Good afternoon. Welcome to both our live and virtual audience. Hopefully everyone out there in cyberspace is having a good day here on PM&R Saturday. I'd like to welcome you all to our spasticity management presentation. Please remind that all cell phones should be silent or muted and that this is being both audio and video recorded. The evaluation forms for the entire conference are either on your app or will be emailed to you after the conference. It is my distinct pleasure to moderate this session. My name is Mike Salina. I am chair of PM&R at Cooper University Healthcare in Camden, New Jersey. And I have brought together some very esteemed colleagues, the folks that I reach out to when I'm struggling with practice management issues. We're going to try to cover both the private practice issues as well as the academic issues that are involved with spasticity management. So without further ado, I'm going to bring up my colleague at Jefferson, Dr. Kimberly Heckert, who is going to discuss spasticity fellowship, an idea whose time has come. Thank you so much, Dr. Salina. I'm Kimberly Heckert and I'm the director of the Spasticity Management Fellowship at Thomas Jefferson University in Philadelphia. And I want to apologize in advance that I am losing my voice a bit from all the yapping I have done and schmoozing with friends these last few days. So you'll forgive me for that. Before I start, I will disclose that I am a speaker for the Talks and Companies, AbbVie, Ipsen, and Mertz. And I have been on advisory boards and have done consulting work for AbbVie, Ipsen, and Mertz. During this talk I will discuss brands when it's clinically relevant and I may discuss an off-label use of medication. Those in this room are probably aware that there is an enormous unmet need for spasticity treatment, including a great need for physicians who have expertise in treating spasticity management. There are approximately 13 million patients with upper motor neuron syndrome and about a quarter of them with spasticity. And 15% or almost 2 million undertreated. I think that's probably a lower number than in reality. This is from a couple of years ago. The question I raise is, is a PM in our residency enough? As physiatrists we are to be the leaders in spasticity management, but there are very few program requirements for advanced spasticity procedures. And as we all know, the scope of our field is incredibly broad. So for residency requirements, in order to graduate from an ACGME accredited program, only participation in 15 neurotoxin injections is required. And right now there is still no requirement for neurolysis and no requirement for back up and pump procedures, although they are included in the logs. There's no requirement. I'll make a case for a spasticity fellowship, and I want to do this in the context of practice management, meaning how might your academic practice change if your institution would decide to create a spasticity management fellowship? Well, many of us who are doing spasticity management are doing it because we had some fellowship training. Spasticity management fellowships are new. So those of us that do it, the advanced techniques probably had some training through an SCI fellowship or a brain injury fellowship or did other non-accredited fellowships or took courses to increase our skills. But even amongst the fellowship programs for brain injury, for SCI for instance, the accredited programs, there's disparity between how much exposure and practice a learner will get with advanced spasticity management procedures during that time. It may not be a primary clinical focus, and let us not forget that spasticity is managed very differently across disease states. For instance, our MS patients, as we know, are quite sensitive to our treatments compared to our TBI population. Presently, spasticity fellowships are not HCGME accredited. There are some pros and cons to this. I would say the biggest pro from my seat in the room is that our fellowship is incredibly flexible with the fellow's time, and I'm able to tailor the experience to the individual. So when an individual needs more practice with a certain skill, I can give him or her that experience immediately in real time by adjusting the schedule, and I don't have to ask, and I don't have to record X number of weeks for something. I can just do that. Cons, the funding can be challenging. It is possible that fellows might be able to bill to cover some of their costs, as long as they're not billing for the procedures that they're training for in their fellowship, but not every institution can do that for various reasons. So, you know, our institution relies heavily on donations from grateful patients. That's how I got the seed money to start our fellowship program and educational grants. I think we may have a dead. Could you advance the slide for us please? So regarding asbestos defellowship as it applies to practice management, a fellow can greatly strengthen continuity of care across various settings within a large institution. We have seen this first hand and by that I mean a fellow can follow patients in your own department and can follow patients to their neurosurgery appointments, to their surgeries, to the neurology office, the orthopedic surgeon's office. They can see children in pediatric clinics and follow them through transition into adult clinics. So that's a tremendous strength both for the learner and also for the patient. Logistically there could be patient care and systems practice issues if you were to start such a program. For instance, how will you trial patients for ITB therapy? Where does the intersection with physiatry and neurosurgery lie in terms of certain responsibilities? But the good news is that communication through these departments can certainly be strengthened and that's what we saw at Thomas Jefferson University. So for the sake of the fellowship, those relationships were made stronger and new protocols were developed. The other thing to note is that the volume of patients is going to change. Remember that first slide I told you? There are a lot of unmet needs for patients with spasticity and when they find that it's going to be offered at your institution, your clinics are going to blow up and so you have to be prepared for the volume of patients that you're going to get and make some decisions possibly in advance about how many pumps you're going to carry or how many physicians or mid-level providers you might need to cover that burden of patient care responsibility. Next slide please. Oh, we're good? Okay. Okay. So I would say for certain, anticipate growth. This could lead to coverage issues. For instance, if your pump patient practice goes and grows and you're quite comfortable managing intrathecal baclofen pumps, but not all of your associates are, maybe it's been a long time since they saw a programmer. Maybe they only used the TI-81 from decades ago. That could be a concern because we wouldn't want you to have to be on call every weekend. And then there's also support staff considerations. We went through a learning curve in my practice for the people who are making appointments, the people who are helping me to order specialty drugs to understand that they can't, for instance, just move a patient by a week without checking to make sure that this is not going to negatively impact their health. I think that if you're able to talk about departmental or institutional support, it would be a very easy argument, and I could certainly help you with it, that this is a good return on your investment. The potential for growth for a spasticity service line and recognition for the institution as a center of excellence are very good things. It does draw expertise for all aspects of the care team. So if you have such a service line, you're going to find, you're going to attract more physical and occupational and speech therapists that like to work with neurorehab patients because that will be the volume of patients coming through your outpatient center. So across the whole continuum of care, you are going to be able to retain good talent. Spasticity fellowship may have the following potential consequences in summary. It could improve continuity of care for patients. It could strengthen interdisciplinary collaboration, and it could improve awareness of spasticity among other departments. And you must be prepared for the growth that you will see, and that's never a bad thing. I think that's all I have. I'll end with a slide of some of the most special people in my life, our present and former fellows. Thank you. Thank you, Dr. Heckard. I should have mentioned that we are going to take questions at the end as a panel together to encourage collaboration. Next on our expert list here is my friend and colleague, Dr. Dan Moon, who's going to talk about adding motion control analysis into your spasticity clinic. Dan is at Moss Rehab Jefferson Health. Does it work now? It should. Yeah. Oh, nice. All right. So we have the gait analysis lab at Moss Rehab. There's a lot of history. This was actually started in the 1970s. There were actually two gait labs in the country at that time funded. One was Rancho Los Amigos, which is part of the orthopedics up in L.A., and this is in the Krusen Center, which is what we have. It's a collaboration between Temple, Drexel, and Moss back in the day. What we do is we provide real-time force line visualization. We were able to... And that's something we invented, a limb load monitor, electronic gait mat. We also have a variety of dynamic EMGs, as well as we pioneered the use of thermoplastic AFOs and the myoelectric arm. So this is what the old EMG collection unit looked like. I meant to show you what the new one looks like, but either way. So we'll go into, you know, what do I do when I see somebody in the gait lab? If it's the first time I'm seeing them, I do a physical examination and then we record video of these patients. This allows me to replay the video, so I don't have to ask the patient to walk a million times. And you'll see in the video, we have a live force line vector that comes up and we can look at that as well. We also can collect gait mat data, which allows us to analyze the temporal and spatial parameters of gait. And then finally, you know, we do 3D motion capture and dynamic poly EMG to look at the muscle. So I'm going to show you in the next couple of slides a case that we saw and how we, you know, incorporate this. So what questions are we trying to answer by doing this analysis? You know, first we see an abnormality in their gait or a joint deformity. And what we want to try to help figure out is, are these limitations due to contracture or is it due to some, you know, other phenomenon, you know? And how does this abnormality impact the gait? You know, if it's an ankle plantar flexion deformity, you know, how does it, you know, affect the gait higher up? And then finally, we can also determine which muscles are being activated. Is it being activated voluntarily or is it due to some sort of spastic or dystonic or co-contraction phenomenon? And then, you know, we can also help delineate, is this pathologic or is this more of a compensatory behavior? So here's our case. This is a 38-year-old male with no prior history of neuromuscular disease. All he had was a hip dysplasia. He actually was sent to me by a sports medicine doctor who saw him for leg length discrepancy. You know, and he told me he's been walking with a limp for 20 years and he uses this like two and a half centimeter or one-inch shoe lift on the left side to help compensate for this. He also has some hip pain and stiffness, but other than that, he's fairly, you know, he's fairly normal in presentation. He denies any weakness or numbness. You know, he did have a hip surgery at two years of age, but there's no family history of anything. When you go to his physical examination, I think the main thing you see is he does have some limitations at the hip and he also has some tone, but no clonus. And his knees are easily arranged, but when I measured his leg lengths, they were equal by a lot of it. I measured about 94 centimeters. And here's his video so you can see. Can you play the video, please? So you'll see as he walks, you know, of course, so he has a scissoring gait pattern and you'll see as he walks across. So, you know, just in case, I got his scanogram and his leg lengths are equal. I did think he had a little scoliosis, but he doesn't want to get any x-rays because he doesn't want any extra radiation exposure. Later on, I did refer him to a neurologist, which I'll talk about later, and she got an MRI of his whole, like, back and brain, which showed just a little degenerative changes, obviously. So this is an example of temporal-spatial parameters that we collect, just to highlight a couple of things here. I know there's a lot of numbers, but we can collect his velocity. His walking velocity is 1.25, which is fairly normal. This is appropriate for his age. But we also see, the things I like to look at are the time and stance phase. So you can see if one side is more affected than the other, he'll spend less time on that limb. In stance phase, you can also see the step lengths, and as you'll probably know from your own experience, when people have weakness on one side, they also tend to take longer step lengths on that side because the other limb is stable. And then finally, what you can see is their base of support, how far apart are their legs. In this case, he has a negative base of support. You know, we measured on average he has about negative 2 centimeters. So his feet are crossing over each other. Okay. So, you know, that's what I wanted to focus on with this patient. That was the issue we wanted to address. So, you know, and one of the reasons why he could have this, you know, does he have, you know, is it just due to hip dysplasia, which is assumed this whole time? Does he have weakness? I did detect a little bit of tone in his adductors, so I wanted to further assess his hip adductors as well. So it's probably all of the above, but what we ended up doing is we did an instrument and get an analysis. You know, fortunately he had the insurance to cover it and, you know, and this is what the system looks like. And you can see here, he has all these funny gadgets on him that are collecting motion, joint and motion data. And I don't know if you can see... I should have blown up this slide, but you'll also see these blue electrodes over his muscles and that's how we get EMG data while he's walking. And the way I explain to patients when we're gathering EMG data, I'm pretty much telling them, it's like an EKG, but we're actually recording your muscle activities while you walk. Forgive me for overwhelming with all these graphs. You know, we tend not to be a graphical audience, but you know, in summary what these graphs can show you is, you know, you can start off with the... what is this here? The pelvis, the trunk. You can see how far forward they're leaning or backward leaning. The pelvic tilt here, you can see... I can highlight the pelvic obliquity. If you looked at the video, you can see one side was rising higher than the other. But what did we find? We found he did have increased right hip flexion compared to the left side. The left hip tends to be adducted compared to the right side, but sometimes what I wondered was he purposely abducting it. We also look at kinetics. This is a little bit more of an engineering analysis, you know, because we're looking at moments and power generated. I think the main thing I would gather Vertical ground reaction forces you see in some Iowa. Surface poly EMG recordings we gathered and just to highlight. I know there are a lot of slides up here He has some hip adductor firing and swing fit Causing the narrow basis support, I'd say it's a combination of all the above. So what do we do next? And here this is, you know, where you incorporate what, you know, what we typically learn how to do. You can do diagnostic nerve blocks. So you can play this video. And here we did the right operator nerve. And you can see he does, he has less, less of a scissoring gait pattern, he still has some. He does still lean to the left. But you know, is he really better? You know, I wanted to get objective data. So we did a pre and post block temporal spatial analysis, and you can see below his basis support actually increased slightly, so it's less. So he had, I think he went from negative two to zero, negative 0.02 to zero. So. All right. And then what I ended up doing afterwards is I gave him some botulinum toxin injections to the adductors. You can play this video. So. And you can see it still persists. The other thing I did just in case is, you know, just like everybody else, you stick the needle in and you turn on the EMG, and they were indeed spastic. So yeah, in conclusion, this is a nice tool to use, especially for people who are fast walkers or you have somebody with bilateral lower limb involvement. I think when you have like a spastic diplegic patient who's had a lot of surgery done, this is a beautiful tool, at least just to get them on video camera and look at the sagittal and frontal views of them and see what's going on in each joint per se. The instrument analysis, you know, it allows, it gives you objective data. It gives you just, you know, it allows you to see what's going on underneath the surface with the muscles. And it drives your hypothesis, helps you, you know, prove things and guide your treatment. If the patient has a narrow base of support, the one thing to be aware of is a force plate can only detect one foot at a time, but you can use like a foot switches to determine because the force plates allow you to see when they're in stance or in swing phase. It's not a diagnostic test. This is why I have to tell a lot of people, but it just, it's like an EMG. It helps give you more data to help support your hypothesis or guide your treatment. A lot of times when we get denials by insurance companies, they think we're doing something experimental here, but that is not the case. I know I showed you a lot of curves and a lot of technology and if you wanted to get started in one place, especially because this whole session is about applying this to your practice, the easiest way to get started, I think the most practical way would be to get a dynamic EMG system. And I think what's nice about this is you can use it for the arm or leg. If you want to do, you know, gait analysis with it, you can get some foot switches and that way... you can see it gets more intense. And this allows you, if you were wondering which muscles you wanted to treat or target your toxin for, this would give you some sort of baseline for that. And also, if somebody is referred to you for surgical planning, not only could you determine which muscles are spastic or dystonic, you can also have them do volitional activities and see what they're activating volitionally. The most common example of this is when I have somebody walking for me and their ankle inverts in swing phase. If you see the tibialis anterior activating, you can tell them, you know, tell the surgeon, this patient would be a great candidate for a splat, a split anterior tibialis tendon transfer, to help them dorsiflex the ankle without inversion. However, on the downside, I will admit, I do love doing these studies, but the analysis and the report that you have to generate from this can be very time consuming. And that's all I got. Thank you. Thank you, Dr. Moon. A quick note to our virtual audience. I know we're getting bombarded that you're getting... The screen is freezing during the presentation. The request is to please keep refreshing your browser. The technical staff is continuing to work on that. Next up on this all-star lineup is Dr. Monica Gutierrez from UT Southwest. I'm sorry, UT San Antonio. I'm sorry. She is going to be discussing the use of social media in the management of your spasticity clinic. I first wanted to come up and show everyone my... This is the poor man's gait assessment, and I use my phone a lot. This is when you don't have a fancy gait lab. You ask for permission, and you record in slo-mo, and you watch again and again, so... I did that, too. Okay. I always have a gait lab. It's my gait lab. Okay. All right. So there's options, but I'm learning. I'm learning. That's why we're here. But thanks so much for being here this afternoon. And I get to talk about something that I think is fun, that I get to engage in a lot, and that's social media. And how can you integrate social media into your practice, and promote what you're doing, and also learn? This is me. I am at UT Health San Antonio. I practice mostly outpatients, spasticity, brain injury, long COVID as well. I treat spasticity, dystonia, migraine, have toxins, pumps in my practice, and my disclosures are below. So why? Why do I do this? Why do we do this? Why do I want to tie in what I do, and who I see, and the work, the good, good work that we do for our patients? And some of it is to be an advocate, to, you know, I think it's important that I have a social media presence, that I can advocate for our specialty, so people know who to send these patients to, who have spasticity, and to learn who a physiatrist is, and what physical medicine and rehabilitation is. You know, I went into medicine, I went into medical school, I thought I'd be a pediatrician. Obviously, I'm not a pediatrician, because I didn't know what PM&R was. And you know, now I do, and I think, and we have papers that show the earlier the introduction, the more likely people are to go into our field. So it's important that people hear about it in pre-med even, before even medical school, and early in their medical school. And so, you know, this is where young people are getting their information, so we have to put PM&R and all the super cool things we do, like spasticity, out there. We have to advocate for patients with spasticity. We already talked a little bit about how many patients have spasticity, and how little access there is to care for patients with spasticity. Now we know that patients with spasticity, a lot of them are just given oral meds, and we know that those don't work as well as some of the targeted treatments that we do, either targeted drug delivery, or fungicide and toxin injections, or surgeries, or whatever else that might be. And so I kind of want to be that voice and have information out there, so patients can start to learn as well. I want a wide audience to adopt these treatments for spasticity, so I think if we put it out there, people learn. If you're putting out, you know, sometimes I even learn from people showing their ultrasound procedures, or ultrasounds on social media, or they might put it on YouTube, and I'm like, ooh, okay, all right, that's what the nerve looks like, okay, I'm gonna go for that one next time, when I'm, you know, doing my block. Tying again, improving access to care and reducing barriers, and have fun. It's fun to be on social media. So what is the world of social media? And Twitter, I'm a big, you know, there on Twitter, on the bottom is, you know, where you can find me there. So, okay, so who has Twitter? Anyone, raise your hand if you're on Twitter. Okay, yay, Facebook, just the boomers, no, more than that, all right, okay, excited, excited, Snapchat, yes, okay, Doximity, this is like professional doctor stuff, good, Insta, all right, yeah, that's for fun pictures, LinkedIn, professionals, love it, okay, TikTok, a couple TikToks, all right, that's good, I didn't even put, there's even new stuff now, my kids are in Discord, is that what it's called, Discord, yes, okay, anyone have Discord? My kids spend a lot of, oh, there's Discord, all right, I like it, okay, new things coming out. So, who is using social media? And, you know, it was tons of us here in this room, whether it be different sites, but you can see in 2008, it was 10% of the population, in 2021, it was 82% of the population. So that's eight out of ten people are going to be on social media that are using this, that are out there, that are following you, that are, you know, maybe getting their information, and the more and more we see that people actually want to go to social media for their health information, so it's important that they have good, accurate information. I think we've learned that more and more, even throughout the pandemic, and we need to make sure that we are the people that are putting this good information out there on social media, related to what our specialty is, related to exercise, related to disability, related to spasticity, related to post-COVID. This is also a strategy that's been taken up by the World Health Organization, that's been taken up also by other major national and international groups, and saying, you know, if social media is done and done right, this is a bridge to health equity, because people who may not otherwise have gotten the information are able to get the information now, and they, you know, can get contact with people and learn things that maybe they wouldn't learn before. Like I said, World Health Organization is one of those organizations that says, you know, here's, you want people to access credible health information, and that can create positive health outcomes, so social media is a way to do that. World Health Organization, that's, oh, they have, like, tons of millions of followers at this point. So what are some of the benefits of it? You can raise awareness, public health surveillance, general wellness, medical information, peer support, extensive reach for the clinician, and then, you know, promotion of your own work. And sometimes people are like, well, I don't want to promote what I do, but you should need to. You need to say, like, okay, this is what we're doing. This is how we're helping people. We are, you know, in a specialty that focuses on disability and helping make people's quality of life better and changing their lives, and so we need to put it out there. So this is, you know, so I said, it's okay to promote your own work, and this is one of the papers that I'd written during the pandemic when we all had to switch to telemedicine, and so virtual things became very important for patients as well, and this is, you know, one of the papers that we wrote about evaluating your spasticity patients via telemedicine, which a lot of stuff can be done via telemedicine now. Of course, I can't do the injections yet, but otherwise, I can see them and make a plan before they come in and then ultimately, you know, decide and maybe do a treatment on that day, and so there's a lot of part that people can see and do via telemedicine, so this is something that, you know, I will, when I have a paper that comes out, I will, especially related to spasticity, make sure that it's going out on social media, and this is something that you can see from other spasticity leaders as well, so Dr. Sheng Li, he also uses social media, LinkedIn and Twitter mostly, and he will, you know, put some of his, he has his pinned tweet as one of his major papers related to a new definition of spasticity that he led. There's another example of one of my papers that we did, that I had my first paper in the archives, which took kind of a while to get there, but cost efficiency analysis for spasticity management based on botulinum toxin prescribing habits, and so these are the things that, believe it or not, when you put stuff out on social media, it gets more attention, it gets more reads, and so that's the tie-in to when you're doing social media, you're advancing your agenda and you're building your brand, and there are, believe it or not, there are papers that say, when you use social media, that there are going to be more reads to your paper, people are looking at it, they're going to have more downloads, and so there's also, when you talk about promotion in the traditional academic setting, then usually there's conventional metrics for papers, so that means, you know, what's someone's age index, how many paper, how many times has your paper been downloaded, how many times has it been referenced, and that sometimes takes years and years to happen, but there's also alternative metrics, or altmetrics, or plummetrics, and these are ways that they say when your article's taken up by news media, or when it's on Twitter, or when it's on social media, and each article in major journals as well also has an altmetric or a plummetric too, and that's something that can also be added to, you can put that into your CV when you go up for promotion, and there's reviews that says, okay, there is scholarly influence of doing this stuff on social media and promoting your work there, and so it's important to get on there, and not just like, okay, this is me, and I'm not going to connect with anyone, I'm just going to start telling my stories, but it's important to connect with our national society, with other people in the field, with the major journals, with advocacy groups, because then they'll also start following you, and you learn from each other, and you promote each other's work. So what can Twitter do for you? And this was an example of a study in the annals of surgery. It said visual abstracts increase article dissemination. So this was a prospective case control study. So if someone put their articles on Twitter, and they put a visual abstract, so something either like a graph, or another visual abstract that was maybe like the poster at a conference, that when this was done, just compared to, let's say, an article that didn't have any type of social media presence, it had seven times more impressions, eight times more retweets, and then actually almost three times more people that visited the article online, and that's something that's measured by the journals, and so it's important to put it out there. Today I found out that Janna Friedley was presenting, and she's like, these are the top 10 articles that have been downloaded in the PM&R Journal, and two of my articles, one was in the one and three of that list, so it's like, oh, okay, where I was a co-author. So this was a randomized trial on Twitter, and with academia, and so they randomly chose some papers to be shared by Twitter, with a large group of people who cumulatively had 58,000 followers, and then there were some that they decided they wouldn't be shared, and you can see the ones that were shared very, very much had increased change in citations, increased altmetric score, and so it was very, very much beneficial to get the articles out there on social media. So four times more citations compared to non-tweeted papers over a year. So if you're gonna tweet, if you're out there, this is kind of a how-to. I'll talk a little bit about that, and so you wanna put an exciting opener, like hot off the press, and sometimes I'll put a little emoji in front of that, and then proud of our new paper, and then you can kind of, where it came out, you can say, you know, a quote from there, something impactful about it, who are the stakeholders, always have a link of the paper, you can put like a tiny URL, so it won't take that many, you know, characters, and then an image, like we said, image art from the articles are very important, and then you tag the other people in that image as well, and so that way it can be shared and get out there. So do you want to be an influencer? These are the best times to post on social media, so if you're on Instagram, eight to nine in the morning, Facebook's an afternoon thing, you can see Twitter's 12 to 3 p.m., LinkedIn, I guess people are doing it after work, from five to 6 p.m., and so this just says like, and specifically for healthcare, what times are most people engaged in it, and so the one for Instagram healthcare engagement's kind of like Tuesday morning, and then Twitter is kind of midweek, mid-morning seems to think, so sometimes I will save some of my tweets for that time, actually. Join the conversation, so use hashtags, you know, for spasticity, we use hashtag spasticity, in our field, we're using hashtag physiatry, we're using, for this conference, hashtag AAPMR2022, and so usually, you know, there's ways to follow these hashtags, you know, the other reminder, this is mine on both, I have like Twitter and Instagram that I use, they're different names, you usually should probably have the same name, but I don't have the same name, all right. So what do you tweet, and these are some of the things, you know, I will, that are some of my, I did a search for, okay, what am I tweeting about spasticity, and again, if I tweet anything about patients, I always have their permission, there's a super easy media release form, they just sign one line to be able to get put out there, and, you know, we'll maybe talk about, you know, the first one was when my patient, who was able to get injections, and able to use, drive her car finally, the other one was not anyone that was my patient, it was a very famous runner who had a runner's dystonia, but was getting Botox, so I, you know, made a commentary about that, because that's something that I treat as well, and then sometimes you use, you know, interesting things that are just going on in real life, I think this was like after, the picture after Will Smith slapped Chris Rock at, you know, Emmy, or whoever it was, and then they had all these pictures of people shocked, so I use that to make something about spasticity, and then I use it to learn from friends, so Paul Winston, he is on Twitter, he puts a lot of spasticity-related content, he does a lot of cryoneurolysis, so I get to learn about that stuff, he does a lot of, you know, so I get to see his ultrasound technique, I get to see what he does in his practice, Dr. Pacelli, he's from Italy, I got to kind of see what they do in other countries as well, I get to learn from my patients, so sometimes my patients follow me, and I, you know, if it's a publicly identifiable profile, sometimes I will follow them, I get to see how they're doing, I get to see how they're doing in therapy, I get to see them walking out and about, follow the social media rules, you know, you are what you tweet, so people are gonna see what you're out there, you have to kind of put your best behavior out there, and so thank you so much for being here, for listening, for following, I hope that you won't be scared of using social media, especially promote the good work that you're doing, and promote our good field, thank you. Thank you. Thank you, Dr. Gutierrez, just again a note to our live stream audience, all live stream sessions will be available in the AA event platform immediately after the broadcast, non-live stream clinical symposia sessions will be available within 48 hours after the session's end time, I know that there are still some continued difficulties with the live stream, we'll do our best to rectify them. So I get to back clean up in this all-star lineup, and talk about our interactions with other specialties, and to paraphrase an African proverb, it takes a village, how do we work with other specialties, both medical and non-medical? These are my disclosures, I work with many of the device and drug companies involved with spasticity management, potentially there may be some discussion about off-label drugs and devices, if that's the case I will bring that to your attention. So this is what we do, spasticity interventions, the purpose of this session isn't to describe in detail all the interventions that we can do, but it runs everything from non-pharmacologic treatment to highly invasive types of therapy and everything in between. I think it's important for us as physiatrists to be able to have facility with all of these techniques, even if we as an individual practitioner don't provide it, that we know who in our community we can refer to and we can certainly quarterback our spastic patients. So I think this is kind of a good checklist for us to make sure that we have those referral sources. So in reviewing the literature as well as my own personal experience, these were the top 10 both medical specialties and non-medical specialties that we interface with. So in an effort to not show favoritism to any specialty group, I put them in alphabetical order so that there is no rank order list. I get along with all of these folks, sometimes the relationship is smooth and easy, sometimes it's a little bit klutzy and I do my best to try to smooth it out. So we'll kind of go through this group and see how we interface with each of them. So first, our anesthesia colleagues. Sometimes it's a pretty variable experience. We teach four pain fellows at Cooper each year and so these are folks who have gone through medical school, gone through residency and getting specialized training in pain management and the awareness of what we do in spasticity management even some relatively straightforward oral or non-pharmacologic therapies is pretty variable. I can recall our fellow last year evaluating a patient for me with what was probably undetected cerebral palsy where the chief complaint was a knee pain and didn't even pick up that both ankles were plantar flexed and the knee pain was actually being generated somewhere else in the kinetic chain. Important to recognize that a lot of anesthesia care is being delivered by non-physician extenders, CRNAs. The CRNAs that I work with and have worked with in the past have been really really great but recognize that their training can even be more variable and that when you interface with them it can be entirely haphazard. In fact just last week I got a request from a CRNA, could you come and turn the pump off and then turn it on a couple days later after they get out of the hospital? I'm like no, do you want to manage the withdrawal? So recognize that when you're interfacing with our anesthesia colleagues you have a pretty variable interaction potential there. They can be an absolutely great resource with regards to intrathecal trialing. These folks are comfortable with performing spinal anesthesia, extending that to a lumbar puncture or placing an intrathecal catheter usually isn't too bad. They're also a really great resource depending on on your system if you're if you just feel comfortable managing a baclofen pump and you want to add some pain medication into it that would be an off-label indication. You could often turn to your your anesthesia colleagues and say hey I got the spasticity under control, keep the baclofen where it's at, just add whatever magical mystery mixture you would like to add in to help control the pain. I kind of live in both worlds a little bit in this but the pain and spasticity role for intrathecal delivery and it's really a almost a schizophrenic existence. Now everyone in this room who manages intrathecal baclofen feels very comfortable with it typically and they're absolutely fine with it. Yet when you start to get into some of the anesthesia like interventional procedures people back off that a little bit. As opposed to my anesthesia colleagues who are great friends of mine who will put sharp pointy objects into some of the most delicate area of the human body and not think twice about it but gosh you send them a baclofen pump and their world comes unraveled. So sometimes they're competitors and you know I'd like to think that we could all get along and as Dr. Heckard mentioned there are plenty of patients to take care of and there's no reason why we can't all work together. Occasionally you may need to have our anesthesia colleagues do a little bit of work if we're doing chemo denervation or neuralysis say in a child or a behaviorally impaired adult or someone who just can't be still enough that would actually make your procedure more risky. Sometimes our anesthesia colleagues don't have a great awareness of that. Tell them to use short-acting agents. Tell them to avoid neuromuscular blockade. I can't really imagine that anything that we do from a spasticity perspective really truly requires neuromuscular blockade but just to reinforce that. Emergency medicine. So these are one of our colleagues on the front line of medicine. Recognize that this is a very very high turnover rate in any individual department even in an academic center. They usually have a pretty good understanding of oral medications and complementary and alternative medications. I've learned a lot of tricks about how you could potentially manage side effects from say medical cannabis or medical marijuana from my ER colleagues. They don't really have a terrific terrific understanding about percutaneous procedures or intrathecal drug delivery. I'll plagiarize my colleague Dr. Heckert who always teaches our fellows. They never think it's the pump when it is and always blame the pump when it isn't. And this is one thing that you need to reinforce with our ER colleagues. They're usually pretty good with recognizing withdraw or overdose. One thing that I sometimes have to put out to our emergency department colleagues. There's some older literature that suggests to use flunazenil or pfizer stigmine for backliff and overdose. That is not the current recommendation. Those are both very cholinergic drugs. It's very easy to lose an airway. Also recognize that there is actually a subspecialty within emergency medicine, medical toxicology. And they're typically used to dealing with oral medication overdoses or illicit drug overdoses, sometimes intravenous. My interactions with them when it comes to backliff and withdraw or backliff and overdose. It's pretty scant and they're googling it or PubMedding it while I'm telling them what to do. But that isn't always the case. The biggest challenge I have in managing a spasticity patient who presents in an ER is, do we have, if someone goes to an ER that's far away from us or a while away from us, do we have the local ER stabilize them and then transfer them to us? Or just say look, put them in whatever vehicle you can and get them here. That can be a real challenge and a real subtlety of management. I tend to lean on try to stabilize them locally unless you're in a really exigent circumstance and then transfer them rather than just having them sent a long distance without at least some degree of stabilization. Intensivists and hospitalists, again pretty good with the oral medications, not so great with the other things. The biggest thing that you need to pay attention to with our intensivists and hospitalists is the NPO patient who is on oral spasticity medications. There really is not good recognition of these folks need to be supplemented. There really isn't a good handbook on what to do, right? I mean there's no exact mechanism of what we do. So we could do intravenous replacement. That's what some places do with baclofen. They will take a sterile baclofen solution that will typically go into a pump and use that intravenously as a supplement until someone can eat again. The conversion ratio is about 3 to 1 which means that if someone's on say 10 milligrams of oral baclofen you would give them about 3 milligrams of intravenous baclofen which is a pretty darn expensive undertaking if you're using branded baclofen. Usually we use on the benzodiazepines because they're more easily accessible in the IV route but there's there's no direct conversion rate between those two. Some folks will use intramuscular benzodiazepines as an alternative. There is a recent dissolvable granule meaning that a baclofen product that you could just put in someone's mouth and have oral absorption. That is not well integrated into our health system yet. It doesn't have lots of penetration in many situations. And lastly if someone's on tizanidine maybe you need to use a clonidine patch. I could tell you that our internists and hospitalists don't have any degree of ability to manage those sorts of things. Not a terrible idea in my opinion that you be consulted on every patient who has a pump in the hospital even if it's not your own because you will help allay fears very very quickly. Neurology again kind of the basic understanding of oral medications maybe less so on chemo denervation, neurolysis, and targeted drug delivery in general. I have very close neurology colleagues who are very very expert. In community settings they often can assist with lumbar punctures. Again they can have a very varied presentation. They can be referring doc to us. They can be a complementary doc to us. They can be a competitor to us. So the best we can do to to manage things in a calm manner the better. Certainly our movement disorder specialists and our MS specialists are colleagues that that we can work with. Important to recognize from the patient's perspective that just because we're managing that spasticity doesn't alleviate the need for you to follow up with your neurologist for things like seizure management and your MS medications and migraine therapy. You need to stay connected even though you might be seeing them more than our neurology colleagues. Neurosurgery I think these are our biggest colleagues are certainly when it comes to targeted drug delivery. Sometimes we need to see them before we proceed onward. Make sure our hardware is okay. Make sure the shunts are functioning appropriately. There is no such thing about too much communication between us and our neurosurgical colleagues. We need to know when our patients are having surgery. If they're new implants are we going to start drug at the time of therapy? What's the starting dose going to be? Where do you want the catheter tip to be? Certainly in replacement and revision situations a lot of that information is appropriate. On replacement therapy will drug be available at the time of replacement or are they going to jumpstart from old pump to new pump? Some neurosurgeons feel really comfortable with that. Others do not. So they want fresh drug going in at the time of surgery. So you need to make sure that that drug is there. One big question you have to ask your neurosurgical colleagues. Are you willing to help me manage outside patients? Meaning someone who you don't directly manage comes into your system. Will you help me manage these patients? Some neurosurgeons are comfortable with that. Others are not. They need to be an active partner if you're going to do targeted drug delivery. If you don't have this you really need to think about how else to construct it. Maybe you have a weekly conference. That's what I do in my current situation. Every Thursday morning me and our biggest implanter have a sit-down. We know what cases are coming up the following week. If there was some emergency that came up we address it and we're always emailing, texting, that sort of thing. Orthopedics outside of our pediatric colleagues there's not a tremendous amount of understanding of spasticity management and even somewhat unbelievably not understand the difference between contracture and spasticity. They just see it as restricted range of motion. You know, hey you got that stroke patient moving a little bit better. Can't you do that for this other patient? Like no that's a lower motor neuron lesion. That's not going to help with the spasticity intervention. There are some unusual presentations that sometimes our orthopedists don't recognize. Post-surgical dystonias, whether that's spine surgery or knee arthroplasty. I've seen, I usually see about one or two of these a year. Folks who develop a knee flexion dystonia after an uneventful knee arthroplasty. Those folks can respond very nicely to spasticity interventions. If you could find an orthopedist who can do tendon releases and contracture releases, they are worth their weight in gold. They are not very common across our health system. Recognize the time it takes for an orthopedic surgeon to do a knee flexion contracture release. His partner's already done four knee arthroplasties. So it can be a really challenging undertaking. So if you find that, you hold on to that referral no matter if it's inside your system or outside your system. PT and OTs, these are folks who refer to us. I will say very candidly, I get most of my referrals from physical and occupational therapy. One of the things that I didn't recognize until sort of the midpoint of my career, exactly when my midpoint happened I don't know, but they have some specialties also. You know, I was very used to sending patients to therapy and saying, you know, could you do serial casting after I do a toxin injection? Because the places that I was working with, everyone knew how to do serial casting. But out in the community that's not the case. There is a neurologic physical therapy subspecialty that really focuses in on the neurologic patients. So out there in the community you need to know who does, who takes care of neurologic patients. Most physical therapy doesn't deal with neurologic patients. They're more the musculoskeletal, sports medicine types of therapists. These are folks that you need to keep a, keep contact with. You should put it in your calendar that once a month you're gonna have some interaction, whether it's live or virtual, to a PT or OT group in your community. And you need to keep going back because there's a really high turnover in this specialty. Buy them a cup of coffee and a box of donuts, they will love you forever. An industry can help with that. You know, sometimes they'll buy the donuts for you. Trust me, you do, give one physical therapy talk, you'll get five referrals the next week. And you have to keep up with that. Explore the potential of actually seeing them in their therapy location. Pharmacy. Again, pharmacists have to deal with a lot of different things. Sometimes their understanding of what we do is not great. You know, they don't like to go over the FDA speed limits where we might feel comfortable with that. I would make the argument when you're discussing with pharmacists that you want to have all the different brands available. Not only from a cost perspective, but from a supply chain issue, as well as an academic mission. All of my trainees should be very comfortable in managing all the available toxins and intrathecal baclofen products because if all they know how to do is inject toxin A and they leave my supervision and all they could do is inject toxin B where they're at, they may struggle with that and we don't want that to happen. Some places like compounded medications, other places don't. Primary care. These are the fertile field for referrals and lots of insurers require primary care referrals for us to see patients. They quarterback all of these things and with the multiple indications for toxin, such as bladder, headache, and even cosmetic reasons, they can help us know whether other folks have gotten toxin injections or not. A primary care physician who wants to take care of adults with developmental medicine, they're worth their weight in platinum. They're even more than the orthopedic surgeon who will do surgery for them. They are really few and far between. And lastly, radiology and interventional radiology. Especially the neuroradiologists can be really helpful in interpreting difficult scans, but sometimes they don't recognize what a nuclear medicine cisternogram or CT myelogram is and what you're looking for. They can help sometimes with the lumbar punctures. The MRI challenges with these systems. Who holds that responsibility? And this is not trivial. There have been patients who have died because the MRI protocols were not followed. Is it the managing physician? Is it the ordering physician? Is it the supervising radiologist? Try to develop those protocols with your supervising radiologist. So it takes a village. We don't do this in isolation. And if you don't have a good relationship with all of those individuals, work on developing it. This is my village. This is where I work every day. It's a fun place to work. And we have now come to the end of our formal presentation. I'll now open the floor up both live and virtual to question and answers. I have nothing right now virtually. Any questions from the audience? It's Dr. Salino, correct? Yes. Hi, I'm Caroline. I'm one of the nurses over at Rady Children's in San Diego. So on your list of 10 people, I'd encourage you to add nurses, MPs, and PAs. At our program, our nurses run the Botox program, the intrathecal baclofen pump program. We run all the limb deficient, all the specialties, and do all the case conferences with our physicians. And our MPPAs pretty much with us run the baclofen program. And they do all our casting, serial casting and everything. Couldn't agree with you more. Yeah, so I hope to... And we're the ones doing all the baclofen pump surgery cases. So we're working with the admins and coordinating all the back end with our orthosurgeons. And so I encourage you to put us all up there too. So I guess I would include nurses in all of those disciplines. Especially also in the primary care world. You know, the nurse practitioners run a lot of primary care. Yeah, we're doing referrals and the POTS and working with the background. Certainly I didn't mean to exclude nursing in any way, but they're more sort of inherent kind of under that discipline. Yeah, all of us in the background for each department. So thank you, because it is true that that is exactly our team that you put up there. Just the background. Awesome. So thank you. Would you consider coming to Philadelphia? I would... Maybe afterward? Hey, no, it's... I will say it is hard. We've got eight physiatrists and we have four nurses and... It sounds like you have plenty of help over there. Go ahead. Hey, Rita Hamilton, Baylor Dallas. I have a simple question. I'm on the other side of my career. What are your thoughts on ultrasound guided botulism toxin injection? Should I really learn ultrasound at this stage of my career? So I'll take a quick crack at it and then let my colleagues do it. I think there's an increasing body of literature that shows both your accuracy and safety improves with the use of ultrasound. It's a bit of a learning curve, but sometimes old dogs can learn new tricks. And I say that with the utmost affection. You know that. But I'll let my colleagues... Sure. I'll just say I'm a little older than I look and ultrasound was not part of my training. My department got its first ultrasound machine the year right after I graduated, like within a month of when I graduated. So a little bit of exposure, certainly no practice injecting. And I injected exclusively with EMG amplifier and STEM guidance for years. And you can pick it up and I'm still learning a ton, but I do feel that there are certainly times when... So if I'm using ultrasound, I'm always using EMG amplifier guidance at least. I always use physiologic... But I would need a little bit more confirmation because I'm not hearing what I would typically want to see. Or the spasticity is more dynamic than static. And so it happens when the patient gets up and starts to walk and, you know, it's hard to do, to inject someone when they're walking around. So if I can identify the muscles by good clinical physical examination and then use ultrasound for the procedure, I think it's well worth learning the skill. And the lovely thing about doing it that way is you can take your time learning and begin to use it more and more as you feel comfortable. I'm still a heck of a lot faster without it, but when I need it, I'm so much more likely now to just turn it on than I was, say, 10 years ago. Yeah, I do spinal cord injuries. So 99% of mine have atrophied muscles and I'm just like, where is it anyway? It doesn't look like a textbook at all. So it would probably really help you in that regard. And, you know, some people have a real, like, I just, for some reason, like, cross-sexual anatomy really clicks with me pretty easy. So if you are like that, then it might come actually more easily for you than you think. If not, there are courses and it can be fun. I think the patients really, really love it. They really, you know, enjoy seeing their muscles. They enjoy, if you tell them the gender of their muscles, you know. and they're billing like clinic and a hospital. So the hospital can bill for that ultrasound. Go ahead. Hi. I'm Eric. I'm a medical student. Um, thank you guys for your time. Um, just a question. It's more of a generalized question about that interdisciplinary communication, some of the breakdowns and, um, like you mentioned. Um, I think Dr. Gutierrez mentioned maybe like the integrated rehab setting versus like a stand-alone. Um, does that, like a stand-alone rehab hospital, do the issues sort of come up more in one or the other and how to navigate that? I'll take a first crack at that. I think they used to. Um, I think we're doing a better job. Lots of times electronic medical records allow faster communications. A lot of our surgeons now will actually do telemedicine from acute rehab and do a check out there. Maybe they need some imaging. So we'll get the imaging locally, send it to them and do their post-op checks remotely. So I think it was more of a problem in years past, but it does seem that there's better technological solutions. I don't know if the panel has any different feels. Well, with technological solutions, let's not forget that Christmas day last year, I taught a neurosurgery resident how to do a cap aspirin on a back lip and pump via FaceTime. So things can happen. Um, and you know, we've come a long, long way at our institution with communication, but, uh, not, not, uh, more than a month ago, uh, Ben, we got a call like that. I said, Ben, come to the hospital. You just had a baby and he said, what? And I said, the pump, the patient we sent for implantation got implanted yesterday and we didn't know. So, you know, we still have a ways to go at times. So one question from a virtual audience that I'll place to the panel. Uh, are there resources for developing a multidisciplinary center of excellence for spasticity management if such a thing exists? You better take that one. I'd like to know that too. So, uh, you know, I think it depends a little bit about what you mean by multidisciplinary. I mean, I think that there could be a pretty good idea that you co-treat with a, co-treat and co-assess with a physical therapist and perhaps a nurse. I think it's going to be hard from a scheduling perspective to get some of those other medical disciplines in at the same time. Uh, not impossible, but potentially. And, you know, there are some funding sources for multidisciplinary clinics, usually more at the state level than they are at the federal level. Monica, do you have any different sense in Texas than in New Jersey? Yeah. In... We have a... Our pediatrics have a multidisciplinary spasticity clinic and it's a peds rehab doctor, an orthopediatric orthopedic surgeon, orthotics, prosthetics person, and physical therapy. And, um, it's time intensive. It's person intensive. It's definitely not... We're not doing it for the money. We're doing it for the right thing for the patient. And it's real tough for the therapist part, because they have to like get pre-authorization before the patient comes to see them. But if the patient's in another therapy, they can't bill for it. True. And so, yeah. Gotcha. I think we had a question from the audience. Hi. Uh, thank you guys for your time. My name is Ashley, a medical student. And, um, my question is with the increase of, um, higher acuity patients coming to our rehab hospitals coupled with just the decrease in staff, how do you keep the multidisciplinary team strong, um, in the midst of all this? First, I want to say for both you and your predecessor, it's just awesome that you're here as medical students. And then it's also equally awesome that you're asking such intelligent and erudite questions that challenge us. Would you have interest in coming to Philadelphia? I think that's collusion, though. But you guys want to take a crack at that first or? I think it's just right now, just things are so tough again with the pandemic. It's about community and it's about building relationships and just, you know, keeping. Gotcha. Thank you. Go ahead. Sorry, I got one more question. So I love all the different sessions you had in this conversation today. One of the things I would love to see is how do you implement... And I don't know, how many people here are on Epic? I'm on Epic. Okay. How do you implement Epic into your spasticity clinic in regards to... I had no choice. What? I had no choice. Yeah. But I mean, like in regards to flow sheets and communications and DME and auth referrals, like we have special orders for our DME that's been customized for our PT, for our OT. We've done like special letters and ABS instructions, dot phrases, flow sheets for back up and pumps and stuff. I think that's the bottom line is the customer... The laws vary across state lines, so. for EPIC to monitor? Like you can pull a registry for your back-living pumps or for your Botox clients and see who hasn't shown up and things like that. Do you guys have any of them? So we do, but I can't say that I know it's an EPIC construct. Like I don't know if there's some back-end data capture. I mean, I see the reports. Yeah. So I built one. We had, yeah, we worked with our programmer and we did a whole EPIC database registry. And I presented it at EPIC was all on the use of eight plates and how to monitor your eight plates, how to monitor your DDH patients. And so you just literally press a button and then it tells you all the patients that didn't show up in the last six months. So in the background, we built the parameters with our orthosurgeon. Sure. And then there was a programmer that, of course, put that in. But then the clinical part was what we pulled in. And then being able to... I would be very interested in how you built that, because there could be so many applications even to monitor end-of-battery life. Oh, yeah. We do. Yeah. Like our CCS patients and stuff like that. We can run reports off of that. I kind of shudder to admit we use an Excel spreadsheet for that. We went from there to EPIC and it literally is a press of a button now. That's fantastic. Yeah. And then you can just forward it off to your scheduling people and then they just take on that. The nurse reviews it and then it goes... I push it over to a scheduling group and then they call everybody who hasn't shown up in the last six months. We published a paper on it. I have... I would love to see that, yeah. And I think... I don't know if anybody else has shills, but I think this is the really wonderful thing about getting together and having dialogue. Yeah. Because we learn from one another. So thank you. Yeah. Dr. Toomer, our colleague from New Orleans... I'm sorry. I just wanted to jump up. When you say you use an Excel spreadsheet, there's still a lot of value to having records outside of EPIC. Speaking from disaster preparedness, being in a hurricane situation, you lose your access to electronic records. There are hurricanes in New Orleans. I haven't heard. No, I know. But then also, so we recently... we went to EPIC about a year ago, a year and a half in my office. We didn't realize that patients had the ability to cancel their appointment when they got their reminder call. And some of them were sending in messages, but it wasn't getting routed to us. So we had a couple of pump refills get canceled, completely drop off the schedule. And the only way we knew it is because we had that paper calendar as well. So EPIC does a lot of great things, but it's good to not 100% rely on that because you can miss things that way and there can be mistakes. So having paper helps. I've had the exact same problem and concur currently. We got a minute and six seconds left. So we'll take this as our last question. I'm Audrey Chavez. I'm a brain injury fellow at Spaulding right now. And my question is for Dr. Gutierrez. As you're building your social media presence and having patients that start following you, do you have problems with boundaries with the patients messaging you or anything like that? That's a great question and very infrequently actually. And so occasionally I will have... you know, there's sometimes patients that will send messages. You have that tendency if they have brain injuries that, you know, they don't understand those boundaries and that you can't be speaking to patients on social media through the messaging, because that's not a HIPAA compliant place. And so sometimes I have to say, sorry we can't communicate this way, send me a message on my chart, sort of thing. So very infrequently, but it can happen. Thank you. And with 12 seconds to go we finish right under the wire. I want to thank both our live and virtual audience for attending today, from my colleagues up here in the panel. I think we definitely fertilized each other's with some ideas and thoughts to take home to our practice. Enjoy the rest of your Saturday, the rest of your conference and be safe. Thanks.

spasticity management fellowship

patient care

outcomes

PM&R residency

advanced procedures

institutional support

interdisciplinary collaboration

raising awareness

patient volume

electronic medical records

multidisciplinary team