I want to thank you all for joining tonight's Member Community Session. Before we get started, I just wanted to review a couple of housekeeping notes. As a reminder, this session is being recorded and will be available along with the ability to claim your CME through the Academy's online learning portal. It's going to be available through next year, so you'll have plenty of time to watch it and claim your CME. For the best attendee experience, please mute your microphone when you're not speaking. You are invited and encouraged to keep your camera on and to select hide non-video participants. This will ensure that speakers are prominent on screen. To ask a question, please use the raise your hand feature, which is typically found under reactions and unmute yourself if you are called upon. Alternately, you can use the chat feature to type your question. Please note that time may not permit the panel to field every question, but we'll certainly do our best. And I know they're ready to get started, so Dr. Elson, over to you. Hi, everyone. Thank you so much. Welcome to the AAPMNR 2022 Community Performing Arts Medicine Session. We're all really happy to see you and really excited about growing this community. I know some of you guys are here live, and we really want this to be informal, so please feel free to send questions through the chat. We would love to create as much discussion as possible. And if you watch this in the future and want to reach out to us through the Fizz Forum, please feel free to do that as well. All right, let me share my screen here. All right, so quick overview for the schedule for tonight. Dr. Elson, your audio just got very quiet. Oh, there you go. So quick overview for tonight. So we're going to do a very quick introduction for you, and then we'll go into the physical exam of the dancer, go into cross-training of the performing artist, and then we're going to hear about the Performing Arts Medicine Fellowship curriculum. And then we're going to go into some case studies. So we have an action-packed night, and again, we welcome any type of questions or discussion that we have along the way. So just to bring us back and remind us why we're all here, we're looking at performing arts medicine. So as physiatrists, we are the key practitioners, we believe, to take care of these artists. And it really comes down to, you know, just like every other type of medicine, diagnosis, treatment, and rehabilitation, as well as getting into injury prevention. But really, I think the thing that makes the artist unique is understanding the physical and psychological needs that are different from other athletes and human beings. To be a practitioner that takes care of performing artists, you know, we basically are doing sports medicine, but we really need to understand the specifics of what we're doing. And that can be done both through personal experience or if we're just passionate of working with these people and being able to ask the questions about what is involved in these activities. Whenever people ask me, you know, how are artists like athletes, you know, especially if you think about a musician or a dancer who's dancing on point, how is that like an athlete? And in fact, the artists don't often identify themselves as athletes, but really, it does require the same amount of precision, the same amount of skill. The one main thing that's different is the expression and the actual art of these genres. So there's a certain amount of vulnerability and a certain amount of emotion. They can't grunt. They can't complain as they're doing it. They really have to be in the headspace of the performance. And whether it's a dancer working at a physiologic extreme or a musician who's, we call a fine motor master of small, intricate movements, there are different types of unique attributes that are required of each one of these arts. And so being able to understand that can really help us take care of these artists a bit better. And also understanding the psychological experiences that someone needs to have in order to make it as an artist and to understand everything that's going into it, especially the social consequences, the types of competition, the anxiety, and then also the uncertain careers. You know, for us, if we go out on leave, we have a pretty good job stability and can come back. You know, if an artist goes on a leap, it's very likely they'll be replaced. And I kept the slide in here just as a tribute to Dr. Hamilton, who's one of the leaders in dance medicine, because I really liked what he said about the perspective of, you know, the type of process the artists very often have is, you know, when they come in, they're very often through their minds, they're wondering, you know, what if I can't dance? Even if it's just like this little tiny hangnail, like, what if I can't dance? What if I can't dance? And we see them as being overly dramatic, but I think being able to understand where they're coming from helps us be able to treat them a little bit better. And we're trying to really overcome the stigmas and the barriers. And I think that's one of the biggest thing that we can do to promote, you know, physiatry within performing arts medicine is to really help break down these stigmas. It's frequent that artists will not come see physicians because they think that either what they're doing is not serious enough to stop performing, so they don't think they need to come in, or they think that we're going to ask them to stop or that there's going to be some major intervention involved. So I think that letting them know everything that we have to offer can really help break down those barriers. And why are we doing performing arts medicine at AAPNR? And I think I wanted to reverse the order of this. I think it's really important that, you know, we maintain our ties to the Academy because the Academy is really our home. Our home is, you know, how we're going to get paid at the end of the day. It's how we're going to be able to practice medicine the way we want to. This is our platform. But from there, I think if we can go through and, you know, get other physiatrists doing this well, then we can both improve the physiatry name recognition and also serve the performing arts community and really help get these performing artists the best treatment that they can get. And so here at AAPNR, by our involvement here, we have peer networks, peer supports. There's a lot of people here who have a lot of experience setting up clinics, treating professionals at all different levels. And so we can really help both each other and our specialty grow. So with that, I am going to turn it over to Dr. Davenport. Thank you. I'm going to talk about physical exam of the dancer. So let me get that on. So for the physical exam of the dancer, this talk really is to physiatrists who already know how to do a physical exam. So hopefully this is not anything basic. I tried to keep it high level for us. So we're going to go through some physical exams and then pearls that are dance specific. And of course, with our general approach, as always, we're choosing whether we want to go ground up or top down when we're looking at our dancer as usual. And then I always say kids don't stop. Athletes don't stop. Musicians don't stop. Dancers don't stop. So when I have someone in my office who's a dancer, a musician, and they stopped, it's something that is usually real, if that makes sense. So this is not usually something that they're going to come see me if it's so we're really looking for something, if that makes sense, when we're when we're doing this exam. Usually with our dancers, we assume it's going to be a chronic injury, but you don't want to forget your acute injuries. You don't want to forget your Ottawa foot and ankle rolls when we're going through all of these. And especially a chronic injury could be an acute injury that was missed or danced over. And so remembering our acute issues while we're looking at these chronic parts. And then we wanted to tell ourselves, are we doing evaluation, a quick and dirty screen or a full, thorough evaluation? So some foot and ankle pearls to talk through this. So we want to look at asymmetry side to side and the tight or the loose side could have the pathology. So that's one thing we want to be aware of. And I always trust my dancer when they tell me that they're tight because you may or may not notice a difference because their range of motion might be so elevated at baseline. So that is extremely important. Tailored tilt, of course, is when you kind of stand in parallel and roll on the inside and outside to see if they're tight there. This is something to pick up early in hopefully teenage years because it is something that we can correct early if we know of it. And whenever I do my range of motion, we really want to look passive active weight bearing with dance specific. So ankle dorsiflexion is different based on if we're actually doing a plie with that. So we're going to go through a few little areas we want to look at. Our first MTP joint. It can be a tricky joint. There are so many things going on there. I always say when people ask me what physiatry is, I'm like it's just applied anatomy. So if you're starting to see a lot of first MTP issues in your clinic, make sure you know all those nuances of how to find a planter plate versus those sesamoids. And then, again, a lot of times we're going to do palpation to make sure that is everything. The Tomasin's test is going to help us tease out how much is a functional versus structural. So that's when you have the dancer in full plantar flexion, dorsiflex the great toe, and then bring them all the way up. So if they can't dorsiflex here, that's more joint. Whereas if we can dorsiflex here, but then when we bring the FHL on full stretch and now it can't go, that really defines whether it's tendon or joint. So that's a really handy test for that. For posterior ankle, again, having our posterior impingement test, so really teasing out how much is a bony posterior impingement passively versus I like to get them into dorsiflexion and then push actively to activate the Achilles. So that can really help us tease out how much is passive bony impingement versus active Achilles. And then we always want to remember when we're taking our X-rays that the talus is an obnoxious little bone that gets in the way of a lot of dancers. So having the talus on ankle X-ray can not be as fabulous on foot X-ray. So that's why I throw in there the talus is a foot bone, and we really want to look at that. If you're seeing a lot of point dancers, you really want to know how to examine a point shoe, and there's a lot of courses and things out there for that. For our lateral ankle, I cannot tell you, just two weeks ago, I had a dancer come in, and she's like, oh, I was told I had an ankle sprain, couldn't get back on point, and it was a fifth met fracture that was missed. Leg pain. So the anterior leg pain for any of our compartments. A lot of times we might be in a setting, if we're doing an onsite screen, we might be in a setting where we can't make them run stairs or run around, and a lot of times dancers may or may not get any kind of chronic exertional compartment syndrome with stairs or running like our runners do. And so I love to have my dancers flex their feet back, and I will hang off of them, and I'm like, tell me a story, and I'll hang off there for 30 or 60 seconds to really over-activate anterior tib and see if I can activate it that way. And sometimes that will help with that and can be a little bit more handy in that clinical setting. So we don't want to forget our regular things. It's very common to see an anterior tibial stress fracture, and gastric strains are also super common. For knee pain, we tend to, and I have a dancer on my chart that says anterior knee pain, I'm automatically thinking of telephemeral, but we don't want to forget other anterior issues. So anterior horn meniscal tears I have seen many times, often missed by the radiology reads, so you really want to make sure you're looking for those. It's going to be a meniscal mechanism, but then a lot of times the radiologists and us too, when we're busy in clinics, sometimes we just forget to thoroughly look at that anterior horn, so don't forget to look at those. And then our adenostemptowns and to transfer to our airplane, which we'll talk a little bit later with that. For our hip pain, we kind of assume a lot of our professional, let's say ballet dancers are going to have some retroversion. So we really want to look at the full arc of motion and not just the internal or external rotation, but what is that full arc? And we get a lot of what we call hippy grippy stuff or snappy hip stuff that the dancers come in with. And so I'll have them lie on the back and tell them to do a fan kick, and I will see, I will see if they can change how they do it to stop snapping. And I can feel the snap with that, but I always tell them three snaps and you're out because dancers will do a hundred and flare everything up if you don't tell them to stop. Obviously, we don't want to miss our avulsions and our growing dancers, we see these all the time for our hip, and we really want to look out functionally. And so we'll look at some of those functional tests in a minute. Even though we're very much focused on certain body parts that we see the most commonly, we see lower extremity most commonly, we can see dancers injured anywhere. So lumbar spine, spondy is very common and a lot of compensation in the lumbar spine with what's going on the lower chain. In the shoulder, we can get some instability. So I've had several shoulder dislocations in my dancers, and we really want to look at the stabilization. And then overall body habitus, you know, making sure we're not missing any kind of other things that might be not keeping up with their nutrition. I usually run my dancers through a biting. This is something that can be quick and easy to do, and I strongly recommend it. It can take 30 seconds, and you can do it as part of your other knee exam, you're looking at the range of motion there. And again, if you start seeing dancers of a certain genre, you got to learn the equipment. So if you're seeing a lot of point dancers, you got to know how to use the equipment because so many injuries can come from a wrong fit. If you're seeing ballroom dancers, you need to know what those heels look like. And most dancers will tell you, you can really learn a lot from them and go hang out in a shop or a class to find out. But if this is something you're seeing, you got to know how the equipment works. So a few dance-specific things. So when you look at my dancers, we really want to look at them what we call parallel and turnout. So we're looking at these directions, and dancers will usually overtrain one or the other. So it's very helpful to make sure that you're looking at this, and when you're looking at turnout, you want to make sure that they're not compensating and bringing in some range of motion elsewhere like that horrible picture up there of the hyperlordosis that we can see that makes all dance medicine people cringe. That's why I put it there. So you'd want to ask your dancer to plie. If you're not familiar, this is kind of like a turned-out squat. And then you're going to see their alignment with that. Releve is going up on your toes. Again, if you're not familiar, starting to see a lot of dancers, these are some terms that can help you communicate better with your dancers. Plie and releve, if you get those two, plie, releve, and parallel, and turnout. If you just get that, it's a great start of working with dancers. And if you're seeing a lot of dancers, I really like to have my dancers be able to do 25 controlled single leg releves. That may not be practical in a clinical setting, but I can at least educate them that for a cross-training purpose. Cambray is your lumbar flexion forward and back. And again, we really want to make sure that we're not sinking into the hips or hinging at one spot like an L5, and maybe that's why we're getting our spondy there. Posse, bring the leg out to the side and then developing, bringing it straight out, extended beyond. Again, this is a cause of a lot of hip issues. So we really want to make sure that they're containing that and not really grinding in the hip socket or overusing that. Airplane tests, we really want to make sure that the dancer has control. I call this an advanced 8-inch step down. But I will say the alternate is the 8-inch step down, because just because the dancer tells you, I dance 40 hours a week and I'm amazing, doesn't mean they actually have any body control whatsoever. So sometimes if they fail this miserably, I will have them go 8-inch step down to see if we can get that under better control. And again, similar to how we do the 8-inch step down with this, you're looking for knee alignment, good control, core control, making sure you're not going into valgus. I always say when in doubt, listen to the patient. Sometimes dancers come in and they have this very, very specific rep. And even though I see dancers all day, every day, sometimes it's still something I've never heard of. So that's what I love about physiatrists is we always want to make sure we know exactly what our patients are doing. And our patients love to show us. So I always make sure I have space somewhere, somehow, that my dancers can really show us what that thing is that's bothering so much. So we can take questions now if you have them in the chat. As Lauren said, we don't want to keep this too formal. But at the same time, I do want to keep the presentations rolling so that if you have questions, we're going to keep rolling with the presentations. But we can jump in and always do that. So we can move on to our next presentation. And if you think of any questions or comments, feel free to type them in and we'll catch them at the end or in between. All right. So we, Lauren, did you need to say anything? No, I was just going to introduce you. But you can take it away. Hi, everybody. I'm Tracy Espiritu McKay coming to you, well, from Jersey. But from NYU, Rusk and Harkness. So Rebecca is going to be helping me because I don't really know how to use my husband's computer. So next slide, please. I have no disclosures. Next slide. All right. So objectives. We're going to be talking about cross-training for the performing artist. And we're pretty much going to define what cross-training is first. That would be helpful. Briefly, we're going to talk about the common injuries experienced in both the musician and dancer populations. We're going to review the reasons for these injuries as well as the importance of cross-training activities that are specific for these populations. Next. Okay. All right. Rebecca. All right. So what is cross-training? Cross-training, you hear the term a lot. It's ultimately an exercise protocol that uses various types of training that are a little different from what the athlete or the performing artist, what their main activity is, so that they can become more well-rounded in their health as well as their muscular development. It typically recruits different muscle groups that are constantly requiring the body to adapt, and it encourages neuromuscular changes that create different muscle and connective tissue adaptations, which ultimately enhance their movement and flexibility in their art form. This prevents overuse, and its intent is to develop the specific fitness components that the performing artist needs. Next slide. All right. So let's talk briefly about the common injuries that you'll see in these performers. So in order to understand how you want to apply cross-training to the performers, you need to understand the injuries that they're feeling or that they sustain. So for the dancers in particular, like Dr. Davenport mentioned, it's predominantly foot-ankle stuff. It comprises about 34 to 62% of the injuries, and if you want references for where I'm getting these numbers from, I've included the sources on the slides. So foot and ankle most prevalent in the dance community, whereas the upper extremity as well as head-neck injuries are most often seen in the musician and vocalist population. In this group of performers, typically the injuries are due to overuse as opposed to trauma. Trauma does happen, but it's very much so overuse injuries. And in the musician population, we like to call their injuries PRMDs for short, so performance-related musculoskeletal disorders, and that's defined as any pain, weakness, numbness, tingling, or any other symptom that interferes with somebody's ability to play their instrument at the level they're accustomed to. Next slide. So some MSK concerns for the musician. As far as their ideology goes, it's usually because they're playing their instruments that require a very precise repetitive movement in a prolonged non-ergonomic posture. These repetitive movements can stress the surrounding tendons, which can lead to chronic tendinopathy. And then you've got a prolonged maintenance of the static posture that really isn't ergonomic, which eventually leads to muscle imbalance and then possibly chronic myofascial pain. You can get work-related muscle and ligament symptoms associated with the weakness, loss of control or speed. But typically, if you were to look at their injuries, you might not really find an objective lesion. So then you sort of define these as an overuse syndrome. Now as far as specific injuries go, violinists and violists, they'll typically talk about neck and upper extremity pain because of their posture. Cellists are talking about back pain because they're always sitting. Bassists talk about back pain because they use their bodies, they use their trunks to stabilize the instrument, and they often play leaning forward, like the top right picture there. With pianists, they typically talk about scapular and wrist pain, usually from overuse. Clarinetists and oboists, they hold their instrument mostly with the right thumb, so they'll typically talk about MCP joint pain. Cladists will talk about left neck, shoulder, and wrist pain, and of course our wonderful Lizzo is there, and she is showing you what that position may look like. And percussionists will typically talk about left wrist pain because of repeated snapping of the wrists and fingers. Next slide. All right, so cross-training for the musician. This is pretty much how I broke it up. You talk about the injuries, you talk about why, and then how they could possibly prevent it. So there's a study out there by Lundborg and Gruten, where they initiated an individualized 11-week program that included a warm-up, upper extremity and lower extremity exercises, as well as whole body exercises. And they found that this functional resistance training could actually influence the neck, shoulder, wrist, and back strength. You have P values here, equal to 0.05 for increases in isometric strength for the wrist extensors, shoulder abduction elevation, as well as neck flexors, as well as an increase in reported endurance of the back extensors. You know, 29 to 59 percent of the participants talked about improvements in their mobility performance, as well as performance-related injuries, but it wasn't statistically significant for the study. But I mean, again, I mean, if musicians are reporting an improvement, you listen to them, and it's evidence for further study, for sure. So there are studies also that show that moderate doses of specific resistance training over longer periods of time, 16 to 20 weeks, as opposed to this 11-week study, has a better effect on neck and shoulder pain intensity versus other low-dose interventions, such as like low-dose physical activity, possible endurance training, and just ergonomic changes. Next slide, please. So now we're going to move on to the dancer. So we are going to talk about contributors to how they get injured. And typically, like I said before, it can be from overwork. It can be unsuitable floors. If you're not familiar with what the ideal floor is, you want a sprung floor, you want some air underneath the floor for some give. So like at a football game, I mean, oh my gosh, a basketball game, if you step on the court, you'll notice that it's elevated a little bit. So that would be ideal for a dancer. Difficult choreography. Choreography is getting harder and harder. People have insufficient warm-ups. Sometimes you'll see dancers, they'll just like sit in a split, and they'll be like, yep, I'm warmed up, I'm good to go. No, you're not. And then there's levels of physical fitness, particularly strength. So then we talk about fitness. Typically, dancers will say, I'm fit because I'm not getting an injury. That's not what it is. So fitness really incorporates elements of body composition, cardiorespiratory efficiency, and muscular strength. And in the dance community, there is an unfounded fear in some communities that increased levels of fitness can actually undermine the aesthetic appearance of the dancer. And as you know, there are lots of body image issues in the dance community. But there's published data there that shows exercise training is not detrimental to either dancers' aesthetics or their performance. In fact, it improves their performance because they found that exercise training results in positive adaptations of the key parameters that are associated with the aerobic fitness and muscular strength. Next slide. So cross-training for the dancer. In addition to a whole bunch of other wonderful medical benefits that we are well aware of, like decreased blood pressure and cardiovascular demands to exercise, improving your lipid profiles, your glucose tolerance, insulin sensitivity, that doesn't matter to the dancer. That's great for fitness. That's great for us and for health reasons. But they care more about things like reduced body fat, increased basal metabolic rate, the improvements in their muscles' ability to generate force, which can eventually enhance their performance, the strength that provides lower extremity strength for the power that they need during things like leaps and jumps, as well as muscle endurance for prolonged periods of use. So for them, that's important, right? That's what I put here, because that's what they see. But you also have to be careful about flexibility training with the dancer, because the majority of acute dance injuries actually have been found to happen during flexibility training. That was a really interesting article to read. So if you're interested, it's there, and I think you'll have access to these slides later. But if you aren't aware already, hypermobility in the dancer population is prevalent. Dr. Davenport talked about the bite and score. I mean, these are things that we typically do in the clinics. So it's important to tell a dancer, for example, a dancer practicing yoga, they may sit at the extreme range of motion without fully engaging their muscles, and they need to focus on the control and strength of their muscles, especially at that point, because they're not really benefiting from this program just by sitting in a split or trying to extend past their normal levels of flexibility. So that was the brief overview of frost training for the performing artist. That's my little nugget. I think we're taking questions later, but that's it for me. Thank you so much, and if you do have questions, feel free to stick them in the chat now. We'll start, that way we can start thinking about answers. I think we're going to head over to Dr. Li now. All right, go ahead and start, Dr. Li. All right, go ahead and start, Dr. Li. I was trying to unmute. Now, all of a sudden, I forgot how to do that. Well, your picture's so cute. Your daughter's photo, beautiful. Hi, everybody. Thank you so much for joining us at this hour on a Wednesday evening. We're so excited to just talk about what we love to talk about, taking care of performing artists, so that's wonderful. I'm here today to talk about our Performing Arts Medicine Fellowship curriculum at the University of North Texas Health Science Center. We created a Performing Arts Medicine Fellowship in 2019, and so therefore, my motivation to talk about our curriculum is a little bit selfish, to just promote a little bit of our program here, but also to just share some of what we went through and what we thought it was important to educate a fellow, and so that maybe those of you who are interested in creating something like this at your institution, maybe you can take some of that with you, and then we can all start to expand our training programs for our physiatrists and others. In establishing our curriculum, we set some of these goals. I'm not going to read this because that's a little boring, but I'll say this. Our goals were developed keeping in mind that anyone who will be participating in our fellowship is already a physician who already had completed their training in their primary specialty. We were thinking maybe a PM&R or others, maybe family medicine or other specialties who would be primed to take care of our performers, so other than the obvious goal of providing clinical experiences to be comfortable with medical issues specific to our performing artists, we really wanted to focus on guiding the fellow to understand the culture of individual disciplines of the arts and help them develop their own practice interacting with many different performing artists holistically. These are the objectives. Instead of reading out each of these objectives, I just wanted to spend more time later on outlining the curriculum design. We try to be a little bit more creative because it is, after all, performing arts medicine, and we will be reviewing the structure of individual curriculum. Some of this was already presented to the performing arts medicine conference a few years ago, but I wanted to see if we can spread the word a little bit more. Here's our curriculum overview. The length is obviously one year. We're not going to do more than that. We have set our didactic days Monday afternoon, four hours. The whole curriculum will start with a fellow, and we would interview the fellow because individual person who's coming to our program likely would have had some kind of arts background, and this person could have had dance background or music background, and depends on the background or maybe no background at all, just have passions for performing artists, and we wanted to have an area of focus for individual person who are going to be with us for a whole year. Our program will also include quarterly interview of the fellow, and we'll review cases, and then we would talk about clinical observations. This will also include pre- and post-online platform assessment. This isn't really going to be like a traditional multiple-choice question per se because it's just one person, but we plan to have more of an interactive online platform. We use a platform called RISE 360. Each day, our didactic day would be four hours weekly. We plan to have a straightforward didactic day, three sessions per month, and the fourth session, we wanted to focus on more research or scholarly activity and wellness day if they have to take a day off or go on conferences or holidays or something like that, and the content will be divided into these sections or what we call modules. The first module will be introduction, and then we'll focus on dancers, and then we'll focus on the instrumentalists. Then we'll focus on voice users. Then we'll focus on hearing health. We'll focus on performance psychology, mental and behavioral health. We'll review some of the related field, and then we will finish out the didactic curriculum with business management. This, we didn't do this with our first fellow, but upcoming sessions, we plan to open our didactics to our medical students. At our school, we have student organizations that is interested in performing artists and taking care of performing artists, so we plan to invite them to our session, and also residents who are training in other programs at our institution. The first module, we'll start with that fellow interview that we were talking about. We'll review their background or experiences with performing artists, and then we're going to try to see if we can tailor the content around their expertise or experience. We will start with learning the terminology. I think Dr. Davenport was saying, okay, if you're taking care of dancers, if you know the words turnout, parallel, releve, these words on point, if these words are helpful in taking care of our performers, especially dancers, that's the same with musicians and others. We're going to go through some of these terminology, positions in ballet or others. For instrumentalists, maybe anatomy of each instrument, musical terms. You should probably know what it means to play fortissimo or et cetera. Then we'll review background of each discipline, so dance, instrumental musicians, and voice users, like different disciplines and genres and things like that. We'll then discuss performer history and evaluation. Then we're going to go ahead and start doing pre-evaluation on our platform. Once we've gone through that, we dedicate about two months into the introduction module, depending on the fellow's background. Then we move right on to the dance module, and we name them getting to the point. We start with common injuries you see in this population. They will learn the basics of pre-season exam, point clearance as well, taking care of young and adolescent dancers. Some of this will coincide with their observerships. Each diastatic session has built-in debrief sessions where we talk about their observerships. A fellow will be required to do a short presentation or share their reflection with each of their observerships so that we will be reviewing this with them. Even if the fellow is really familiar with the dancer injuries, they may be more familiar with one type or one discipline, so we might need to steer their observerships accordingly. For example, if they're really, really used to seeing dancers, if they've been a ballet dancer before, then we may steer their experience to something else in terms of observerships. Thankfully, in Dallas-Fort Worth area, we have plenty, plenty of organizations we can try to guide our fellows for their observerships. Then didactics will naturally sort of steer deeper into their observership experience and will tie those experiences into their patient encounters as well. Each of the fellows have their own, well, one fellow in the past, they have their own private clinic, so we'll try to see if we can observe their encounters during their private clinics and try to see if we can tie in a skill system taking care of the individual dancers. Now, once we've gone through that, we're going to move on to instrumentalist module. Just like the dance module, we plan to go over common musician injuries, and then we'll cover instrumentalist-specific injuries that wasn't covered in the first section. We are assuming that a lot of our fellows will already been trained in evaluating some of these injuries, so we don't expect to train them and teach them each disease processes, but we're going to more sort of talk about how do they present in this population, how to take care of them. Similar to the dance module, these didactic sessions will be linked to their observerships. So, for example, they might be going to our UNC Denton's orchestra rehearsals for their observerships, and they might be able to kind of tie that into their private clinic patient encounters, but also, you know, we will be going through some of the instrumentalist, a common injury that instrumentalists go through. Just like the dance module, if they are very proficient with, for example, orchestra musicians, we are going to try to tailor their experience so that they spend more time with, I guess, for example, jazz musicians instead of orchestra musicians. So, this will be individualized per each person that spend that whole year with us. During the vocalist module, after the instrumentalist module, we will cover common injuries amongst vocal users, but specifically, we'll talk about phonation and dysphonia and common musculoskeletal injuries vocalists go through, including osteopathic dysfunctions affecting voice and sound quality, and this is really unique to our institution because we are an osteopathic institution. This is something that our fellow will be learning through our didactic curriculum. Then, for the, then again, just like the other modules, the vocalist module will also be paired with their observerships. We have plenty of experience that they can go through. So, you know, ensembles or operas around the DFW region is going to be what they're going to be going through. And then, mental health module, we're going to, this is actually going to be delivered through invited guest lectures, and then, and for hearing, we're going to have one of our previous fellow deliver the talks through the hearing health module. They will also spend time with our UNT audiologist. And then, second to the last, we will cover health issues in the related fields. So, choreographer backstage staff, costume staff, sound team, and things like that. The fellow will also have opportunity to work with our Texas Valley Theater backstage staff, as well as costume team. And then, finally, this is really Dr. Survey's alley, and he will talk about how to set up a performing arts medicine practice for our business management module, and how to build a PAM, performance medicine team. And then, we'll go through payment and billing. So, this is how I'm going to finish. We hope to have a new fellow starting 2023. We have interviewed and completed our selection process. We plan to recruit one every year, hopefully. I know this is a very niche area of PM&R, so we know that we may not get a fellow every year, but we really hope to get one every year. And we're starting to make the inventory of our curriculum and specifics of the didactics material. And we want to, hopefully, survey you guys who are interested in taking care of performing artists, and also are already taking care of performing artists. So, if you hear from me in the future, please don't ignore my emails. And we're going to wait until everybody's finished with questions, right? Thank you. I think that if we do have any questions on the talks that we've had so far, we can certainly field them. I don't see anything in the chat. I want you guys to go through the cases. That's great. But if not, we can have Dr. Cervé take over. And I think Dr. Popoli is going to present the first case. So, I will have you two go from there. Perfect. So, this is the part where we get to hear from all of you. So, we have a few of our colleagues have put together some cases that are a bit open-ended, and maybe not necessarily controversial, but have maybe differing opinions in terms of management and things like that, or are just interesting cases. So, we'll hear our initial presentation from our folks. And then there's enough of us here that I'll just ask that you use either if your camera is on, just physically raise your hand so we can call on you, or use the raise hand feature in the chat that are at the bottom so that we can call on folks. And then we want to stimulate discussion to hear from you. How would you handle these cases? What will we do about them? And we'll hear from our panelists as well if they want to weigh in. So, Dr. Popoli, if you want to take it on our first case and we'll take it from there. Sure. So what I plan to do is I will go through the chief complaint in the history press notes and I'll kind of stop and maybe take a poll from both of our audience members as well as the panel in terms of maybe where they would proceed in terms of how they might structure their physical exam or other things, questions that maybe I did not ask that they may have. So I'll start, and this is a 28-year-old professional pianist. He's actually also an electrical engineer, which I thought that was particularly cool. It made for very interesting discussion later in my appointments with him. But he is a very high level pianist. He's been playing for years, plays a variety of styles, but predominantly likes playing jazz. He's right-hand dominant, and he came to me with basically chronic intermittent pain in the left greater than right forearms for about 10 years. And he actually said it was worse over the last two or three months. His description of pain, and this is kind of a very interesting point that maybe I think a lot of us from the performing arts world might make. I think it was important to hone down on what he meant when he said pain, because when I kind of prodded him a little bit, he said, you know, it's not really pain. It's really just more this aching sensation. And then I just feel like my forearms are tired. So it was more of an aching and a fatigue rather than a pain. He described it as being left more than right, and on the ulnar side of the sort of palmar surface of both forearms. He said it was worse when he was playing high tempo pieces. He also noticed if it required a lot of alternating movements of his hands, that would make his symptoms worse. And he said that what he was very concerned about was that it was really affecting the way that he played. He said, you know, I really want to love what I play. And now I'm just waiting to get to the end of the piece. So I thought that was sort of an interesting tidbit. You know, it's not just about, okay, I find this unpleasant. It's I'm not even enjoying my craft anymore. I'm just waiting to get to the end. So I can kind of stop if people want more information now. If they want to hear me just keep going. No. So we have a very interesting case here and we have some sort of functional fatigue. Right. And then also taking a mental toll on this patient as well. Right. So as far as the person's mental health and how they're interacting with their music and their craft. So if you have thoughts, what would you do for this patient in terms of your physical exam? What kind of things would you want to be thinking about ruling out what are people's thoughts right now on this case? Yeah. Jeremy. I would get a little bit more history. I would definitely be asking more about like, you know, how many days a week do you play? Do you do a warmup? If so, how long do you warm up? How much do you play when you play? Do you take breaks? Things like that. I want to know a lot more about, you know, the history of what they're actually doing when they're at the piano. But also ask some similar questions like how much time do you spend on a computer? Because that typing that they're doing is very similar to their piano playing. And that can really cross over a lot. And that would kind of also, you know, guide what I think is maybe the culprit, like the underlying culprit. And then, you know, what I might do on my physical exam. So I can answer that for you. He said he basically plays every day. He generally plays between four and six hours, but on weekends can play upwards of eight hours. He said that his warmups are, he's better, quote, better at warming up than he used to be. He said, you know, in his, when he was, quote, younger, and he made me feel really old because he's 28 and talking about when he was younger. So when he was younger, it was rare for him to do more than a, you know, 15 minute warmup. But he said now he'll warm up for as much as 45 minutes before he plays. And he said, he'd use some stretching. He's learned some Alexander technique that he incorporates into his warmups. And he said that when he's not playing, he tries to avoid using the computer. He has a lot more voice control because he said he just found that he ends up he'll dictate and stuff instead of typing because he finds that that could be a little bit irritating. And the other thing that was interesting about him is he said that he's changed where he sits in relationship to the keyboard. So he said that, you know, for a while he felt like he was having more pain as he was sitting closer. And now he's, he's trying to sit further away because he thought that would, that would make it better. Okay. So we've got some ergonomics considerations in there as well. So any other thoughts from the room as far as things we would want to know about this person before we move on to physical exam? I'm sorry. I just can't get over the 45 minutes of warmup. That's good. Yeah. That's intense. Just got to call that out. It sounds like a lot of his, a lot of his warmup he said was, was stretching and sort of getting himself into a good mind space. Okay. We have a question from the chat as far as like paresthesia is tingling numbness or anything associated with this. So no tingling. And the way that he described the heaviness, I think a lot of us might think of that as being numbness, but you know, he said it doesn't really feel numb and it's not tingling. It just feels heavy. And then how long he needs to play before onset of symptoms. He said it often depended on the piece he was playing. So if he was trying to play something high tempo or high volume. So he said the more he tried to play with power, the faster he would get symptoms. He said that could occur within 30 minutes. If he was playing a quote, easier pace, it might take 45 minutes to an hour. Okay. And then a couple of questions here about associated symptoms as far as neck, shoulder pain, anything else going along with any traumas history. So there's no history of neck trauma, no history of shoulder trauma. He's had intermittent shoulder tightness, but he hasn't really had shoulder pain. He does not have neck pain. And then I saw one other question there about, is he playing any new pieces? Yeah. So repertoire, right? Yeah. So his repertoire, he said is pretty standard. He was trying to play some newer jazz pieces, but he was finding them. So he did not like the quality of his performance. So he hasn't been playing those as frequently. Okay. Very good. So in the interest of time, I'd want to move on to physical exam and just kind of hear a little bit more about your workup on this. Sure. So his physical exam, before I actually did his physical exam in clinic, I had him, well, I guess we can, maybe I'll skip that and see if what else someone might, would have thought of, but so I'm going to skip what I was going to say, just go to actually examining him and examining him. So his, he is a very buff dude. This guy was about five, four, and he weighed 165 pounds and his arms were built about like this. So these massive, massive forearms. And he is larger on the left, which is his symptomatic side than the right. He had no tenderness location to any, basically any bony or ligamentous landmarks of the shoulder, elbow, forearm, wrist, hand. I could not make him hurt by pushing on him. Range of motion was again, not a very remarkable exam. His strength, no strength deficits were noted. In fact, this dude could probably crush a beer can with his pinky finger based on the size of his forearms. And sensory examination was also unremarkable. Okay. So basically a negative neuro exam, reflexes are good, provocative testing, nothing, but just kind of habitus wise, interestingly built individual. Okay. So I will say that the texture, so as you palpate his forearms, he, he, he is very dense muscle. Um, he did not have a tunnel sign. He, but it felt his skin and his forearms felt pretty thin. He just felt very full through the forums. So, um, kind of increased turgor in the arm. Would you say like some swelling in there? Okay. Um, turgor, maybe not turgor. Just didn't, he just felt, he just feels very dense. His muscles feel dense. Okay. Yeah. Okay. So what are we thinking in terms of workup? What do we want to do for this gentleman? Um, anyone have thoughts as far as where they're at initially? Okay. So an EMG and a CPK is a suggestion. So EMG, CPK, I did not get a CPK on this particular gentleman. I did consider the possibility of an EMG, but I wanted to try some treatment first, since he had not had any sort of true neurological symptoms. Okay. And then we have a thought about a compartment syndrome as a possibility for this stop. So that was one of my concerns. Is that where you were going with it? Yeah. So one of my concerns with him is that he had exertional compartment syndrome in the forearms. Um, and so, um, I did some provocative testing with him in terms of having him bring his keyboard in and play in clinic. Um, and I actually also had him bring in serial videos himself over time. And he, this gentleman, when you watch him, he plays with a lot of trunk lean. He really gets into his music and his hands sort of go like this. So he's constantly working pronation, supination of the forearm. Um, and after, I won't talk about treatment yet, but that was a very noteworthy finding. He had a lot of trunk sway, a lot of forearm rotation. And so, um, one of my concerns is that we could provoke his symptoms in clinic when he played on the keyboard in less than 10 minutes, when we took up a lot of pace, um, and had him really getting into his music. Okay. Anyone else have any other thoughts as far as workup on this or things they would do differently? Okay. So let's move on to what you did as far as treatment. How did you approach this? So there is a, um, piano rehabilitation individual in North Carolina, right in Winston Salem. She teaches at Salem college as barbalist or sync. So she does a, um, a full evaluation of, uh, pianists. And so we moved him closer to the keyboard. We changed his body posture and she started working with him on developing power through, um, using the upper body and sort of elbow and shoulder rather than, you know, using the trunk and rotating the forearms. So within six weeks of him actually changing the mechanics of how he played, he was no longer having symptoms after having had them for 10 years. So this is a really interesting point, you know, as far as, um, technique, right. This ultimately came down to a change in technique. And so for us, especially in the, um, you know, at UNT, we see a lot of musicians and, you know, it really is a partnership between us and their studio faculty, right. It's it's because I know some stuff about the saxophone, but I'm not a saxophone expert. I don't know how to change somebody's technique or, you know, so, you know, it really does take a partnership with people who are experts at the instrument itself to, to sometimes make some of the changes that you want to make. Um, and so that's a really good point. And so our, our working diagnosis on this is exertional compartment syndrome. Is that what I took from it? That was my, that was my take on this guy. Okay. Okay. Dr. Grissom's talking about perhaps a thoracic outlet. Yeah. So it's interesting that that came up because that was one of the other things I had seen prior to him. I'd seen a number of, uh, pianists who had had dynamic thoracic outlet from sort of hunching forward and developing that pec minor, um, and just get so bad through the axilla that they, that they sort of radiate stuff into the fourth and fifth digits for him. But the striking feature for me was that it was really only forearm that, that there, that there were not symptoms from the shoulder radiating to the hand, that it really was forearm only and those real tight compartments when you put your hand on them. Okay, great. Um, so Lauren, what, what do you want to do in terms of time? Do you want to go with another? Yeah, I think we have time. Um, I know that both Jeremy and I have some quick I have a quick case and then we can spend a little time on, um, on Dr. Stanek's as well. I did see one other question in the chat. Um, so what scenarios would you check compartment pressures in the upper extremity? Do you have somebody who does manometry testing by you or do you do it? I do it for lower extremities. I don't, I have never, I don't even know that I would know what to do with upper extremity compartment pressure testing. I mean, it's certainly reasonable for objective measurement, but I, I don't, I truly don't know how I would even go about it. Dr. Lee, I guess is that the musicians will not consent for that. No way. No way. That's a zero for sure. Acupuncture needle into their hand. I mean, no way, but it is definitely a good thought if you want to quantify, if you're trying to quantify it, right? Like that's how you're going to quantify it. Uh, and so the comment in the chat, there was not an EMG done. Um, but yeah, without the neurological findings, that's why that was chosen to be skipped. So again, in the interest of time, I'm going to move over to Dr. Elson, if you can present your case for us. Sure. You can just present it. Yeah. Okay. So I'll go through, this was actually an interesting, um, a scenario in that I didn't see this patient in clinic. I was actually doing some backstage coverage at the ballet and was kind of sidelined for this and then ended up bringing the patient in later. But so this is a 23 year old male elite ballet dancer who had nine months of progressive symptoms, which he described as a deep, um, ache in his posterior lateral hip. And it was constant, um, two at baseline, but up to a seven with active use and kind of felt like a grabbing sensation. And it was particularly bad when it was his gesture leg, um, or when he was doing a single leg balance on that leg when it was turned out. Um, other, um, particularly relevant history is, you know, the pain had been there for nine months, one year prior he'd had, um, a right-sided sports hernia repair. And then, um, and then right after that moved to Boston. So he had come from another city, came to Boston, never rehabbed his sports hernia repair. And then within two months of starting to dance again and a new company developed these symptoms. And so far by the time I'd seen him, he had had extensive workup, um, no, no imaging was, um, probably won't get into imaging, but basically the imaging showed nothing he had tried and said, and, um, yeah, I'll go right into the physical exam just in the, in the interest of time. So this was, you know, a quick and dirty exam in the training room type of situation, just looking at him. The first thing we always look at for dancers is hyper mobility. So he was hyper-mobile standing, um, in a gender acrobatic, his knees are in gender acrobatic, anterior pelvic tilt, and, um, his pelvis is rotated to the left. And one thing that was really interesting, like quick and dirty single leg stance, soon as he stood, especially on that left side, like, um, his glute max would just pop out. And so this is something that's just, um, interesting in terms of muscular recruitment patterns. And, um, and this is a very stock, stocky in terms of a dancer, just very, very, very muscular person. So you can see everything. He did have some neural tension, um, passive straight leg raise and slump test was positive on that side, really profound hip flexor tightness on that side, and a lot of increased tissue density, both through the glutes, IT band and hamstrings on that side. And so I think, um, I'd just be curious to see what people's thoughts are on differential here. Absolutely. What are people thinking about for this case? Posterior hip, a lot of, um, hypermobility. Okay. Could you clarify it? Yeah. Okay. Gotcha. Hip joint piriformis syndrome. Sure. Definitely on the list. Yeah. Hip labrum. Sure. Posterior labrum. Perfect. Good. IT band. So, um, so definitely all of those were things that had been considered and he had actually had, um, a intra-articular hip injection before he saw me. And so according to the, um, physical therapist, this did improve his hip range a little bit, but never really got to his symptoms. We have Riddick on the list too, as a possibility. Okay. So yeah, so definitely all those things were very much on the differential. And so based, um, on his exam just right then, we decided that we were going to bring him back into clinic for a little bit, um, for, um, to take a look with ultrasound, but just based on kind of how we think about general rehab principles, it's kind of start to rehabilitate the, um, the dysfunctions that we see, um, kind of lowest hanging fruit. So because he had so much tissue density at that time, we worked on, we did some dry needling right there in the training room, focusing on the glutes. So glute med, glute max, piriformis, um, you know, right at that distal portion where we think we're getting the edge of the obturator internus. And, um, and then we also, um, you know, this was in conjunction with the physical therapist. So we decided to start him on a gyrotonics protocol to really change number one, his posture, his standing posture, get out of the, the gripping through the glutes work on that. You know, he never really fully rehabilitated from that, from that sports hernia repair. So, you know, all that, the transverse abdominus adductor and recruitment patterns. Yeah. So this is kind of like a lower crossed kind of picture, right. With, um, um, just like ridiculous tight hip flexion and over firing of the glutes. So yeah, this is very much a rehabilitation case. Okay. At that point we saw him, um, when I saw him in clinic at that point, uh, he was 60% improved and our working diagnosis at that time was ischiofemoral impingement syndrome. I mean, especially based with all the external rotation work. And so we decided at that point to add some radial shockwave treatments for the, um, for the deep external rotators of the hip. And so we did one treatment of the radial shockwave and he continued with the rehab. And so at 12 weeks after the initial needling, he was, um, pain-free. So, um, just wanted to really highlight that combination of the gyrotonics work, the motor reprogramming, and a little bit of myofascial work to get into it. In case people are not, um, familiar, can you talk a little bit more about gyrotonic Pilates and just sort of how that's structured? Sure. Um, so for gyrotonics, if you haven't seen the device before, I encourage you to look at it. It looks like a medieval device. Yes. Um, if you're familiar with Pilates, same, basically a device that might be where the similarities end, but instead of, um, I guess the idea, the main idea behind gyrotonics is circular movements or many of the, um, many of the patterns are very circular, but the way that it helps engage the muscles really helps to change neuromuscular, it really works on neuromuscular reeducation and changing movement patterns. And I think for dancers, one of the main, um, dysfunctional movement patterns that you'll see is over recruitment of the hip flexors and using the hip flexors as a core muscle, as opposed to being able to turn on the transverse abdominus before the hip flexors kick in. So gyrotonics is one of many different ways that you can use to help re-educate that program because you can't cheat on there. So if you can have a physical therapist that is well-versed in this, and thankfully the ballet has one of these there, so very helpful for being able to rehabilitate it. But when you think about, for a dancer, when you're reaching, you're not just reaching, you're spiraling. So being able to capture that energy and to reproduce that energy and to stabilize through your core as you're sending the energy out. It might sound a little esoteric until you've tried some of these movements, but if you get a chance to get on one of these machines, I highly, highly, highly encourage it. But it's, I feel like you can accomplish these things with standard therapy, but the dancers really like it because it feels like dance in a way, and it just recruits the muscles in very functional movement patterns for dancers. Fantastic. Yeah, and our ballet company also has a gyrotonics tower, and so it's something we use a fair amount. Okay, Dr. Stanek, we're gonna turn over to you. Bring us home. All right, I have what I consider to be an interesting case. I will say that I have previously asked for assistance from another person on this panel about figuring out what the heck's going on with this particular person. So this is a very famous professional brass player who contacted me having several year history of a lip tremor, that's all it was stated as, was a mild lip tremor, had it since like at least 2012. And previously, that tremor had completely been controlled with only 2.5 milligrams of propranolol. And by the time I was contacted by this musician, several other people had already been consulted and nothing had benefited. So this tremor had gotten worse in the last one to two years, and no inciting events, anything like that, it just progressively started getting worse. There was no change in practice habits, no change in performance, no new stressors, anything like that. So the musician is vehemently against increasing the dose of propranolol, does not wanna take more than 2.5 milligrams. Previously had tried some lip strengthening exercises on their own, like just like lip calisthenics, things like that, didn't really do much of anything. Tried working with Jan Kagerreis in New York City, was not very satisfied with how that went. Those of you who don't know the name Jan Kagerreis, she's not a medical professional, but is a trombonist who does a lot of work with people with focal dystonia. Eventually this musician got to me, saw me and a neurologist about the same time. On my exam, there was a pretty substantial tremor that was present while playing, both in the bottom lip and the upper lip. Also appeared to involve some of the muscles in the cheek, so probably the buccinator as well as a zygomaticus. That tremor was present regardless of what register he was playing in, whether it was like in the staff, above the staff, below the staff, made no difference. It was always there. Did not matter how loud or soft he was playing, it was always there as well. Only watched him play on one horn, but he reported that regardless of what type of mouthpiece he was using, it was the same result. So we talked about different medications that could be tried. Again, was very reluctant to try any kind of medication. This person is a very healthy person, does not drink alcohol, doesn't smoke, doesn't do drugs, anything like that. And even doesn't really like to take ibuprofen if they have a headache. So it was pretty much against using any kind of medicines. Wanted to talk to the neurologist, which they had an appointment with the next week, just to get the neurologist's opinion before making a decision on how to go forward. So the neurologist also mentioned using trihexyphenidyl, which was one of the medicines that I had suggested could be tried because that's one of the more effective, I use that term loosely, one of the more effective medications that's out there for focal dystonia. And when I saw this person, at least playing-wise had an appearance of focal dystonia because it only happened when playing his instrument. Did not occur any other times. So since the neurologist also recommended that, he decided to try it. Had a little bit of a change in the tremor, but not much of a huge difference. But it had a pretty substantial side effect of dry mouth that was severe enough to where he was having difficulty playing because of the dry mouth. So he stopped that medication and that side effect of dry mouth actually persisted for over a week after stopping the medication, but it eventually resolved. Again, I had suggested trying a higher dose of the beta blocker to see if maybe that would resolve things or at least make it a little bit better. But again, was reluctant to do that. It tried taking a five milligram dose in the past just for a performance and felt like that medication kind of blunted the musicality of his performance. So he was also reluctant because he felt that, he wouldn't be as musical when playing if he took a higher dose of the beta blocker. So what he and I ultimately landed upon was, let's actually do an embouchure change. So that's what we did. We did an adjustment of the embouchure and the trimmer pretty much resolved with the new embouchure. At least initially, range and endurance were a huge issue. Sound was still pretty good, not quite what it was compared to his initial embouchure, but the fact that the trimmer was gone, he was cool with that. So what we started working on was using the Maggio method. It's the Wuyi Maggio method, which can be used for any brass instrument. And it's kind of both an embouchure strengthening program, but also kind of gives you some ways on how you can actually hold your embouchure either during practice, or you can transfer that over to performance as well. So as of now, he'd taken a month off of playing completely just to try to readjust everything. So no performances or rehearsals for a month, tried the new embouchure. Things are actually going pretty well right now. He says that it's almost like a pucker and pray kind of moment sometimes, if there's like a high soft entrance that needs to be made, just because he doesn't have that feeling of confidence with the new embouchure just yet, but it keeps improving little by little as he keeps going. So that's pretty much this case. He's playing really well right now. He's having no problems at all, other than still not feeling super confident with that embouchure. And so one of the things that I'm still questioning is, is it really focal dystonia, or is this potentially just a worsening of an essential tremor that was previously controlled with the beta blocker? Reason why I really question which of these it is is because the data that we have from focal dystonia, it's not something that typically starts 10 years ago and just kind of sits there and festers for eight to 10 years and then starts to get worse. We think of focal dystonia as something that starts and then it kind of progressively gets worse over maybe one to two years, and then it kind of plateaus or even faster than that in some people, whereas we know that essential tremors can get worse over time. And so that's the big quandary that I had. And that's one of the reasons why I was really trying to push him to try a little bit higher dose of the beta blocker to help prove, would that potentially tell us, is it a focal dystonia or is it just an essential tremor? Because typically, our beta blockers don't do that well for treating focal dystonia, but they do for an essential tremor. So I'm curious what everyone else's thoughts are on this. Sure. So you went with kind of like a task retraining method, right? Almost like a neuroplasticity- That's exactly what we did. Neuroplasticity, like movement-based approach. Yeah. And so, yeah, this does have some interesting crossover features for sure, right? So the fact that it is task-specific, so it doesn't have tremor with any other tasks involving the mouth or face, drinking things, doesn't produce tremor. So if it were an intent tremor type thing, you'd probably see that with other tasks beyond play. So I think you're pretty safe to put it in the dystonia category, but that's kind of where I'm coming from. I'm curious what other people think about this particular one. Please not everybody all at once. Yeah, it's almost like it's 10 at night or something. Jeremy, you and I talked about this case. So at the time we had a really similar case. I actually had a bassoon player who was also older and also very well-established and also a woman. So unlikely to have that diagnosis. And she only tried 2.5 milligrams of propranolol as well and didn't see a benefit. So, I mean, the neurologist said it's focal dystonia. I, there's no, I think, and improved with task change. So she changed her reed and the symptoms started to improve. The size of the reed started to make the breeze a little bit differently and symptoms started to improve a little bit. Didn't go away though. So, I mean, as you know, so it didn't go away. And she ended up, she was on her way out of her ensemble anyway. She was planning to retire and she just kind of retired early, which is, I mean, typically a case, but I feel like you, I feel like it's focal dystonia. Yeah. No pain, right? And it's only when it was- Right, painless. That's critical. But then again, essential tremor is typically painless as well. True, fair. The patient had like the typical features though, like the sort of that personality of, you know, that we talk about practicing over and over and over again. Focused practice over practice type. Yeah, and there was no family history of any neurologic issues whatsoever. Yeah. Right. And Dr. Lubert asked the question about, you know, getting buy-in from a patient, you know, with changing the embouchure. In the brass players, especially that I've treated, you know, I think it depends upon how bad their problem is and at what level they're performing. If they're a really high level player and it's really impacting their ability to do their job, most of them are gonna do whatever it takes to get back to where they were. You know, when it comes to brass players in general, you know, if you're doing, you know, treating someone with focal dystonia, there's not really a great proven treatment for, you know, an embouchure dystonia. So, you know, right now the literature is showing us that retraining is kind of the best thing that we have. And, you know, it's tough for a brass player to, you know, go back to being a sixth grade beginning band person again, because that's basically what you're doing. You know, they've got all that musical knowledge, but if you change their embouchure, it's like you're starting from scratch. Now, granted, their learning curve is gonna be quite different than a sixth grader, but, you know, their sound is going to be different, the way it feels is going to be different. And, you know, when you've been doing something so precise for so long, any little change, you know, feels completely weird. But, you know, if they're really struggling with you, then they'll totally buy into that. And you just have to warn them that it's a long, slow road, and they may not get back to where they were previously, but, you know, it's at least worth trying. I'm curious if you've ever done work with switching the mouthpiece to like a different brass mouthpiece. So if you're a high brass to switch, do lip trills or buzzes or things on a low brass mouthpiece, because it's just a completely different embouchure to try that way. Not that you're going to turn into a different instrumentalist, but just as far as training in that. Yeah, no, in my experience, even if you keep their embouchure the same, when they come back to their original instrument's mouthpiece, that dystonia is still there, even if you have them try a different mouthpiece. Yeah, absolutely. Okay, I actually had a woodwind patient I'm working with right now with embouchure dystonia, we replaced the clarinet and we switched. So there is an actual precedent for taking the clarinet and then spinning it 180. So the reed is facing out. And if you put it in your mouth that way, it'll still resonate. So he flips the horn 180 and can play, and he has no dystonic symptoms when he plays that way. So it's essentially using the upper lip to produce, to phonate instead of the lower. So it's really interesting how just changing the task in some meaningful way, all of a sudden can suppress those symptoms of dystonia when it's there. That's what they asked about graded motor imagery. If that happened as well. Oh, guided imagery, right, yeah. Did you talk about graded motor imagery? No? You're talking about with the woodwind player? Yeah, the brass player that you're taking. Your patient? No, we didn't use any motor imagery. Which is another way. Okay, well, in the interest of time, I'm gonna kick it back to Dr. Ellison so we can open it up for Q&A. So thank you all for contributing on these cases. I definitely appreciate it. Thank you all for the discussion and for your contributions. I think, I mean, this is one thing that we would love to come up more of because we learned so much from each other. And as Dr. Gerson mentioned, I think the one unifying thread in performing arts medicine is that we have to have a team. We don't function as physicians alone. We really rely on the team, the instructors, the physical therapists, everybody that helps us do what we do. Do we have any questions? And feel free to either, I'm gonna put you on gallery view. Feel free to either raise your hand or put something in the chat. And you know, yes, Steve. Hi, I am Steve Lubert. I'm currently a fourth year resident in PM&R at the University of Missouri. Very interested in performing arts. So thank you for y'all's talk. And so as someone who's still in training, I found one of the big challenges too, is like, I don't always have attendings that necessarily are as interested in performing arts. And so whenever you're thinking about establishing a performing arts friendly clinic, like I know a lot of that is going out into the community, but if you're someone who's still in training and are not sure exactly where you're going to be, I kind of feel hesitant to open that door and then just leave. So like how, whenever you're setting up that clinic, did you try to make it more just a single discipline clinic before you make it into a multidisciplinary clinic and then trying to go from there? Like just thinking of the foundation of how to build your practice where you can incorporate and integrate performing artists into it, especially like as a very new position. That's a great question. And I think we can skim the answer on that today, but I think there's a lot of people here who work in a lot of different settings and we can definitely share contact information. And if you are going to be at the assembly, we do have a whole, this is a great time for me to plug our networking session from nine to 10 on Thursday morning. But I think, and I would love for people to chime in because I know that we have people who've set up free clinics, people who work with professional companies, people who work in the academic settings. And so I'm going to give my quick two cents and then let some of my colleagues chime in. But I think that as a performing arts medicine practitioner, we can't just hang a shingle and not know which therapists we're going to refer to at the very least. After that, you can start to get the other allied practitioners, like the other people that like working with artists, the massage therapists, the chiropractor, the people, the acupuncturists, the people that you trust. But then also, as Dr. Popoli was mentioning, who are the instructors in your area? In our area, we have a lot of body mappers that our musicians like to work with. And so I think we can't do it by ourselves. I mean, it doesn't make any difference if you can make a diagnosis, but we don't have a therapist to help us carry out the treatment. And so I hear what you're saying about how to set that up when you're leaving, but I don't think any of us do performing arts medicine full-time. We'd love to, but it really starts off gradually in building. I agree 100%. Yeah, it's about building your team first. And then once you have that in place, then I think in some cases, the audience kind of fills itself because the team has connections and expertise, and it'll be obvious sort of where you need to go to build those connections. I am gonna call out just a couple of quick names in case people wanna share emails and stuff like that. And I wanna try to make sure that I get everybody here who I know is doing a lot of performing arts medicine. Like Dr. Gerson helps run the dance medicine clinic in Seattle, Dr. Davenport is Miami City Ballet and HSS, Dr. McKay is at NYU, Dr. Stanek is at Stanford, Dr. Popoli is at, help me out. It used to be Wake Forest, now it's Atrium. Atrium, has a performing arts clinic there. Dr. Suri and Dr. Lee have the Performing Arts Fellowship and work with a lot of students and professionals there. So there's a lot of experienced people here who see a lot of performing artists and we all work in different settings. So I think everybody would be happy to talk to you about how they've worked to establish the practices that we do. And we're here because we love it. And this is another plug for, AAPMNR is really our home organization, but I really encourage you, because as physiatrists, we need to be taking the lead in performing arts medicine. So for example, Phi Adams Conference is coming up, we really need physiatrists to be there and be represented. And that's a great place. It's a different organization. It's a place where we learn the collaboration and we learn what other groups are doing and it helps move the performing arts field along. But then also we can come back and collaborate here as well. I'm sure, I don't know if anybody else wants to throw their two cents in, or if there's any other questions, we do wanna make sure that we try to get as much answered as we can. And also, this forum is an excellent way to reach out. And we would like to get the journal club back up and going if there's any particular topics that you're interested in discussing. And even if it's a topic about, we could have a discussion one night on starting a performing arts medicine clinic. Whatever you're interested in, propose that out there. We'll set out, we'll pull for dates and see who can come. But I think this is really our opportunity to help each other out and help the physiatrists be in the premier performing arts stocks. I think we're getting close to time. Yeah, I think you guys timed that just about perfectly, actually. I'll just take a moment to say thank you all for putting this session together and everyone for participating. Again, this session has been recorded and will be available online in about 48 hours. So anybody who is registered for AA can go in at any time and watch it on demand.

ballet dancer

hip pain

violinist

thumb pain

opera singer

hoarseness

contemporary dancer

foot pain

forearms

embouchure changes

exercises

performing artists