Okay, so, um... We have a spinal cord injury registry where we, you know, part one of the... Plus, and as very congruent, and our average age, the last poll looked at it, was 66.7 years with a median age of 69. 66 is not old. I'm getting to that age. But let's say it's age-friendly. We'll talk about age-friendly. So what is age-friendly care? So this is something that was... It's really been primarily rolled out. Okay. One of the... was very congruent with things that affect spinal cord injury and in fact, affect rehab across the, you know, what matters. I mean, that's what got me into the, into PM&R was I read the old Crewson textbook. I still remember when I was moonlighting in England, I came across the Crewson textbook and literally that first chapter, introductory chapter taught customize their management accordingly, that really spoke to me and I said I'm not going to be a rheumatologist in England, I'm going to do a PM in our residency. So what matters where they were, and this was in the model systems, where, actually it was a couple of systems, it was retrospectively looking at a couple of. So, and of course that only increases. So there's a lot of, you know, overlap with really looking at high-risk medications, polypharmacy, that really affects SCI. And then mentation is something, you know, we've actually, another talk that I was, did yesterday was on clinical practice guidelines and mental health and substance use disorders and suicide of people with spinal cord injury, and certainly those aspects we very much focus on. So this spoke to me, the, this is basically a forum's framework that the IHI has initiated, and really this is supposed to be implemented as an entire package, not fragmented that, you know, okay, we'll talk about high-risk medications only, because it really affects, you know, when we're talking about what matters, you know, or medications, you're saying medications that don't affect mentation, mobility, and what matters. Mobility is really so that you people can safely do, so that they can perform what matters. So, you know, it's the same as they So basically we started with a full day symposium in those slides. But basically, you know, talking, engaging the entire team to talk about their contributions and aspects and having focused meetings both before and definitely after the symposium to say, what are the things we are already doing? How, what are things that you feel we should be doing to make our, to reach all those forums? And what are the kinds of barriers that we have to address? So one of the things, for example, for mentation is, you know, we don't, you didn't routinely screen for dementia except, you know, people who are presenting with symptoms. So that was something that. Similarly for medications, we had a pharmacist who really educated us on, was a relatively new member of the team, so that was really lucky for us, and the VA has a system called VIONE, but there are other sort of VAERS criteria and other things to look at different medications, but VIONE is something where you can plug in those medications and it kind of strategized them, it's an acronym for V is for vital, like insulin for diabetes, I is for important, like someone needs something for say reflux or some kind of important thing, asthma, for example, asthma medications are important, and the O is like it's optional, you just waste the side effects. and then that's never taken off. So it's really looking intentionally at those medication and the E is looking for every medication has an indication. So really looking intentionally, what is this medication for if the And so our outcome was just the familiarity with the forums out there. decided to do this in our outpatient annual evals because that seemed like the most low-hanging fruit where this could be done easily. And that actually is a way the VA has electronic health factors that you can count. So if someone is doing a 4M note, then as long as they're using the right process, that then captures that health factor. And so you can just count those health factors. to show that you have the systems in place and you've thought about how you're going to implement this in practice and level two is that you have three months of data of how you have done that you submit to IHI. So that was one of our We got, so basically our results are, you know, we had 73 participants. This is basically, so we got our level, so this was symposium was just in early November, 2022. Actually by the end of that month, we had already submitted and received our first level one because it was so. Right now, there are these beta reports that are being run that... So, up to the time where I captured this, this is- Thank you, guys. Thanks, Dr. Sabarwal. So I have a question. We saw the AI talk yesterday. And now you're telling me they're doing something online that's anonymous? How can that be? We know where it's coming from. We could find that out. Well, it's like the CME things. Like they do for AAPM now, where people are putting in the survey, I'm assuming they don't know who's doing it. It's not anonymous. It's never anonymous. Then I'll see. Who rated this a five, and who rated this a six? The thing that I think was really interesting was the first slide, where you show the age ranges and how the over 80 population's gone from, what, 7% or 8%, maybe 9%, up to 16%. And that's amazing. That's in our system. Now, I would say the model systems published something about a year and a half ago. And of course, this is data that's been out there. But their average age for quite some time, since the 2015s, has gone up from 27 to 43 years. But they never even used to capture how many people are 75 and older. Now, they reported that it was a significant proportion, certainly not as high. But they were able to compare with 10 years ago, how many people were 65 and older versus now. And it's a significant increase across the board. And I'm sure you could stratify who's tetraplegic versus paraplegic and, again, look at the numbers on that. And it's probably greater, my guess would be greater, paraplegic. No, no, I think it's multifactorial. It's because people are, A, hopefully living longer. And that goes across the board. And it goes across with aging of baby boomers across the US. So that affects everybody. But it's also people living longer after SCI. But then also, there's a second peak, which is only increasing with older people getting central cord syndrome and tetraplegia. So it includes incomplete tetraplegia. So yes, there's probably a higher number of incomplete injuries that are in that, but not necessarily by level of injury. Excellent. Any other questions? I'm the only one who gets to ask questions. Yes. Oh, thank god. So it was a really great presentation. And I would like to speak to you more about this. So I work. My name is Muyono Park. I'm newly incoming geriatric community chair. And this is going to be the topic for the next year. Presenting as a theme. And I work in the Burke Rehabilitation Hospital, which is freestanding, 150 bed. And we just got the first level one certification. And submitting the data, what is really it comes down to when we are talking to the administration about getting any resources? How you make this system age-friendly? They either focus on financial or patient experience scores. So I'm very curious to know, was there any change after you implementing this that in that regard, anything you could go to like a CEO of the hospital or even health system that this made a difference? Yeah, I think it partly, hopefully. I'm lucky that our leadership is aligned in terms of what really matters. It's the quality versus cost. I mean, it is the value. It's the quality slash cost. So some things that add value. I think with some things, it's easier to quantify medications, for example, medication related. I didn't have to make that pitch so much partly because in our setting, this whole health concept was already integrated. So what matters is integrated. I think in terms of the patient experience, I think focusing on the what matters, which also is the most difficult thing. You can talk about it and say we've done the 4Ms, but really to do that consistently that the physical therapist, which actually the physical therapist is not a good example because they do that all the time, is to really what do you need this function for and focusing on that. But yeah, the resources are not that much. It's really a question. The bigger thing is engaging your frontline staff. Any other questions? Thanks, Sunil. Good job. Good job. Go ahead to your other talk. All right. Who's coming next? It's going to be Allison Capizzi. She's going to speak about Headache Management in a Traumatic Brain Injury Rehabilitation Program targeting Military Special Operation Forces. So that was a single center study with the 50 patients over one year, and all of them are special forces? Correct. So now that you have this data, what do you do with it? It's good to collect data, but what are you going to do with it? You want it easily repetitive throughout the VA system, because as you know, you have regional centers, and then you have the home centers for these guys, for the veterans, that are going to take up the slack and the non, what is it, I don't know what the frequency is in spinal cord, is there annual visit where they go to the spinal cord center? I don't know if they continue that the same way for TBI. We don't actually have annual, like a requirement for annual visits. Right, so it's done at their home base, their home VA medical center, or their CBOC, right? So it needs to be reproducible, that somebody in primary care can do it, or they're gonna toss it to either neuro or PMRS services. So yeah, so it's an interesting pilot study. So it looked like on the bar graphs that they still kind of touched, that you had a trend, you know, that things are getting better in a trend. Is that you need better intervention, or do you need a higher number of N? The private sector runs a lot differently than the VA healthcare system, right? So the VA is a lot more combined. It's like the largest HMO in the world, basically. No, thank you, thank you. Any other questions? Oh, thank God. Yeah. There are no small questions. Well, it's a short one. There may be short questions, hopefully there's a good answer. I'm interested in, so, you know, a lot of veterans wind up with migraines, headaches, tinnitus, and they tend to ignore that for long periods of time, and they don't really bring it up, they just kind of, it is what it is. I'm interested, though, because you kind of, you spoke about the anxiety. Because I'm a veteran myself, and a lot of my friends, a lot of the people that I talk to, we all deal with things that we just think STEM's. Thanks, Allison. Good job. Very good job. OK. Thanks for sending that back. Our next presenter is Rashna Hachandani. I'm sorry. I'm so sorry. And she's going to speak about increasing health care provider awareness. I am a PY4 resident at Geisinger Health System. So I'm stepping in for my colleague, Dr. Pena, my co-author, to present our quality improvement research that is aimed at increasing health care professional awareness and education on assistive technology, AT, to improve patient safety at home. So our project specifically focused on how AT can enhance safety and support the transition from inpatient rehabilitation to home, which is especially relevant for individuals with traumatic brain injuries, a leading cause of lifelong disability affecting approximately over 5 million Americans, according to the CDC. So these patients, they often face challenges in managing their health and safety, often due to cognitive, emotional, sensory, and motor impairments. And that can lead to the dependence on caregivers and impact their independence at home and also within the community. So assistive technology, we feel, has the potential to maintain this autonomy, ensure safety, and also provide the psychosocial support, and thereby aiding in activities of daily living, reducing caregiver burden, and offering a cost-effective solution. And especially with the rising trend of smart home technology, adoption post-COVID-19, and the growing receptiveness among patients, even older patients and family, to using AT, our study was aimed to familiarize health care providers with accessible AT to enhance the safety of TBI patients post-discharge after an inpatient rehabilitation stay. So in our study, it was a prospective cohort study. So it comprised of physicians and also physicians in training. Our sample size, it was about 10 participants. They participated in a detailed one-hour educational session covering a wide range of AT devices with a focus on affordability and also practicality. So the devices that we introduced were ones such as a senior-friendly phone that had incorporated large buttons and also had some audio modifications to those who were hearing impaired. It included a medication dispenser, a light bulb security camera system, a smart contact sensors, and also a smart display. So tools that we focus on to support communication, memory, medication adherence, and safety monitoring. So our study, it measured the change in health care providers awareness, anticipated use, and comfort level in discussing assistive technology with brain injury patients and caregivers. We observed a notable increase in the number of assistive technology devices participants felt at ease discussing from an average of 2.4 to 6.8 after our intervention. Furthermore, we also, based on a 1 to 5 scale where 1 indicates strongly disagree and 5 strongly agree, we witnessed an increase also familiarity with assistive devices from an average score of 2.5 to 3.8. And then the intent to use assistive technology with patients from 2.5 to 4.1. And the comfort in educating patient and families about assistive technology from 2.3 to 4.0 post intervention. So in conclusion, so we found that our educational session, it was the first important step in enhancing health care provider awareness and willingness to engage and promote assistive technology. And so this was our starting point and a stepping stone. Because as we move forward, we hope to incorporate more of a hands-on demonstrations to the providers in inpatient rehab facilities, including the occupational therapists, physical therapists, even speech therapists, and then even including nursing as well and physicians to kind of effectively train patients and the caregivers in more of a practical and hopefully in a continued use within the home too. And then again, we hope that this could be more of a foundation for showcasing even how technology can be harnessed to improve patient function. And one of our more ambitious goals is to kind of open up that dialogue as well on the potential role of maybe how physiatrists could be possibly become like the consultants and specialists and kind of directing assistive technology for patients. So thank you for your attention. Thanks, Roshna. Good job. It's tough to fill in for somebody else and then have to sit there for their questions. That's OK. So I'll open up. Anybody have any questions before I have to do my job? Oh, come on. Ask a question. You're going to make me do it. Fourth year medical student, right? You're a resident or medical student? Fourth year resident? Oh, so I can be mean. So for me, as an older guy, it would have been helpful to know what you actually discussed, what kind of devices were actually discussed. Were you there during the meetings? I was. I was. So you're part of this? Yes. OK. So what were the typical devices that were? Yeah, so we initially, so one of the devices was, the first one was more of like a senior adapted phone. So it had more of the large buttons. Like big buttons, big screens, stuff like that? Yeah, things like that. Grandpa played baseball today. What position first base? That's what he used to play, that thing? Something like that. Yeah, yeah. And then also, the audio is also kind of modified. So you can kind of turn up the hearing in order for those who are specifically hearing impaired. So we tried to look at devices. We picked them also because we wanted to consider cost. So in terms of the cost, we kind of picked devices that range anywhere maybe from $10 to like $100, or a little bit more, a little bit more, like $150. So that was one of the devices. The other ones were some of the home security cameras. So there is a lot that's available on the market. So even just like light bulbs that have the multifunction that can also be, yeah, they can be a camera. And then so that for loved ones if they want to check in on their patients. So when it comes down to it, it's always about cost, right? Exactly. And do you guys discuss that as residents or within the residency about cost? Do you guys talk about any dollars and cents things? So I mean, In medicine and what you're doing and what you're not doing. Yeah, we do try to take that into consideration and also the patients that we see and then what would be like a limiting factor for them. We were never allowed to discuss financials as residents for anything. But it always comes down to cost, except maybe in the VA. But even then, you go to the chief of staff's office, or worse yet, the director's office and have to choose. Weirdly, that still comes down to cost. Lots of money for certain things, not enough money for certain things. You have to show why you're going to do something. So it always comes down to cost. So did you guys discuss? Virtually everybody has a smartphone now. Virtually. Yeah. Everybody, even in central Pennsylvania. Yeah. Formerly known as northern Alabama. But. So did you talk about things like that? Yeah, so that was. What will go in with their cell phone? Are you wearing the thing around the neck where you have the button? Yeah, so we did try to look at a little bit more of more like smart home technology. So yes, we did want to kind of consider costings that would be more affordable, specifically looking at our patients. And central PA. And the other thing that we wanted to factor in was how easy is it to install? And how easy is it for patients, generally who are a little bit older patients, to use this? And it could be user friendly. And then we also wanted to look at some of the. So we kind of looked at some of the pros and some of the cons as well. And then kind of moving forward, when we look at doing the hands-on demonstration, especially when we bring it to the attention to the therapist, to seeing how it would kind of work even when they're doing their therapy sessions. And maybe getting some feedback on that if we need to look at other types of devices, too. There's a ton of devices out there, from Ring, to SimpliSafe, to just the baby cam. Yeah, yeah, absolutely. And they kind of have like a multifunction as well. Do you have a question? I have a loud voice, but thank you. It's OK if you're back. Oh, yeah. OK. So I really enjoyed that presentation. I am curious if you have just anecdotally had some feedback from your patients that have done it, just from your own experience. So I know a lot of some of the patients, or caregivers, or family members, do like the sort of safety monitoring devices. So the light bulb cameras, or sort of like some kind of like a little bit of a video monitoring. It just gives them more kind of like the comfort and ease. So rather than having like a caregiver who needs to be there maybe 24-7, this allows them to step away from the home to do their errands, or things like that. So it gives them that chance to just to see. Is that going to take us in place later? So we haven't started it, but this is in terms of like anecdotally, just hearing from patients who've kind of made those steps on their own. So then that kind of helped us formulate this project. But we haven't quite yet initiated the second. So this would be so what the next step in terms of what we want to do is to try to introduce this more to the patients and their caregivers about the options like about incorporating this to help kind of help with like you know safety upon discharge and then it would be more of like a discussion with the family and the patients about which one. Yeah yeah. Yeah, yeah, so those are definitely some of the things that we need to consider and exactly having that discussion Exactly see stuff and we were watching her caregivers and making sure that they didn't like steal her blind. Mm-hmm Okay, good job You made it. Thank you Medical students Okay, thanks for us now you did a really good job All right, yeah, I want to screw that up. Next is Tanvi Sinhai, you're a fourth year medical student? Third year medical student. Third year medical student. Holy cow. I am, yes. Look at you. Good for you. All right, well, we'll be nice to you. We'll try. You're going to discuss exploration of diagnostic accuracy of body anthropometrics. I got that right. To identify increased pressure during power wheelchair pressure relief maneuvers. Mm-hmm. Sounds important. Sounds important. Well, yes. Hi, everyone. My name is Igo Batanya. But thank you to my institution, UAB, and my mentors, Kathy Carver and Dr. Rachel Cohen, for supporting me in this research. And yes, I'm not going to say that title again. It's a mouthful. But essentially what that means is that we were essentially just looking at different body classifiers to see whether the prescribed pressure relief maneuvers that people use in power wheelchairs are actually doing just that. If they're actually relieving the pressure off of those sites that they said that they would. But before I go into our specific research, I kind of want to back up and talk about pressure injuries as a whole. And so over 2.5 million people in the US develop pressure injuries every single year. And they're the second leading reason for re-hospitalization and or morbidity in the spinal cord population. And this follows urinary complications. Interestingly enough, urinary complications are the most frequent cause for re-hospitalizations. But the skin changes for spinal cord populations are the cause for the longest stays in the hospital. So once a pressure injury forms, they could heal within days, weeks, or months on their own. But if they become infected, they could become chronic, and they could sometimes not heal. And in some severe cases, they could lead to things like osteomyelitis. And as you guys are aware, osteomyelitis could lead to bone necrosis, bone death, systemic symptoms, et cetera. I thought the financial burden of this was also quite notable. In just the first year of somebody having a spinal cord injury, the costs go upwards from $50,000 to $200,000. And this obviously varies per person, but that's just per year. And it could go down after the first year. But this varies with the level of the injury, the severity of the injury, and the complications that somebody might face. And obviously, if somebody's clinical course is more complicated, this would drive up the costs, et cetera. But between the complications that somebody might face and the re-hospitalizations that they might need, it's important to either prevent pressure ulcers or pressure injuries from happening or prevent the current ones from exacerbating and really follow the current clinical guidelines that are out there. So the current clinical guidelines that are out there are to move every 30 minutes for about one to two minutes. And there are very loose definitions about what tilt and recline settings are out there for individuals who use power wheelchairs. And there is different data, so I don't have specific data listed on my poster. But it really does vary on the individual. And so for those of you who don't know, individuals who use power wheelchairs can do tilt or recline. And so tilt keeps your hip angle in space. I mean, it moves the whole wheelchair. But recline will move your hip angle, and it just moves the back of the wheelchair. And so both of these maneuvers basically just move the pressure from the main bony prominences, which collect a lot of pressure, such as the coccyx, the sacrum, the ischium, the greater trochanter, et cetera. And so they basically help tissues reprofuse, help prevent ischemia, et cetera. And so in general, as tilt and recline increase, the pressure is reduced over these bony prominences. But as Kathy Carver, somebody on the DPT, she was involved in this research at UAB, found some of the individuals who came through our clinic or came through the wheelchair clinic at UAB, some of them actually had increased pressure when they did these, quote unquote, prescribed pressure relief maneuvers. And she found that a lot of these individuals had very somewhat similar anthropometric information. And so they had this paradoxical increase in pressure in what should have been pressure relief maneuvers. And I mentioned all of the complications of financial burden. And so we just found it increasingly important to kind of target this group of individuals and kind of see what we could do to kind of help target the clinical guidelines and potentially cater to these individuals, because we were sure that there were more untapped groups. But that brings us to the primary objective of our research, to examine the accuracy of various body anthropometrics to predict if a person experiences pressure increase during these pressure relief maneuvers. And in my poster, I say specifically people with these upper torso and larger abdominal girth anthropometrics. And that was specifically the group that we found had these increased pressure differences. If you look at the middle of my poster, that middle bottom with the methods, we were able to recruit 15 participants from that UAB outpatient wound clinic. And for inclusion criteria, they needed to be at least 18 years old, use those power wheelchairs with the tilt and recline settings. Exclusion criteria, we didn't want them to have a wound back just because we were collecting pressure information. So we didn't want to have any confounding pressure data from that wound back that they were currently potentially using. And obviously, if they were medically unstable, they wouldn't be able to participate in data collection. We found, just on average, this happened on coincidence, some more information about our patients, our participants. But six of them were female. Nine of them were male. We'll collect a more heterogeneous group of individuals going forward. But about all of them used the wheelchair for about 17 years on average. So they had been using a wheelchair for a while now. And they were familiar with their situation and what worked for them and what didn't work. So if you look at number one, what we did first was we measured their seat to shoulder height on their left and the right side from the hip at the cushion to their acromion process. And then we measured their abdominal girth. And so this ratio is called their char, or I'll be referring to it as their char. That's just shoulder to abdomen ratio. And then for number two, we used the BodhiTrack light mapping system, which is just a pressure mapping system. And we placed this. It's a mat, essentially, for those of you who don't know. And we placed it between the current cushion that they use. And it was able to give us real time pressure information. And so if you look at these heat maps on the right, you can actually see what we were able to see with those reddish yellow areas being higher collections of pressure, green areas being less pressure, and just mockups of their preferred upright and preferred pressure relief positions, which is the two positions that we were kind of looking at specifically. And so what we did was we looked at these two positions and we calculated the difference between the two. And we classified that difference as the peak pressure index. And we said that if there was a greater than 10% increase in peak pressure index, then that was classified as an increase in pressure within the pressure relief maneuver. If it was decreased or less than 10%, then we would not classify that as an increase in pressure just because we didn't find that significant enough. That was just subjectively defined by Dr. Cohen, Kathy, and myself. After that, we just used receiver operator curve analyses. And we generated sensitivity, specificity, and area under the curve, and defined cutoff values, which I will refer to in this results section right above. And so for our findings, we found that 60% of our 15 participants experienced increased PPI during these pressure relieving positions, which mean that over 50% of our individuals that we recruited actually had increases in pressure during these pressure relief positions. We interestingly found no demographic differences between them. And that's something that we did on our own research. But we also wanted to slightly delve into that just to account for those factors and see if that had any role, but we didn't find any differences. But these were some of the classifiers that we kind of looked into in terms of the anthropometric data that I've kind of been talking about. So we looked into abdominal girth, weight, BMI. And then obviously, as part of CHAR, we looked at that shoulder to abdominal girth information. And so the AUC for the different anthropometric classifiers varied with the abdominal girth reaching 0.792, weight being 0.833, BMI being 0.64, and the CHAR being 0.75. I won't read off all of the cutoff values and sensitivity and specificities. You guys can hopefully see that. I know it's small. I can zoom in. Oh, that's. I think it's probably on our app. Oh, that's. OK, perfect, perfect. That is very convenient for me. But in terms of this, what I want to point out is that weight and abdominal girth are the highest area under the curve, which is important because these were the classifiers that we really wanted to focus on for our conclusions. So in conclusion, we found that while weight had the highest area under the curve, we did prefer abdominal girth just due to its ease of collection. It was harder to kind of standardize the weight of the wheelchair, the individual, the cushion. And so it was just easier for us to measure the abdominal girth. And if you see, the values between 0.833 and 0.792 were pretty comparable. And so we want to continue testing more classifiers, but kind of just focus in on these two, and specifically abdominal girth. But this study was not without its limitations. The two main limitations that I wanted to highlight was that there was no standardized cushion or wheelchair. And so this could limit the internal validity. I kind of mentioned that. But secondly, the major limitation was with the mapping system. I mentioned that there was a lot of pressure that collects over a lot of these bony prominences. But the pressure mapping system didn't allow us to kind of localize specific areas of pressure. So even though you have these boxes on these pressure maps I have over here, it wasn't like we were able to focus in on specific areas. Oh, yes. Oh. I'll get to that. And so it was hard for us to kind of focus in on where it was collecting other than where the heat was kind of picking up on. And so in terms of where we found increases in pressure, we found overall increases in pressure. And so in further studies, we want to hopefully find either a mapping system which would allow us to do that. Maybe we need to understand the mapping system better, or I guess just address that limitation. That's something I just wanted to address in our research. But overall, more work does need to be done to clarify and structure the recommendations for the frequency of pressure relief maneuvers based on an individual's risk factors, body anthropometrics, because there is a clear increase in pressure that we were able to find even just with this specific group. But this does offer some preliminary information towards classifiers of anthropometric information. And hopefully, we can provide some sort of better recommendations for pressure relief maneuvers. Thank you so much. Does anyone have? I know you have a question. Nice presentation. Well, I'm going to see if anybody else has. I'm going to try to avoid having to ask a question. If somebody else has, I'll thank the veteran first, OK? Oh, no, no, don't do that. I was walking this way anyway. So I just want to ask about some of the limitations. You did a good job of saying it's not just body habitus. Did you look into that at all? So I think when we identified some of those bony prominences, I think in that case, like, it would collect more on like the greater trochanters, for example. And that's where, like, in the pressure mapping system, we would be able to see it on these outer edges. And that's something that we would be able to know and we did image all of these. But again, that's part of our limitations where we wouldn't necessarily be able to use that information because it would just be more of a visual for us when we are collecting these images for our data. We wouldn't actually be able to collect this information that you see, like the sensing area over here from the specific box from the greater trochanter unless we were able to target that specific area where the pressure collects if they had a bony pelvis or a greater pelvis, for example. So the mat just showed an overall increase. Couldn't say it was ischium, it was sacral, it was coccyx. You couldn't get that out of it. If we wanted to target that, we would have to pick a specific bony prominence and then we would have to target this box every single time. But because individuals would move. So, I mean, Dr. Stover would be ultimately very happy that you did something like this and you should look up who Dr. Stover was, being that you're, especially that you're at UAB. Okay. We'll do. So there's that. So do you know where the $50,000 to $200,000 quote comes from? $50,000 to $200,000, where I found that information? So that's a study that came out in the 80s from California. It was a California insurance thing and that's been used now for the last 40-something years that a decubitus costs a minimum of $50,000. And there's not a whole lot of good data after that one study on that. Typically, and to just keep going and switching gears, so when you're sitting in a wheelchair, do you know the bony prominences that typically take up most of the pressure? I would say the ischium. It's ischium. So you typically see more ischial decube, typically, in a wheelchair versus in a bed, where you're going to see more sacrum and coccyx. And the trochanter is, yeah, but it's a poorly fit wheelchair. The trochanter is going to take up some pressure. I'm not surprised that when you go into recline that you have an increase of pressure just the way gravity runs and everything. It'd be nice, especially as technology advances so quickly, if you could actually pinpoint where that increased pressure is because you're taking pressure. The whole idea of the tilt and recline is to take pressure off the ischium. That's it. You're not going to reduce pressure overall. There's no mat, there's no position, unless they're floating in air or in water or something, in a tank, that you're going to take pressure off that. Thanks. That kind of helped me answer this question, actually. But really good presentation and discussion here. I think a lot of what we do sometimes is not entirely arbitrary with pressure relief, particularly like Q2R turns. And as I kind of often mention, you can sacrifice one area to protect another and vice versa. And so this kind of delves more into that, which I think is a really appropriate and timely discussion. But just to get to a little bit of the point of the seating pressure, I want to just make sure I understand this. So if we use a true tilt function in a power wheelchair, not reclined, and we can really offload the ischia, potentially some sacrum and coccidial areas, we're getting weight shifted off that. We're just distributing it to somewhere else that's more pressure sensitive. Is that the key? Yes. As opposed to there's a paradoxical increase in that weight in what we thought were offloading. Yes. Yes. So basically, if you're tilting, you're basically just changing where the pressure is localized. So if they're in upright, it's going to sit in one position for a while, which is why every 30 minutes they're going to want you to change. So that even if for those one to two minutes you're putting it somewhere else, at least it's not concentrating in that one position for a while. Is that what you're asking? I'm not sure I understand. Yeah, we're still accomplishing what that tilt function is. Yes, yes. But because of this research, you're pointing out that with patient's specific anthropometrics, you are now just more inclined to note that there are certain more pressure sensitive areas that are still not the ischia or the coccygeal sacral areas. Yes, yes, yes, yes. Sounds good, thank you. And for the $50,000 to $200,000 point, I didn't realize how outdated the information was. And it is kind of. Everybody still uses it. It's not you. Yeah. Look, you're a third year medical student. You did a phenomenal job. I couldn't have done what you did, a third year medical student. Look, I'm sports trained, but my residency was under Dr. Fried, who was one of the early gods of spinal cord injury. I wouldn't have known any of this otherwise. You did a really good job. We're happy that you're here. Thank you for presenting. Thank you. We're all thrilled that you're doing this and thinking about coming into PM&R. Thank you so much. Thank you. So I think unless anybody has another question, we're good for this session. Thank you so much for coming. These have been chosen as the best of the best of our research presenters this year, all eligible for the presidential award or citation. I think it's a citation, but it's actually an award where you get free tuition for next year's meeting in San Diego. Thank you. Thank you all. You all did a really nice job. I can't tell you where to go.

spinal cord injuries

age-friendly care

pressure injuries

financial implications

assistive technology

patient safety

home care

healthcare providers

body anthropometrics

pressure relief maneuvers