more into that. But before we do, getting back to the patient's perspective, how does a patient know what pain means? When they're sitting there in their practice room and they feel something, does that mean there's an injured tissue? Does it mean they should stop? Does it mean that maybe they're too anxious or maybe they're hyper-focused on pain? And why do they get pain when they were able to play for years and years at that level and have no problems? These are unanswered questions for our patients. So I'm gonna talk about a theoretical framework called construction and also known as predictive processing. So here we're looking at a specimen in nature that has its own inherent reality. But when we look at it, we bring something to this picture based on our past experience. Construction of experience occurs continuously in the brain. The brain simulates perception constantly. The brain predicts in advance what our experiences will be and uses afferent corrections to help modify and improve future predictions rather than just relying on afferent signals. Prediction is something that our brain does that's goal-oriented, that evolved to help us survive in a world awash with too many incoming inputs to process. The name of the game in construction is a recognition that there is extreme nuance, diversity, variability in experience. Pain is not actually something that everyone feels the same. It's a conceptual category that we impose on our experience. It's more accurate to talk about an instance of pain that is experienced in a given moment and is very, really constructed from moment to moment and from person to person. Now, an example of this is when we've probably all had experiences when we've been with a patient and we've been trying to decide if something's musculoskeletal or nerve-based. We ask them, is it pain in this area? Is it tingling in this area? We try to distinguish those two, what we consider basic categories. But sometimes patients just don't think that way and we just can't get them to separate out those categories. And this can be accentuated across cultural and linguistic boundaries. So if you consider reality of all the sensory possibilities to be the dough of the universe, our concepts are like cookie cutters that we impose on that dough. We have to impose order and simplify in order to make sense of things and survive in this world. Diagnostic categories are simplifications. We routinely ignore variability and sweep things under the rug that don't fit into our diagnostic categories. And we come to each patient encounter with a set of concepts that we're trying to fit things into. We need a box to put things in or in to make sense of them. And one of the important concepts of predictive processing is that what we deal with is more the model than the thing itself. There are what are called body budgeting regions in the brain in the interoceptive network that are very much affective, that are considered the brain's main drivers of experience and behavior more than logic or reason. And affect is one of the ways our brain decides what is important, what to remember, what to emphasize. An important point when you look into this theoretical framework is that emotion, thought, and sensation are not separate. They're actually very much intertwined. As is the mind and body generally. So we draw on prior experiences in order to make our predictions. So even subconsciously, as a musician is practicing, they may remember, when I played this passage before, I became tense, and that's going to form part of their predictions, which is going to actually influence what their experience is going to be, both sensory and motor. Here's a illustration of some of the brain areas involved in the interoceptive network where these predictions are being created. Now, now that we've posited that there is prediction going on, now let's ask, could anything go wrong with that? And could that be in our purview as medical providers? How does the brain know when it's made an accurate prediction? Well, it's going to need some kind of feedback to know whether that is the case, whether it was accurate or not. How do we know if tissue is injured or at risk? Well, it's helpful to remember that our brain is tucked away in our skulls and it can't see our tissues directly. It has to rely on indirect information in order to make a judgment and frankly, a guess about this. What happens if we don't have a good way of verifying our predictions and getting good feedback? Is it possible that if feedback is reinforcing our erroneous predictions rather than correcting them, it creates a self-fulfilling erroneous cycle? For example, if you have pain, you stop the activity, you feel better, you may reinforce the perception that rest was what your body actually needed. An analogy to this is a common knowledge in anxiety treatment that anxiety often leads to avoidance and avoidance reduces anxiety. And then that reinforces the perception that avoidance is the appropriate response. But it's well known that avoiding too many things can actually accentuate anxiety. So it's erroneous learning. Now, a paper just came out in JAMA Psychiatry about using pain reprocessing therapy to treat chronic back pain. And it was compared with placebo and it was compared with usual care and it showed significant benefits and fMRI changes in the networks that are pertinent. PRT or pain reprocessing therapy is essentially a cousin of CBT, but it's specialized to pain and it's a very applied way of doing this. One of the things it does is addresses pain beliefs, teaches pain as a false alarm, which is not a new thing, but the way that it's applied is relatively new. Now, there are other chronic pain apps and workbooks out there of variable utility, but there's absolutely so much more research needed in this area. And the neuroscience breakthroughs that have been coming out over the past decade or so and the new techniques that are opening up new understandings of these networks in the brain are very exciting. And likely to lead to a lot more clinical oriented research in the near future in this area, things that we have not been able to reliably study before. Domains of the mind that have previously been very unquantitative are going to be available to us to study. Now, this is a lot of information and there's so much more where that came from. And it takes a while in my experience to chew on these concepts and make sense of them and internalize them. And so I'm gonna make a recommendation for a book that I think is the best lay book out there for summarizing this recent neuroscience of construction as it applies to human experience. The book is called How Emotions Are Made. And it is not just about emotions, it's about all types of sensory motor experience. And even better, there's an audio book available. So I find this very exciting and I would very much like to be able to bring a better understanding to these very challenging concepts. It just pains me day after day and week after week to be so limited in being able to answer these questions and being able to help solve these patients' pain sooner and quicker and getting them back to playing. And so I would like to be part of that. And I invite anyone who's interested who finds this interesting to join me and see if we can't have a breakthrough in this area. Thank you. Thank you so much. Lots of food for thought. And please save your questions for Dr. Homer for the end. And I forgot to mention that we will be taking questions both through the chat and you can also raise your hand at the end. So we'll be calling on you guys soon. All right, next we have Dr. Kathleen Davenport and Dr. David Popoli for resilience and dancers, how we can build and foster resilient dancers particularly during times of increased uncertainty and stress. Evening, I'm gonna bring up my slides. One hopes. You all got the preview. So I'm David Popley, and I'll be talking about resilience in dancers. I'd like to begin by exploring a little bit why this matters. Certainly there's been a lot of discussion about resilience as it pertains to the COVID pandemic, and also some of the financial distress that folks are having as a result. But why does it matter for dancers? What I'd like to offer is that there's both a risk to not developing a resilience practice, as well as an opportunity for those who do. As it pertains to risk, we know that dancers actually experience burnout at higher rates than the average population. They actually start to approximate what we see in medicine. Somewhere between 30% and 50% of dancers will say that they feel burned out. And that can lead to decreased performance, which can then affect job stability. Additionally, burnout can then lead to stress, anxiety, and depression, which may already be lurking underneath the surface because of things like being worried about auditions, or having financial constraints, or having a physical injury. For those of us that work with dancers, then, we have an opportunity to help them train their resilience, not only for personal and professional growth, but also to confer a strategic advantage for career longevity. I do not want to claim that I'm the first person to think of this. There have been many people that have gone before me who are incredibly talented and have set some precedents, and I'd like to draw your attention to a couple of those. Up here in the upper left-hand corner, the United States military actually has mandatory resilience training for all four branches of service. This was done in response to seeing elevated levels of things like PTSD, as well as challenges reintegrating soldiers back into civilian life. For those of you that work in sports medicine, I'll draw your attention to the bottom right-hand corner. That's the USOC, and they have a very rich tradition of doing things like positive imagery and have made it a purpose to train their athletes in resilience as well. And very last, if you are not familiar with the Mars One program, that's a program from NASA designed to land a man or woman on the surface of Mars, and they too have a significant resilience training program because they know that mission is going to be about two years long and likely be fraught with quite a bit of adversity. If you'd like, if you want to put what you think resilience is in the chat, that might be interesting. Otherwise, I'll sort of bring you to this word art that I provided down here. And resilience is really not any one thing. In fact, it seems to be almost a study in contrasts. If you look in detail at this little word diagram, you'll see that the word strength is in there, but also flexibility. Teamwork, but also leadership. Resistance, but compliance. Adaptability, but steadiness. And action, but also reaction. And I think what that tells me is resilience is not any one thing. There's no one definition. It means different things to different people. And it may change over time depending on the circumstance. I would say that we as physiatrists are sort of uniquely positioned to teach resilience. We see it a lot in our own patients and their outcomes. And I'll show you examples of that as I go through these slides. But also because our careers are this sort of study in contrast. We are asked to be leaders. We're also asked to be team members. We're asked to talk about both ability as well as disability. We're asked to talk about recovery, but we're also asked to talk about maintenance. I'd like to, in the rest of this talk, kind of explore concepts that we can teach. I just told you that resilience is not any one thing. So expecting that we're going to teach it as a broad concept really doesn't make a whole lot of sense. We really need to break it down to its components. There's been writing about something called the four C's of resilience. So I'm going to work backwards across this slide and we'll kind of break through those concepts and how we might teach them. The first major component of resilience is adaptability. And that's, you know, the ability to bend and flex in real time. But adaptability just by itself does not confer resilience. We need to also have deliberation and intent. We need to look back at things that have happened, process them, and then be able to plan for the future. Within adaptability, the first major concept that we can help teach a dancer is control. And you might think of that as being modulation. The ability to kind of respond to a situation that looks like it might be overwhelming and kind of keep your cool. And just sort of think about it as something you can get through. And we can find practices to help teach that. Additionally, challenge. And this may seem a little bit odd, but this is really more about risk tolerance and the ability to see a potentially adverse event, not just as a catastrophe, perhaps, but also as something you can learn from as an opportunity. And then within deliberation and intent, we don't generally have trouble teaching dancers about commitment. They tend to be very committed folks who have a lot of resolve. But with respect to resilience, what we're really talking about is setting goals and then kind of being able to maintain focus and sort of continue along the path. And then lastly, confidence, which might seem a little bit out of place, but for the purposes of resilience, what we're talking about is the ability to have purpose, to sort of have a higher meaning through mindfulness and introspection. I'd like to begin with confidence because I do think it's one of these things where that's where we start building a resilience practice. And when you're speaking with a dancer, it's important to be able to use terminology that they might already be familiar with. So when I'm working with a dancer, I'll talk about finding your center. And that's something that they're already familiar with from rehearsals. But for resilience, it really means sitting down and thinking about who you are, what you're about, and how to apply that. And so a very quick thing that you can use in clinic. Again, I don't expect you're going to give 25-minute lectures to your patients, so we really need to think about small, digestible things we can do. We can do something called a six-word memoir. It's a little bit like a self haiku. We say, sit down, give it a couple minutes, and just think about the things that make you tick. Who are you? What is your purpose? And that way, when you're confronted with a really big obstacle, something that seems insurmountable, or you have to kind of slog through these boring things, you can say, well, at least what I'm doing is aligned with my purpose, and so I can kind of get through this. This example here on the left is actually my daughter's six-word memoir. And I'll tell you that this is a little bit colored by the fact that at the time she was learning how to ride a bike, this was four years ago, but she's held on to this. She actually keeps it near her mirror, and she'll say if she's having a bad day, she looks at it. It kind of helps her maintain her way. And so I'll tell dancers to do that, too. Once you've come up with this six-word memoir, put it near your mirror. Put it in your car. Take a picture of it and put it as the wallpaper on your phone, something that allows you to refer back to it. How it parallels to the rehab world is we do this all the time. And this is setting long-term goals and then sort of maintaining short-term gains to get towards those long-term goals. Sometimes, though, things don't go your way, and so we need to find ways to control our emotion and control our response to a potentially adverse event. And so when I'm speaking with a dancer, what you can use is this concept of mindful movement. I talk about doing a mindful warm-up and a mindful cool-down, and that's great because it means they're going to do a warm-up and cool-down, double bonus here, but I will encourage dancers to slow down, to do their warm-up or cool-down at 50% of the rate that they normally would. What that allows them to do then is remove themselves from this sort of automatic thinking or sort of being on autopilot and allows them to really focus and process. For a warm-up, that might be, what are my goals for today? How am I going to move through that problem I had yesterday? For a cool-down, it might be, how did this go? What went well? And then, how do I use this to continue to plan? This can be enhanced by something called the 4-7-8 technique, which was invented by this gentleman over here in the left-hand panel. That's Dr. Andrew Wheel from the University of Arizona. And that's a four-second inhale, a seven-second breath hold, and then an eight-second exhale. Now, that was originally designed to help people with sleep, but I'll refer to the study down here at the bottom. It actually helps with people encoding new information, and it also helps decrease stress as measured through salivary cortisol. And again, to bring this back to the rehab parallel, while we're good at this is we talk about active participation with our patients all the time, right? Their rehab is only as good as much as their investment they've put in. Resilience, though, is not just an individual practice. It's really a group practice as well. It largely enhances a resilience practice. And dancers are familiar with this. This is partnering up, right? The best shows in the world are not just watching a soloist for two hours. It's with the company. It's with their partner. And so, for a dancer who might be in a new situation, it's a new city, he or she gets their first job, and they have financial constraints, it's really important to talk about how you find that support system through a really good social history, which we do all the time. But not only to find the support system, but then also to encourage a planned debriefing. It's not enough to just say you have the support system. It's really important that you use it. Plan it. Two weeks from now, I'm going to sit down with my friends, and we're going to talk about what happened, and we're going to talk about maybe venting for a bit, and then thinking about solutions. And we all do this already with team meetings. I don't claim to be able to solve all my problems for patients by myself. I am very fortunate to be surrounded by a wonderful team and wonderful colleagues. And then lastly, as we think about how to move into the future and plan for success, this is really the concept of mental rehearsal. And I'd like to bring your attention to this slide. This is kind of this idea of priming for positivity. This is an fMRI study for a total of 40 participants, 20 of whom were asked to anticipate a neutral event, and 20 of whom were asked to anticipate a positive event. And for those who were asked to anticipate a positive event, you can see that the fMRI demonstrates significant uptake in the medial prefrontal cortex. This allowed them not only to enjoy the present more while they were kind of in the process of doing this, but they actually enjoyed the event for which they were planning more than if they had not done it. The parallel for dancers then is saying, hey, listen, I know you might not have a lot of time off, but when you do have time off, plan to do something. Don't just kind of sit, because if you plan to do something, you'll really enjoy it, and you'll enjoy the present. And again, the rehab parallel here is disposition planning. So what I'd like to reinforce to all of you is you already have these great skills, and now it's just, as Jean-Claude Van Damme would say, it's go time. Thank you, and I will pass over to the amazing Dr. Davenport. Okay, I'm going to get my screen share on. There we go. So thank you, Dr. Copley, for that excellent lecture talking about resilience. And then the question has come up specifically about resilience and moving forward in terms of COVID-19 and within the professional dance community. And so with my roles, I want to bring this into the professional dancers and talk about where we are in terms of updated COVID-19, how to get back, and some issues that we're seeing with resilience in our dancers. So it is a very wide topic to talk about COVID-19 in the professional dance community. Many of us on this call just got off the IADMS, the International Association for Dance Medicine and Science Annual Conference, and I hosted a whole roundtable for an hour on this topic. So it is a wide topic covering many issues. So what we're going to really focus on here in these few minutes is lessons learned from the COVID-19 pandemic of how bringing forward the past lessons into our present and future to help our dancers and our patients. Also, it is about preparing a dancer for return. How do we help these dancers return to their company environment or to their professional work environment? And then recovering a dancer who may be slipping away if we feel that someone is maybe not ready to return or is slipping away in terms of their art form or job. So in terms of during the pandemic, there are many lessons learned about dancing virtually as well as together. And you can see two examples here of in-person coming back together. There is six feet apart on the top and masking and social distancing, really large space, good air movement. And on the bottom, there's no social distancing. The mask is the person who is myself, who's the doctor and the people around her who I tend to mask. So there's a wide variety of practices within the community. So we did learn that in-person is always best if we can. It's about having this social connection. And you can do it safely if you choose to. You can have social distance and masking via vaccine mandates and testing. However, if it's not possible to be in person, Zoom is better than nothing. And having some kind of pod is probably the best combination of safety in terms of limiting your exposure while still having those social connections which can help with resilience as well as your art form. However, I always say girls got to eat. So sometimes we always have these best practices. But unfortunately, within the professional dance community, particularly within the ballroom community, a lot of dancers have gotten COVID because they have to work. And unfortunately, the work can put them at risk for having COVID. So I do foresee, as we have doctors, we are going to see long-haul COVID in our dancer community increasing. So I've already seen several dancers, particularly in the ballroom community, with long-haul COVID. And I do think that this is something that we are going to need to be aware of as we have doctors leading the charge in COVID, post-COVID, and long-haul COVID. So how do we have a dancer return? How can we give them some tips and tricks of getting them together? Again, as David said, as a psychiatrist, we are in a beautiful position that this is part of our training of working with the team. So when we're talking about dancer returning, of course, it's not just about the dancer. It's about the whole environment. So how do we look at that together? So when we look at the dancers, when I have a dancer in my clinic, either I'm going to do a history, which we can consider a survey, or we can do a formal survey with a company or group of dancers. I've done this with my college dancers as well as my professional dancers, kind of saying, OK, where are we in terms of COVID? So a lot of the COVID questionnaires that are going around in terms of surveys ask several things. It's not just have you had COVID or things like that, but there are a lot of things of how are you feeling about dancing? What were you doing previously? Were you dancing on Zoom? Were you dancing in person? What kind of floors were you on? What kind of shoe wear? What kind of partnering? So that we have an idea of their baseline and we know where they're starting so that we can then help get them to their functional goals. And so that needs to be tailored for your dance environment. It's going to be a different conversation for my professional Miami City ballet dancers compared to my ballroom dancers. But really saying, OK, where is the baseline that we're starting? And then how do you feel as a dancer about getting back to this level that your goal is? And then what are these barriers that we have? And then as physiatrists, we can start putting that team around them so that we are identifying barriers that they may not have identified and they're also identifying their barriers. Of course, it's always important to update functional goals. This is where we shine as physiatrists and making sure that when I was talking to my dancer just a few hours before getting on this, I was talking about getting her return to dance. You get that vibe. I'm like, are we returning to dance? And well, I don't know. So making sure that we have the functional goals so we're not putting together a plan for them to return to dance when that's not the actual goal and if that has changed. The company environment, some of us in health care may or may not have opportunity to participate in making demographical changes in our companies. But if we are, these are some recommendations that we may be able to make for our company environment. So informally, many of the dancers felt we were ready to return if the custody had a clear safe plan about COVID protocols. So the more certainty and the more communication that the company had about the COVID protocols, the better the dancers felt that they were being taken care of as an employee. HODs are definitely something that the dancers tend to appreciate because they do feel again that they're mitigating their risks. The vaccine and testing requirements have been controversial. A lot of companies are requiring vaccines to return and that has been controversial but generally has been well received by most dancers. The air ventilation has been updated at many companies that I'm aware of and something that we're certainly still recommending and something that you could ask as a physician. Social distancing may or may not be a possibility for dancers as they return. A little bit more possible for your collegiate dancers compared to your professional dancers. And a little tip and trick that I always recommend for all of my athletes and dancers is to bring a stack of mats so they can change them as they sweat as we know they are not effective as they get wet. So as we continue with getting our dancer back and looking at our allied health care, you know, what are we looking at in terms of working with our physical therapists whether those are on-site physical therapists for our companies or our physical therapists working with our other dancers. So a few things and tips and tricks that I give my dancers if they say am I ready can I go back and not get injured. So I say can you do 25 or 35 releve which we consider to be single leg heel raises. So going up on your toes they should be able to do those slow controlled perfect technique. If you're a doctor who's not familiar with taking care of dancers, trust a physical therapist, get your team together who can tell you if those are perfect or not. They should be able to do 25 to 35 straight through single leg to prevent things like stress fractures, gastric strains, things like that. At Sumi's in Australia Ballet who also was the one who put her dancers on 25 to 35 single leg releve. She also put her dancers on a stair running protocol at 30 degree first MTP plantar flexion pathway to also help prevent stress fractures with impact and help her dancers with impact in the off company time while they were in COVID. It's something that definitely needs to be done under the guidance of a physical therapist because it can go badly and increase injuries but if there's a good physical therapist you trust it can be a good protocol to help with impact. For my dancers who I'm not sure I have a team around them that's as trustworthy perhaps for something so dance specific I'll say go jump in the pool. You know do your beats, do your jumps, do your barre, really get in the pool so you're getting some impact and then another option is something like a jump board if they have access to a Pilates reformer or something in a physical therapy studio depending what they have access to. So gradually turn to impact and jumping and then similarly a gradual ramp up to lifting especially overhead lifting for our dancers who are in traditionally masculine roles that tend to do more overhead lifting and of course volume loading. So we talk about okay if you're going to need to dance for six hours a day in a professional company or more what are you doing today? You know are you being six hours of some sort of activity any kind of cardiovascular core strengthening dance activity because if we're going from say an hour to six hours that's a large jump and so I try to map that out with my dancers as early as possible to map out a clear timeline of how we're increasing that so we don't get behind. As a physiatrist we're putting all these plans together for them and then when we look at our barriers and where dancers are from our starting point and where we need to get them for their functional goals what else do we need to add? Nutritionist, are we still dancing, sports psychology, all of our other allied care. We also need to make sure that we are keeping ourselves responsible for educating our dancers on COVID vaccine, masking, social distancing. There is so much information out in the media that I do ask every single one of my patients are you vaccinated? Do you have questions about vaccine vaccination if they are not vaccinated? I will always say a very gentle spiel for all my non-vaccinated dancers like hey did you know that it's FDA approved now so if you have any questions about it let me know. Most of my dancers are vaccinated they've had it's been a great success it definitely protects you against COVID which is very good for your dance career. So I'll say a few little things like that not pushing it but making sure that they know that I'm a safe space that they can ask for that so that we're looking at their overall health and then of course we wanted to ask them about COVID make sure that we have as physiatrists that we've identified our team of sports cardiologists or anyone else we might need to bring in to treat our dancers with long-haul COVID or COVID symptoms and making sure that we're addressing the medical aspect and not just their musculoskeletal health of their return to dance and any potential post-COVID or long-haul COVID issues. Recovering a dancer is a little bit more of a larger topic and we're not going to spend too much time on this but it is something that we want to think about so as we're getting through these functional goals we're getting our dancers back to professional company we have that moment like I had a clinic a few hours ago we're going are we getting back to dance and then we go how much are we getting back to dance are we getting back to the same level and so this really is a team approach so it's about team communication so from the medical team we really want to put our team together and as a team I actually did this myself in the middle of COVID it was very stressful I actually put together like my own little dance camp where I had my favorite dance teacher I had my favorite dance physical therapist I had my dance massage my dance partner we all came in and did a few days of like dance camp and at the end of it I was like oh wow this stuff I recommend really works this is fabulous like it was so much fun and really rejuvenated myself as a resilient tool and it's something that we can help with resilience is most dancers dance because they love it at some point in their life they loved it so how can we reignite that and use our resilience training to bring that in together and a lot of times this might be like a group therapy of how are we communicating with our coaches our dance partners our parents what do we need what do we not need to help them make sure that they're transitioning successfully with getting back to their career and the other thing is really asking them what feels happy so my dancer today who I spoke with who was not sure that she's getting back to dance and um four weeks ago and then today she's well I woke up back to dance a little bit I said well what sounds fun what's fun what's less stress and what's fun these are my two questions I ask all the time since COVID start what is less stress and what is fun and she goes well it'd be less stressful if I could only dance three days a week I'm like no one's telling me you can't dance three days a week well it'd be most fun to do like just ballet and contemporary do ballet and contemporary these are fun things so what is less stress what is fun and then she's like well what if I want to do more I'm like you can do more there are no rules here it's dancing it's okay so these are the conversations that I said well let's start you back you know in two more weeks when you're getting back from your injury we can start you back just three days a week just ballet adding some contemporary and then we'll see what next semester looks like so really kind of mad stepwise process of what that happy place is for them a recent ring is a nice word as Dr. Popoli also said since dancers tend to relate with that but then also question comes is should we recovering dancers do dancers want to be recovered so at some point as you know if someone's out for an injury or out for COVID or having life changes it makes them rethink their career goals and there are a lot of resources if you're very used to treating patients but maybe not dancers are fantastic resources to help dancers transition out of a professional dance career and into another career that is very fulfilling for them so career transitions for dancers is under something called the actors fund it's a fantastic organization so the actors fund is a great resource that I'll send my dancers to if they have financial needs from being out of work due to COVID if they are considering career transitions or if there's a lot of social issues going on or maybe just a little social issues going on if they're racking up any medical bills maybe due to COVID and financially that's an issue the actors fund so they have a lot of they have a whole dancers resource within the actors fund and I will send them there if perhaps we're trying to transition or have other issues that we need to be addressed so with that I'm going to stop screen sharing and hand it on to you. Thank you so much. Some great tools for addressing the needs of our dancers. All right next we have Dr. Rondeo Lazaro musicians adaptations to the COVID-19 crisis. All right good evening everyone so I'll be talking tonight about musicians adaptation to the COVID-19 crisis. So during the COVID-19 pandemic music makings changed drastically in addition to the risks that are associated with social gathering certain forms of music making such as singing carry an even greater risk of transmission and infection due to the fact that SARS-CoV-2 is transmitted principally through exposure to respiratory aerosols or droplets that carry infectious virus. We saw this early in the pandemic with a notable case of an outbreak occurring in a choir rehearsal in Skagit County in Washington where 53 out of 61 singers who were in attendance were either confirmed or strongly suspected to have contracted COVID-19 and two singers had died. There's also been additional media reports of COVID-19 outbreaks associated with choirs. There have been cases with high secondary attack rates in various other countries so it's become important to more clearly evaluate the risk of music making during the COVID-19 pandemic and develop strategies to mitigate that risk since those changes have implications not just for the wellness of amateur musicians but also the education of music students as well as the work and livelihood of professional musicians. So there have been several studies that have investigated aerosol release from singing and playing wind instruments. This one is a paper from the International Coalition Performing Arts Aerosol Study. So the investigators here used flow visualization, plume level measurements, and computational fluid dynamic modeling to characterize aerosol spread with singing and playing wind instruments. And so they found that performing with wind instruments produced a greater number of airborne particles compared to normal speaking levels and comparable levels to singing and theater performances. However, using the use of masks had greatly reduced the aerosol concentration measured in front of the source. That's the case with both singing as well as with bell covers for example for wind and brass instruments. The computational fluid dynamic modeling showed differences between outdoor and indoor environments. So in an outdoor environment the ambient wind breaks up the musician's plume and expels airflow, accelerates the dilution of aerosol, whereas indoors aerosol spread is increased due to the space confinement and distribution within enclosed walls. And exposure is also dependent on distancing and time with longer time of exposures as well as closer proximity to the musician increasing infection risk. So in their supplementary material, the investigators of this study summarized recommendations for singers and wind instrument players based on their study findings. So those include using well-fitted masks for singers as well as bell covers for wind instruments since aerosol concentrations that are measured at the bell of instruments and in the front of the mouth of singers had decreased across a wide range of instruments and performers when a mask or cover was worn. Their recommendations on the type of rehearsal space with a preference for performing or rehearsing in outdoor spaces and if musicians can't perform outside then indoors performance spaces should be highly ventilated. Other recommendations include social distancing based on TDC and local guidelines, limiting rehearsal time to 30 minutes at a time before leaving the room for at least one air exchange, as well as the use of HEPA air cleaners to supplement ventilation since HEPA air cleaners increase air changes per hour and decrease aerosol concentrations in a room. The International Coalition Performing Arts Aerosol Study released updated guidelines most recently this past August, again reinforcing the previous guidelines that were put out in their paper but with a few updates. So again, your outdoors is the safest space, indoor environments can vary greatly, so still recommendations for use of masks and bell covers. Mask material should consist of surgical mask MERV 13 material or another similar standard. In terms of rehearsal times, there's been some expansion of that, so in spaces with good ventilation rates and HEPA filtration, increased indoor rehearsal times of 50 minutes can be considered, and a minimum of three air exchanges per hour should be used. Although there are spaces with higher air exchange rates, you can consider longer rehearsal times. For physical distancing, they said that at this time it can be decreased to three feet, and again, adjusting farther or closer depending on local conditions. Importance of hygiene, including appropriate containment and elimination of brass fluid. The Performing Arts and Medicine Association put out performing arts guidelines for different performing artists, including instrumentalists, singers, as well as other performing artists, dancers, theater performers. So going over the musician guidelines, they'd stratified risk levels for different types of music making, blue risk level being no known increased risk over normal daily activities, so these include non-wind instruments, string players, percussionists, keyboard players, and this is based on level three, what they described as expert opinion. Yellow risk level being a probable increase in risk over normal daily activities, which include wind instruments, brass and woodwind players, and then red risk level, the highest risk level, which is real world evidence of spread of disease associated with this activity, which as we've seen in previous case reports includes singing. And so then with their performing arts, the guidelines for instrumentalists and singers echo those that I already discussed, physical distancing, face covering, limiting rehearsal time, certain considerations for wind instruments, including bell covers, proper hygiene, and then for singers, again, using masks, considering virtual and socially distanced events. And so how else have musicians been adapting their work and their lives to the pandemic? So there have been a few studies looking at music student adaptations earlier in the pandemic, and with these more recently published studies in 2021, these studies were mainly conducted back in mid 2020. So obviously a lot has changed since then. But some things to note include adjustments in practice time. So studies have been kind of, there have been a couple of survey studies looking at music students over in Germany. One study didn't show any overall changes in practice time per day. Another showed sort of mixed changes, some reported an increase, some reported a decrease. Interestingly, there was a difference between performance and music education students where performance majors had decreased their practice time per day during the pandemic, probably due to the closing of practice facilities or, you know, missing the pressure of routine performances. Whereas music education students' practice time per day increased probably due to their additional seminars as part of their curriculum, either being postponed or taught online, which then freed up practice time. There's more of an emphasis during the pandemic on self-regulated learning, particularly on reflecting and creating a framework for the progress of musical learning. So that indicates that music students have developed a more individual and more self-motivated level of practicing and use their efforts more effectively to accomplish their practicing goals during the pandemic. In terms of mental health, it's been noted that students have shown increased stressful thoughts and feelings, and also a general fear of health problems was a predictor of worse mental health status during this time. There was one study conducted in Spain looking at music students who were enrolled in a program based on mindfulness, yoga, positive psychology, and emotional intelligence, and compared to students who weren't, controlled students who weren't enrolled in that program, the program showed higher engagement of implementing practices to improve health and well-being, including things like yoga and meditation, exercise, that type of thing, as well as higher rates of perceived benefits from these wellness practices. Another study looked at professional musicians, specifically conducted one-on-one interviews with 24 orchestral musicians in the UK during the first COVID-19 lockdown, 12 mid-career orchestral musicians aged 35 through 45, and 12 seasoned musicians aged 53 and over. And some of the common themes that came up in these interviews included, at the time, in mid-2020, a loss of career with the change in their previously successful career, now having come to a halt at that time, a sudden loss of work with the start of the lockdown, missing music-making and their colleagues. Also, a lot of talk about anxiety, about different things, money, their individual future careers, the future of the classical music profession, and emotional behavioral signs of distress, which include disturbed sleeping and mood disturbances. The importance of maintaining their identity as a musician, so which gives them motivation to play and practice, a challenge to identity when they were, as a musician, when they were unable to work or had to take other jobs. But ways to maintain that identity as a musician were ways to collaboratively play, for example, through online projects or through teaching. Strategies for coping in these musicians include support networks of friends, family, and colleagues, using cognitive strategies such as positive self-talk and reframing the situation as temporary, active strategies such as exercise and other daily activities, and social media, which has both positives, connecting with other people, and negatives can be a distraction for some musicians. And then also finding opportunities and positives during the pandemic to expand their musical skills, learn new non-musical skills, and focus on their health and well-being. So some of the alternatives to in-person group music making that we've seen include online real-time joint music making, so for example, Zoom rehearsals or collaboration through specialized real-time online music making programs, or alternative remote joint music making methods, for example, the so-called virtual choirs or virtual ensembles where you where you chord your parts separately and then compile them and then present the and then compile them and then present the finished product to a wider audience online. And then also, you know, live stream performances to share and connect with the audience. And so one survey that looked at musicians' experiences with these different music making methods showed that overall, as far as motivators for joint music making, overall enjoyment of music was still a priority, but social connectedness had increased with the use of these methods. Obviously, a decrease in live music making, but an increase in the use of the real-time joint music making and alternative remote joint music making. Let's talk about some different programs. More common general video conferencing platforms were more popular just, you know, from experience from working with them, but they can tend to have latency issues, so it's not really feasible with those programs to do concurrent live performance. And then this is another study looking at a survey of a wide range of musicians drawn from different communities, not just classical, but also jazz and other forms of popular music, looking at patterns of collaborative behavior among working musicians, both surveys and also one-on-one interviews with selected participants. And these are some of the themes that had come up, you know, artistic opportunity during the pandemic, you know, being more open to taking risks, fostering the intimacy with virtual relationships, developing a hunger for music and art, having an intro focus during this time, you know, working solitarily with practice, you know, nostalgia for, you know, older music, previous projects, being able to reach out, have outward reach with their projects, maintaining their connections, using the synergy of collaborating with other musicians. Some issues with social constraints, you know, with real-time musical interaction, technical and structural constraints, particularly with, you know, technical issues, lack of technical knowledge, financial instability as well, ethical concerns, you know, trying to help with community solidarity, but, you know, concurrently with some of the, you know, racial justice issues that were going on at that time, being mindful of those, as well as, you know, extensive use of internet, as well as other standalone software. So in terms of future directions for research, looking at musician adaptations to the COVID-19 pandemic, it'll be important to look at musician experiences during this past 2020 to 2021 season. I expect over the next year, those types of studies will be published. Looking at, particularly looking at the effects of risk mitigation measures and guidelines, as far as impacts on COVID-19 transmission, and also more recently, through this year, the effects of vaccination, as well as reopening, as concerts are being held, ensembles are getting together again at different levels, and audiences are welcomed back into the performance halls. Thank you so much for your time, and I'm happy to answer any questions during the Q&A. Thank you so much. That was really great to see future directions, things are reopening, where things are changing. So really glad to see all these coming up. I would love to encourage people to put any thoughts in the chat section, any, you can send questions through the chat, you can raise your hand and ask them. If you would like to show your face, we'd be happy to see you. And I think it would be helpful, you know, for anybody who's comfortable, maybe we'll start with our panelists, and then, and then anybody who would like to come, just to say a few sentences about where you're at, because that might help spark some discussion, both amongst ourselves, and for anybody that has questions on our role in performing arts medicine, what we're doing, and what the opportunities are. So I'll go first. I'm Lauren Elson. I am a, I work at Spalding. I have my certification in sports medicine, and besides, grew up as a amateur musician and danced professionally, and now I'm trying to see as many dancers and musicians as I can. I work with, I work on the Task Force for Dance Health at Dance USA, on the iADAMS board, and take care of a local dance company here, and happy to see your faces and answer as many questions as we can. So I'm going to just go across my screen and call on each of you. Let's, we'll start with Rondi. Hi everyone, I'm Rondi Michael-Lazaro. I'm sports medicine attending at the University of Rochester. I'm also, the musician topic is another, you know, is near and dear to my heart, you know, being a musician myself, as a singer and violinist. So I've had to adapt during the pandemic, and I started, you know, just pretty much at the University of Rochester, just before the pandemic, just right before the pandemic. So I've been, you know, slowly, you know, starting, you know, starting out here. I finished my sports medicine fellowship in 2019, so I've been trying to, you know, start my, you know, sort of, you know, getting, getting involved in performing arts medicine through, we have the Eastman Performing Arts Medicine Program, in collaboration with the Eastman School of Music. I've been, you know, starting to work with people like Dr. Ralph Manchester, who's the head of the Eastman Performing Arts Medicine Program, and head of University Health Services here. Thanks. Next is Scott. Hi, I'm Scott Homer. I specialized in hand and upper extremity at Spalding and Brigham and Women's, and I'm part of the Brigham and Women's Performing Arts Clinic with Michael Charnas. And so I'm specifically interested in instrumental musician injuries. I grew up playing drums, and play some strum string instruments as well. And, and I'm just very interested in, you know, the topic that I talked about today. And I'm hoping to, basically, my goal, ever since I got injured as a drummer, was to learn more about this, and made it through all my medical training and realized that much of it was unknown. And now I'd like to figure out more. Next is Kathleen. Hi, I'm Kathleen Davenport. I'm the Director of Physiatry at HSS Florida in West Palm Beach, and I'm the company physician for Miami City Ballet. I'm one of the co-chairs of the Dance USA Task Force on Dancer Health, and I have just rolled into the role of Vice President, President-elect I. Adams, the International Association for Dance, Medicine, Science. And I see a lot of local dancers, and musicians, and other performing artists in the South Florida community. Next is Ying. Good evening, I hope everybody's doing well. My name is Ying Li, I work at UNT Health Science Center. I work with Saj Surve, who was here earlier, but I don't see him anymore. He might have signed off. He started the Performing Arts Medicine program at UNT Health Science Center. Also, he and I, together, we run a Performing Arts Medicine Fellowship. We see Texas Ballet Theater dancers. We also see musicians and dancers all around the DFW area, including Fort Worth Symphony, as well as Dallas Symphony. We also have a clinic on the campus of UNT College of Music, and so we see a ton of musicians there every week. If you are interested in further training, we can provide that for you, if you want to come down to Texas. Next is Jeremy. Hey everybody, I'm Jeremy Stanek. I'm on faculty out at Stanford University out on the West Coast. It's actually still kind of sunny here, for those of you on the East Coast. I've started a Performing Arts program out here. My background is in music as well. I was a professional trumpet player before I became a physician. I've been treating musicians and dancers of all ages and all abilities, you know, from around 10 years old up until, I think, the oldest patient I've had was a dancer who was still in her mid-90s dancing. So, all abilities, all skill levels, I see them and have been actively getting our sports medicine fellows and our residents involved as well, both in research and in treating and seeing our musicians and dancers. Okay, Matthew. Hi, I'm Matthew Grierson. I am in Seattle, Washington, and I have a private practice clinic where I'm medical director for the Seattle Clinic for Performing Artists. And outside of my day job, we have a non-profit that we started here in Seattle, where we have a free clinic where we bring in physical therapists, acupuncturists, chiropractors, massage therapists, and lots of physiatrists. We'll let the orthopedic surgeons come in too, just as long as they promise not to recommend surgery. But we do that clinic once a month, which is a free clinic for dancers and performing artists. And like Jeremy, we see people across the entire spectrum. You know, last week, we had a trombone player who was 70 years old and having some neck arthritis issues affecting their playing. And oftentimes, we'll see brand new dancers even just going up on the point who have questions about that. So, it is a really fun and rich community here, where we all learn from each other. It's one of the wonderful things about physiatry is what a team-based sport it is. And, you know, none of us have all of the answers. And so, the more all of us start to collaborate with each other, the more we're going to learn more. We are actually recruiting for a study in Seattle. Unfortunately, if y'all aren't in Seattle, it's not going to be all that helpful because it's a study of Seattle area performing artists and how they were impacted by the COVID-19 pandemic. And so, it's a qualitative study. So, hopefully, we'll have some of those results to share with you next year as they come in. But I also serve on the Adams board, and I love working with performing artists. Thanks. Next is David. David Gottlieb. I'm at Atrium Health Lake Forest Baptist. I have to make sure I get the name right now because we switched names. And I founded the performing arts medicine program at Atrium Health Lake Forest Baptist before I did medicine. I was a professional actor. It was my old day job and realized I, number one, wasn't that good at it. Number two, couldn't make a living doing it. So, ended up doing, hanging out with all you guys instead, which is awesome. In addition to performing artists, I also work at UNC School of the Arts outside of my private clinic to work with their dancers and musicians. And then I founded a certificate program for the School of Medicine for resilience. So, try to train medical students. Great. And Tracy presented at our first community session. I don't know if you're there. I would like to introduce yourself. Hi, everyone. My apologies. I am hiding in a bedroom away from my sleeping four-year-old daughter. But my name is Tracy Espiritu McKay. I am an attending at NYU Langone. I'm a staff physician at the Harkness Center for Dance Injuries in New York. In my practice, I like to treat performers, musicians, dancers, actors. My background is that I did professional musical theater in New York City. And the goal was always to treat the performers when I left the field. So, I'm happy to be here. And my apologies that I'm turning my camera off again. Thank you. For any of you joining us, we'd love for you to introduce yourselves. And if you have any directive questions, I have a lot of potential discussion questions, but wanted to hear from you guys first. I can speak up. So, I'm Steve Lubert. I'm currently a third-year PM&R resident at the University of Missouri in Columbia, Missouri. I am really excited about just being more involved in the field, especially with performing arts. Being a past musician myself, I had a pretty colorful musical past. I was a violinist trained with the Suzuki method. And then I played the trombone with marching band and jazz band, was a drummer, and then in college took up beatboxing. And so, that was an exercise in a lot, as well as taking up learning how to sing on top of that. My a cappella group was really excited about getting me to learn how to sing outside of just doing vocal percussion. So, that's my background. Hey, I was gonna say hey, my name is Mike. I was here last week as well, and I like to listen and do as much as much as I possibly can of some of these meetings, but I'm a fourth year Pumanar resident, Cleveland, and I am in the midst of my sports fellowship applications and doing my interviews, but prior to Madison, I toured primarily in the heavy metal community, hard rock community. I worked in management and things like that. One of the things I often see underrepresented in this sort of world is that touring more hard rock metal musicians, so having sort of lived in that world for a while, I kind of see that there's a lot of issues that come up with them, so that's kind of what interests me, but also I got some young daughters that are getting into dance and things like that. Trying to take it all in. It's such an interesting community that I kind of love it in general, so thanks for having this stuff. I hear some audiology lectures in our future. Next. Hi, I'm Jenny. I'm a Pumanar resident at Hopkins, third year. I'm interested in doing sports medicine, but with some performing arts medicine focus, I grew up classically trained in piano, and that's why I became kind of more interested in performing arts. I've never been a dancer. I don't have the rhythm for it, but I've always enjoyed just going to, you know, ballets, like all sorts of dance performances and all of that, and also, I just felt like growing up, you know, playing music, there isn't a lot of good care. You don't really know to seek out this, like, specific care for musicians or performing artists and whatever, and so I actually have a question for the group is, how do you increase the awareness, like, besides having more providers being interested in the field and providing this care, but how do you raise them among letting them know they're also athletes, and they need, like, prehab and prevention and, you know, all of that, and to know when to seek out care, know how to take care of themselves before they seek out care, and who to go to, et cetera, because recently, I guess I was able to get a grant from AMSSM to, like, a community grant to help, like, put an event, a community event on for the performing artists and the local Baltimore community to really try to reach out to inner-city kids. With COVID, it's been hard to, like, actually get that up and running, but just kind of using that route, but realizing that a lot of people actually don't know about this, and to get the community engaged to even sign up for this event is a challenge in its own. That is a very loaded question, and I think that could spark a very great discussion. If anybody else wants to quickly introduce themselves, we'll jump on that topic, because I think it's, I think we have a lot of people that can contribute to answering that. I'll say hi real quick, then. Hi, I'm Dana. I apologize in advance for very poor lighting and potentially poor sound, as I am at a coffee shop, but I did my residency at UC Davis. Now, I'm doing a Pete's Sports Medicine Fellowship at Northwestern and Lurie Children's. I have classical training in dance, piano, and violin, and so performing arts medicine plan for that to be a big part of my career after fellowship. Thank you for having these sessions. I'll just go ahead and introduce myself as well. Sorry for the lighting as well. My name is Ramsey Katragada. I am a transitional year, PGY1 currently, and reapplying for PM&R residency right now. I just wanted to join the session because I just thought performing arts medicine is a very interesting field. I had never really heard much about it until I was exploring community sessions for this AAPM&R conference. My background in performing arts is primarily as a dancer in multiple Indian genres. I performed prior to med school. I was a part of competitive groups and performed at different competitions. So, I really enjoyed the presentations, particularly about dancers. Excellent. I think if there's anyone else, feel free to raise your hand and jump in. It's really wonderful to see you guys all here. So, we're going to go back to Jenny's question on how do we advertise? How do we get people involved? I feel like there's so many different places I want to jump on, but before I forget, the one plug that I do want to put in is please use our Performing Arts Fizz Forum community because I think by performing arts Fizz Forum community, because I think by putting a question like that out there, you might get some ideas and input and can really reach a really broad audience. There's a lot of us that are doing community outreach and I'm sure there's many more that aren't on this call today. I think you might get some ideas and some help for your project and maybe some collaborators. Does anyone want to start off by tackling part of her question? I can at least say something about being a physiatrist who's new to an area. I've been in the San Francisco Bay Area for about three years now. One of the reasons why Stanford hired me was because of my interest in performing arts medicine and they wanted me to build a program out here because there was really nobody in the Bay Area doing that. So, starting a program out from program out from scratch, nobody knows who you are, what you do, anything like that. So, I just kind of went out and beat the bushes. I got to know a lot of the physical therapists in the area. I said, hey, here's who I am, here's what I do. I did the same thing with all of the college music programs in the area. I wound up going out to each of those programs, get a one hour lecture for their students. One of the programs out here has a pretty strong music program. They've invited me to come back every year to be part of their Dean's Lecture Series, and I'm doing that again this Friday. So, just getting out there, introducing yourself, say, hey, here's who I am, here's what I do, and then try to utilize some lecture time or something like that to educate your audience, whether it's professionals, amateurs, whatever. I reached out to our local American Federation of Musicians chapter and said, hey, I've got this program started, and they were very, very receptive. They had me come out and do a presentation for their membership, and then they sent an email out to all of their members saying, hey, we've got this resource now available to all of you. So, just, you know, reaching out to all of these people can really work wonders for you and give you a good educational opportunity to reach people and educate them. I think I saw Kevin. Yep, I agree with that. To add to that, a couple other tips and tricks, because those are, I think anyone on the call would agree completely with Jeremy that that's kind of how we've all kind of built our programs, done the things, beat the bushes, done the lectures, meet with people. I can let Matthew speak on it more, but when we were in Seattle together where I did my residency together with Matthew, we put together the Seattle Dance Medicine and had a journal club, so that became a really tight community that then after I left, and Matthew has expanded now beyond my wildest dreams, but it's been a really tight community so that then you have more resources not only to help each other, which helps with resilience, but then also to get the word out to dancers and things like that. Another thing that's really important is just marketing. I don't know anyone on this call that sees 100% dancers or 100% musicians. We all see a very mixed clinic, but we all market ourselves very much as dance and performing arts medicine because honestly, you know, for what I do, there's always going to be an 80-year-old with chronic low back pain, right? That's not that hard to get. I'm not going to lie, but making sure that the dancers know you're there and making sure that the musicians are aware that you're available to them, that's a little bit more specific, so I always make sure I put that on my taglines, on my signatures everywhere. This is where I advertise myself. The other stuff will come, to be honest, and then last, for the professional dancers, Lauren and many people on this call can also speak to the fact that we'll do a lot of health fairs for the professional dancers, especially in the pre-times. The COVID times make it a little bit harder to do screening clinics, and with Dance USA, we have a screen for professional dancers, and we work with that to be able to put together the whole community and do a screening for them so that we're putting together almost a whole health fair in a day to be able to help them and serve the community. So those are a few other tips and tricks that I think many people on this Zoom have used to help build and get the word out and serve our communities. We have a really different model down in Texas, so we've actually done a couple different type of engagement with the local performing arts institutions. With Texas Ballet Theater, we actually were able to prove to them that having us on board actually reduced this cost for them, and so when we went to them, we were able to provide financial gains for the board for the Texas Ballet Theater, and so they employed us to retain their low costs and occupational sort of injuries cost for them. And for our educational perspective, I think what we've done is we, because we're so planted in UNT College of Music and we have their like musicians clinic on campus, we have ample opportunity to educate them from college level up to PhD level to the faculty, so we regularly give lectures in their courses. So yeah, so they are able to educate, we were able to educate them on health and wellness, and that kind of ties into the TMEA, the educational requirement for Texas, where we actually have in our, in state of Texas, is a requirement for each music educator to provide some sort of a health and wellness content for their students. So we are there to kind of help them in that way, and so it's a little bit, we, in the beginning, we try to kind of model the sports medicine model in a way, like we wanted to have like a training room for the for the College of Music and also for the dancers and performers on campus, and we try to replicate that at TCU, not as robustly as UNT and then and other institution, Texas Women's and things like that, but we realize that dancers, while they're small muscle athletes, they are very different from athletes, and also musicians, they're all just, they're just different, so we had a hard time kind of replicating the training room model as we originally envisioned it to be, but it's becoming something else, so maybe you can try that if you're willing to, anywhere you go, it might be a different rules and different laws and different organizations, but you can try our model as well, if you're willing. All of that's great. I just wanted to chime in and say, you know, as you're starting out, it's very daunting, it's, it feels like this is inaccessible, and just realize that it's not like there are too many musicians or too, I mean, too many people taking care of musicians or dancers or performing artists, circus artists, I even see comedy club performing artists too, but I mean, I mean, go to the Dolly Dinkles Dance Academy and, and just show up one day and say, hey, I want to give your dancers a lecture one Saturday morning or something like that, and they would love that, and go to, like, the local high school and offer to give something to the high school students. I think so much is focused on, like, the elite or the, even the university level artists, athletes, that we forget that some, there are more grassroots opportunities, and then that's where you start to really build those skills and figure out where you fit into this world and, and what niche you want to carve out for yourself and practice with those lectures, and people will start to get to know you, and just one day you'll, like, wake up and be like, oh my god, my, I, the 50% of the people I saw today were performing artists, how did that happen? You know, it starts slow and it blossoms from there, but don't, you know, whatever you can do to start is, is going to be a great start, and you can always use all of us here as a resource, too, if you have questions along the way. Yeah, I think there are, I say, I think there's a lot of great ideas that have been brought forth, you know, I think, ranging from, you know, if you go back to the original, the first dance medicine studies, like, from 20 years ago, where they incorporated a medical team into the Boston Ballet, and they were able to prove that it was actually a huge money saver to have an in-house team, but, you know, your point is, like, how do you get earlier than that? And there are also a lot of studies that show that performing artists don't go to the medical field because they don't trust us, and so really what we're trying to do is build trust, and so we heard a lot of different ways where that was, people had some great ideas of getting in and getting access to the artists. And we know that there's a culture, you know, within the arts, and so a lot of the organizations like PAMA and iADAMS are really trying to bring everyone together, bring the instructors together with the dancers and the medical team, so that way the medical, or that the instructors know that we're there to help, and we can start to collaborate a little bit more. So I really encourage you to get involved with these organizations, so that way you can collaborate with teachers and try to help change the thought process and the teaching and the culture. All right, I see a note from Frances. Hi, welcome. Her question are, what are some ways to get more in-person exposure to performing arts medicine during residency? And she's in South Miami. For example, she'd like to volunteer somewhere. I think Kathleen can handle that one. Yes, yes, and so I was trying to read the whole thing very quickly. Yeah, in South Miami, in the future, you could come volunteer and hang out with me in my clinic right now during COVID. I have lots of people who want to come shadow me, and we're not allowed to have people in the room, so it's like this horrible time, but please connect with me. We're not going to be in the COVID times forever and ever and ever, and we'll be able to have people in and bring them in and have shadow, but yes, for sure, it can be tricky, but yes, I know you are in Larkin now, so yeah, let me know, and hopefully at some time we'll be able to connect. Also, don't forget, you can reach us on the Fisk Forum. I'm pretty sure you can send direct messages through there, and I don't know if you guys, if all the panelists want to just throw your email up in the chat, so that way if anybody wants to reach out or has questions, then you can get a hold of us, but you know, like Kathleen was saying, it's harder to get into shadow at the moment. We're not taking any rotators at the moment, but we do have lots of ideas and so many different places to go. I wanted to hop on that last question, because I think most residency programs or even sports, math, and fellowship, depending on where we match, may not have the exposure or attendings who specialize in performing arts, so how do we gain the skills ourselves besides, you know, attending these lectures as much as possible, but there's a lot that goes into hands-on, like teaching, learning experiences directly versus just reading up things and watching videos. I'd like to say I learned everything I know from all the performing arts medicine physical therapists I worked with, but also, you know, during post-call days, during residencies, spending time with the team, like the head physician for the ballet, you know, just trying to find little chunks of time where you can shadow, even if it's not within your system. During fellowship, I didn't have any direct performing arts coverage, but was able to go to, there's a healthy dancer clinic in California, so I was able to hang out there, so I think it's about finding the people in the community, and you know, there's a lot of information at these conferences, so I encourage you to, you know, IADAMS content is up for another 30 days. That's a really great place to start getting some information, and you have access to, I think, over six channels worth of lectures over three days, so lots of great information there. Anyone else have any comments on that? Only just that you have more skills than you think you do, and your primary skill is going to be listening to the performing artist and hearing them, and yes, you know, there's aspects of the physical examination, aspects of little things that you can do with them, but after you get, you see, like, you know, 10 people, write down all the questions you have about, like, how that went, and post it in fizz form, and we can always give feedback that way, too, or find one of us at a conference, and you know, Kathleen and I, when we were residents together, we stalked somebody, one of the big gurus in dance medicine in town, and I don't know, you might have to, stalking people is always an option, too, if they're gurus in the field. You might not have someone in your city, but there's still ways to engage with them. I'll piggyback off of what Matthew said a little bit. One of the other things that I spend a lot of time doing is learning from dancers. We're learning from musicians. You know, they are very happy to teach you about what they do, right, so if someone uses terminology you don't know, or if you ask with genuine interest, they will give you an unbelievable amount of education, and so in learning to speak their language, I think is one of the biggest contributors to developing relationships with the communities. A lot of them do not seek medical care within the traditional system because they feel very isolated by people who don't know what they're talking about, so I think Matthew makes a really excellent point. Thank you. Anybody else? When things are better, I'm sure you can just kind of spend a week, two, three weeks, four weeks, wherever you want. COVID doesn't exist in Texas, so you can probably come now. I'm going to come hang out and do a fellowship. We would love that. If you want in-person interaction with performers, we can help you. I mean, I think we all help each other. I always ask questions to these amazing people. I don't know everything about everything. I'm partial to string players because I was a string player, so I understand them really well, but other than that, you know, I just recently had a singer in my office, actually like yesterday, and she just taught me everything about her whole pedagogical process. I had one patient cancel, so I just sat down with her, and she just taught me her whole pedagogical thing, and I wrote it down and read about it, and it was really great, and so now I'm going to approach singers completely different because of her. Thank you so much. We are getting to that time. I'm really hoping that we're going to be in person next year. I think it'll be really nice to collaborate, but please don't hesitate to reach out to any of us. This is a labor of love. This is why we wake up in the morning. We wouldn't have it any other way, so this is the group of people. This is why we went into medicine. This is what we want to be doing, and we're happy to learn from each other and share. Thank you. See you all soon. Good night.

musicians

COVID-19 pandemic

virtual performances

collaborating remotely

teaching lessons online

virtual experiences

music creation

performing arts medicine

performing artists

online platforms

building trust

financial benefits

gaining exposure