Good afternoon and welcome. My name is Heather Vincent. I am currently serving as a faculty member at the University of Florida and the director of physical medicine and rehabilitation research. I am very delighted to be with you this afternoon with a dynamic lineup of some great presenters today on the topics of general rehabilitation. The following abstracts were selected from the peers from a panel that went through and stringently evaluated the quality and ability for the research to make a difference in the field of physical medicine and rehabilitation. What I would like to do is introduce our five speakers, allow their videos to be presented in a row. So we'll move from video to video to video and save the question and answers for the end period. I encourage viewers to use the chat function and communicate with us if there's a question that you have for our speakers and we will try and get to all of those or as many of those as we can by the end. I'd like to introduce our speaker lineup. First is Dr. Emma Desjardins from New York University Grossman School of Medicine. Dr. Brian Medvedevich from the Good Samaritan Hospital Medical Center. Dr. Alberto Esponazi from Moss Rehabilitation, future Dr. Victoria Peele from University of Washington School of Medicine, and Ms. Natalie Webster from the Hunter Holmes McGuire Medical Center. Let's go ahead and begin with our first video from Dr. Desjardins. We look forward to hearing the series of videos. Enjoy. Hi, my name is Emma Desjardins and I'm a PGY3 resident physician in physical medicine and rehabilitation at NYU Rusk Rehab. I'm excited to talk with you today about this original research done with Dr. Allison Shrikande at her outpatient pelvic rehabilitation practice. This research is about a new treatment protocol for women with chronic pelvic pain syndrome. The treatment protocol was developed with the theory that a multimodal treatment is needed for a multifactorial problem. Chronic pelvic pain syndrome affects over 9 million women in the US, but is notoriously difficult to both diagnose and treat due to its varied etiologies and the multifactorial pathophysiology for pain and dysfunction. Chronic pelvic pain syndrome involves a constellation of symptoms arising from pathology in various organ systems within the pelvis and is defined as six months or more of non-cyclic pain in the pelvis, anterior abdominal wall, lumbosacral back, or buttocks. Endometriosis, pelvic adhesions, irritable bowel syndrome, and interstitial cystitis are some of the common etiologies and often more than one are associated. Given the varied etiologies, response to standard surgical or pharmacologic treatment is poor and pain recurrence is common. Therefore, chronic pelvic pain syndrome can be thought of as a functional pain syndrome with three proposed mechanisms for pain in this disease being, one, neurogenic inflammation leading to neuropathic pain, two, trigger points in the pelvic floor muscles causing myofascial pain patterns, and three, continuous pain signals from the pelvic anatomy involved causing central pain amplification and viscerosomatic cross-sensitization. We found that our novel treatment protocol specifically targeting these three mechanisms can both decrease pain and improve function for our patients. The protocol consists of six sets of weekly injections, trigger point injections to the bilateral levator ani muscles and hydro dissection of the bilateral posterior femoral cutaneous and pudendal nerves. You can see on the poster three diagrams of the anatomy involved demonstrating the trigger point locations for the puborectalis, pubococcygeus, and ileococcygeus muscles. Each muscle was unilaterally injected each week for a total of six injections. Also, you see the course of the posterior femoral cutaneous and pudendal nerves. Both nerves were unilaterally injected at one visit with both contralateral nerves injected at the following visit for a total of six visits. All injections are performed with ultrasound guidance. The trigger point injections use lidocaine and were done by a subgluteal posterior approach. Lidocaine reduces inflammation and needling of the top band of the muscle helps to reset and relax the muscle, both relieving sensitization of nociceptors and therefore breaking the cycle of pain. The hydro dissection is done with dexamethasone and lidocaine once on each side and then with Tramel and lidocaine at the next four sessions. Tramel is an herbal NSAID alternative that has been shown to inhibit secretion of pro-inflammatory cytokines and was used for this protocol to limit steroid burden. Again, lidocaine was used not only for its immediate anesthetic effect, but also because it has been shown to decrease neurogenic inflammation. In addition, the hydro dissection technique itself creates space around the nerves, allowing for decreased fascial restriction and more blood flow to the nerve. All of this contributes to effectively reset the hyperactive nerves and decrease central sensitization. In keeping with the multimodal approach, all patients continued their various other treatments, including pelvic floor physical therapy, cognitive behavioral therapy, NSAIDs, CNS neuromodulators, diazepam suppositories, meditation, and yoga. This study was a retrospective chart review that looked at 100 female patients who were diagnosed with chronic pelvic pain syndrome. Physical exam for diagnosis included internal examination of the levator ani to determine strength, tone, and presence of trigger points. All patients were found to have trigger points, as well as to have a positive TINL sign of the pudendal nerve with tenderness at Alcox canal. Also, patients had allodynia of the ilioinguinal posterior femoral cutaneous and genitofemoral nerve distribution. All patients had scored their pain and function using the visual analog scale and the functional pelvic pain scale at both pre- and post-treatment office visits. For the visual analog scale, patients were asked to rate their pain over the last 24 hours on a scale of 0 to 10. The functional pelvic pain scale was used to assess patient's function as it relates to pain, and each category was scored from a range of 0 to 4. The total functional pelvic pain scale score was added to between 0 and 32. Higher numbers indicated more pain and therefore worse function. The categories include bladder, bowel, intercourse, walking, running, lifting, working, and sleeping. These categories are very important to quality of life because patients with chronic pelvic pain syndrome often have coexisting anxiety, depression, and difficulty with interpersonal relationships. And these categories, especially intercourse, can have a significant impact on psychological health. The average patient age was 38 years old. The average duration of pain prior to treatment was six years. Endometriosis, anxiety, and herniated lumbar discs were the most common comorbidities. Many patients had previously tried surgical treatment, and the majority of patients had tried NSAIDs, muscle relaxants, and CNS neuromodulators without relief of pain. The difference between the pre- and post-treatment scores were determined, and in the category of pain as well as all functional categories of the functional pelvic pain scale showed improvement. The improvements in pain, total functional pelvic pain scale scores, and individual functional categories of intercourse, walking, sleeping, lifting, and working were statistically significant. Improvements in bladder, bowel, and running function were not statistically significant. Limited improvement in bladder and bowel function may be related to common comorbidities of interstitial cystitis, overactive bladder, and irritable bowel syndrome, which may need additional targeted treatment for functional improvement. In addition, improvement in running function may need more time for neuromuscular re-education after pain is improved. We also see that when we organized the groups based on who saw no change after treatment, who experienced improvement, and who experienced worsening, the categories with the largest number of patients with improvement post-treatment were pain and total functional pelvic pain scale. Side effects were recorded and limited to one patient who experienced clitoral swelling that resolved after three days. Overall, based on this data, this novel treatment protocol is safe, well-tolerated, and amounts to a significant increase in quality of life for these patients. Hello. My name is Brian Mavredich. I'm a PGY-4 resident at Mercy Medical Center in Rockville Center, New York. The research project I'm presenting today was spearheaded by one of our recent graduates, Dr. Amir Ali. The title of the research project is a retrospective chart review of thromboprophylaxis for deep vein thrombosis in post-operative hip fracture patients. We were concerned that the post-operative hip fracture patients who received aspirin as DVT prophylaxis more frequently had DVTs compared to those on low molecular weight heparin or factor Xa inhibitors. DVT is a second most common complication following hip fracture surgery. Without thromboprophylaxis, the incidence of DVT range between about 42% to 50%. The more common agents used for DVT prophylaxis are aspirin, low molecular weight heparin, factor Xa inhibitors, but there is disparity in the literature concerning which agent is optimal in preventing DVTs. There are two main arguments proposed for DVT prophylaxis in the post-op hip fracture patients. The first stating that aspirin is one of the most effective, inexpensive, and the safest method for DVT prophylaxis in these patients. It also stated that the use of more potent agents such as factor Xa inhibitors and the low molecular weight heparins are associated with a higher incidence of bleeding and wound related complications. The second argument say that aspirin is not optimal for DVT prophylaxis. The purpose of this study was to compare the incidence of DVT in post-op hip fracture patients on various chemoprophylactic agents to determine if aspirin is sufficient preventing a DVT. This study was a retrospective study with the population including post-operative hip fracture patients admitted to Mercy Medical Center's acute inpatient rehabilitation facility. Our inclusion criteria included those with increased DVT risk. I'm sorry, the inclusion criteria was hip fracture patients with post-operative repair or fixation and the exclusion criteria included those with increased DVT risk pre-hip fracture that included an active cancer diagnosis, inherited prothrombotic hypercoagulable disorder, and previous history of DVT or pulmonary embolism. The data points gathered included age, gender, type of hip fracture, anticoagulant used, and comorbidities. Our study included a total of 157 patients with a mean age of 81 years old. 154 of the 157 participants were non-smokers and approximately 69% were men in the study. The thromboprophylactic agent used was determined by the hospital the patient came to from our rehab unit from. Whichever agent they recommended was used during their rehab stay. 35 or approximately 22% of the patients were on aspirin, 53% on heparins, and 25% on the Noax or Coumadin. We did not have any patient included in the study, not on a thromboprophylactic agent. What we found was 15 or 9.6% of the patients developed a DVT during their stay in our rehab unit. Our results were as follows. For those on aspirin, there was a 25.7% incidence of DVT, which is 9 of the 35 patients on aspirin developed a DVT. For those on the heparins, there was a 6% incidence of DVT. And for the nose on the Noax or Coumadin, there was a 2.6% incidence of DVT. A chi-squared test of independence was performed showing the relationship between the anticoagulant used and DVT frequency was significant with a p-value of less than 0.001. In conclusion, our results refuted the recommendations made by various orthopedic articles claiming aspirin is one of the most effective and expensive and safest methods for DVT prophylaxis in these patients. Our findings represent the importance of sufficient thromboprophylaxis to prevent potentially fatal pulmonary emboli. Hence, adequate anticoagulation with heparin or Noax is imperative for good patient outcomes status post-surgical hip fracture or fixation. In our study, the anticoagulation medications were separated into three primary groups irrespective of the dose of the anticoagulation. And for this reason, we recommend further research into analysis with account of the dosages of these medications. Thank you. Hello. My name is Alberto Scanasi, and I am the chair of the Department of Physical Medicine Rehabilitation at Moss Rehab in Einstein in Philadelphia. On behalf of my co-authors, I am pleased to present adherence to onabatulinum toxin A treatment in post-stroke and multiple sclerosis patients with spasticity. And this is from the ASPIRE study. Our disclosures and additional data for this analysis can be viewed on the poster itself, which are accessible via the QR code at the bottom of this slide. The objectives of this study, of this analysis, was to identify baseline clinical characteristics and treatments-related variables that impact adherence to onabatulinum toxin A treatment in both post-stroke and MS patients. And this data was from the Adult Spasticity International Registry, the ASPIRE study. ASPIRE is a two-year, international, multi-center, prospective observational registry. It included 730 adults with spasticity across multiple etiologies, which were treated with onabatulinum toxin A at the clinician's discretion, meaning this is a real-life study. Clinical meaningful thresholds for treatment adherence and non-adherence were used for this analysis. Treatment adherent was defined as patients who had three or more treatment sessions with onabatulinum toxin A during the two-year duration of this study. Treatment non-adherent was defined as patients who had two or fewer treatment sessions. Multivariate logistic regression was used to analyze the stroke population, and descriptive analysis were used for the multiple sclerosis population. This was due to the difference in the number of subjects for each diagnostic category. In total, 43 baseline demographics and clinical characteristics and 33 treatment-related variables were assessed. In ASPIRE, 411 patients, or 56% of the population, had spasticity resulting from stroke and received at least one treatment with onabatulinum toxin A during the two-year study. Of the stroke population, 346 patients had data for all variables and were included in the final multivariate model. 83.2 of the patients were classified as treatment adherent, meaning that they had more than three treatments, with an average of 5.3 treatment sessions and a mean treatment interval between sessions 1 and 2 of approximately 18 weeks. In contrast, 16.8 of patients were classified as non-adherent with less than two sessions and a mean interval greater than 24 weeks. On the right side of the slide is a force plot that shows the variables that were included in the final stroke model. Factors that were associated with non-adherence to onabatulinum toxin A treatment are to the left of the dotted line and shown in orange, while factors associated with adherence are to the right and shown in green. Asterisks indicate statistical significant variables, while the pound sign indicates clinical meaningful non-significant variables of interest. Variables that were found to impact adherence in stroke patients will be summarized at the end of the presentation. In Aspire, 119 patients or 16% of the population had multiple sclerosis and receive at least one treatment with anabotulinum toxin A during the two-year study. 77% of the patients were classified as treatment adherent with an average of 5.4 treatment sessions and a mean treatment interval between sessions one and two of approximately 18 weeks. In contrast, 22% of patients were classified as non-adherent with 1.5 sessions and a mean interval of approximately 26 weeks. Descriptive data for the MS population are shown in the tables. Variables that impact adherence will be summarized on the next slide. Summary of variables that impacted treatment adherence to anabotulinum toxin A. As you can see in this slide, in the final stroke model, variables that were associated with adherence with treatment for spasticity included those patients that received treatment in Europe, the use of orthotic devices, and prior surgical procedures. While variables associated with non-adherence included higher age of enrollment, use of assistive devices, treatment interval greater than or equal to 15 weeks, treatment for thumb and palm, and moderate severe disability on the DAS upper limb pain subscale. In the multiple sclerosis analysis, baseline characteristics and treatment related variables that were found to impact treatment adherence included patients that were relapsing, remitting, or other multiple sclerosis types who were more adherent than secondary progressive. Patients naive to botulinum toxin for spasticity were less adherent than non-naive patients. Adherence patients treated for the lower limb or both limbs had higher severity scores than non-adherent patients. Patients who use acupuncture were more adherent, while patients that use assistive devices were less adherent. Patients with treatment intervals less than 15 weeks were more adherent than those with equal or greater than 15 weeks. Patient treated for the equinovirus foot, flex hip, or flex toes were more adherent, while patients treated for the stiff knee were less adherent. Clinical satisfaction with onobotulinum toxin to help manage spasticity or help with the therapy exercise was higher for adherent than non-adherent patients. In conclusion, this ASPIRE analysis provides real-world insight into variables that can impact adherence to treatment with onobotulinum toxin A for spasticity, which can help optimize spasticity management strategies and improve patient care. Thank you very much. Hello, my name is Victoria. I am a third-year medical student at the University of Washington School of Medicine, and this project was done in collaboration with Jana Friedley of UW Rehab Medicine and Mark Sederberg of the University of Utah Sports Medicine. We were interested in this project because we all know that exercise is something very important for health, and exercise as medicine is this concept that we've all been interested in and that they have both done research in, and we wanted to be able to extend this concept of exercise as medicine to all populations and not just the general population of able-bodied people. And in order to do that, we started thinking about barriers and what makes exercise difficult for different people. The population that we decided to focus on was people that have had major limb amputations because they face very unique physical challenges that can be different than what other people might face when they try to exercise. We wanted to find out for these people that have had amputations, what struggles do they face? What things might help them exercise? What things might stop them from exercising? So the research was designed with this thought in mind of how can we increase the health of a population? And in order to do that, we really need to understand what's stopping them from achieving the exercise goals that are recommended. The baseline we decided to look at in terms of how much exercise should people be doing was the United States Department of Health and Human Services exercise recommendations. And they suggest that Americans should exercise aerobically, so having the heart beating faster than usual, about 150 minutes a week. That comes out to a little less than a half hour a day. They also recommend that people should do strengthening exercises at least twice a week. So with these standards in mind, we designed a survey and we went forward with that mode for the study. So this was an observational cross-sectional study and the survey was given online. We provided it on social media and we also handed out links on iPads to complete the survey within a Seattle area clinic for people who have had amputations. In the survey we asked not only about people's exercise habits but also about the barriers they faced. We listed some potential barriers and had people select which ones, if any, applied to them. We also asked about their base pain levels, whether they have limb pain or phantom limb pain, what level of amputation they had had, why they had had an amputation, and their pain attitudes. This was one of the interesting aspects we threw into the study was this SOPA scale and it measures people's adaptive or maladaptive attitudes towards pain. We wanted to see how that might interact with their level of barriers and their exercise time. And finally we asked normal demographic questions about their background and where they lived. We provided this study over the summer of last year, of 2019, and what we found was we got 124 valid responses, all from adults. We only did 18 and over and these people had had major limb amputations, so an arm or a leg. Actually 98 and a half percent of them ended up having lower limb amputations. So out of this population we found that 24.2% of them met those aerobic exercise guidelines, so that 150 minutes a week. We found that 53.6% of them met that strength requirement of twice a week and about 18 and a half percent of our respondents met both of those requirements. Now these numbers were in interesting contrast to the numbers for the general population in the United States. So when you look at everyone not focusing on a specific disability, we actually see that about 43% of people meet the aerobic guidelines. So our population was significantly less than that, which brings up the question of maybe there are different barriers in play here. So this was a very interesting result. Another very interesting result was that our population having over 50% people meet the strength recommendations is actually far more than the general population. Only 21% of Americans in general do strengthening exercises twice a week. We're not sure why this is, but it could be that people who have mobility restrictions have to do a lot more strengthening in order to get around day to day. So moving on with the results, at least 75% of these people had at least one barrier to exercise. The most common barriers we saw reported, which you can see on the graph here, those two top bars were chronic pain and instability. These are the big factors that a very large percentage of our respondents said kept them from exercising. When you look at the general population, we saw a totally different study showing that the general population struggles more with motivation and inconvenience and health concerns. So definitely some unique barriers came up in this study. We ran some correlations and we found that people in our study that reported having higher numbers of barriers reported exercising fewer minutes per week. We also found that people who reported having higher numbers of barriers reported having more negative attitudes towards pain. These negative attitudes towards pain also correlated with lower minutes of weekly exercise. And those negative attitudes towards pain included things like the belief that pain always causes harm, the belief that medication is needed to treat pain, and the belief that emotions can influence pain, a belief that can be adaptive. And when we publish this, you'll be able to read more about these negative pain attitudes in the SOPA scale. Obviously this study was limited. It was a very small sample size and it was a fairly homogenous population. Most of these people were white, most of them had lower limb amputations, and most of them were in the United States. We would like to do larger studies in the future to find out more of how these principles play out when looking at a much more diverse population. What these results showed us in general is that people with limb amputations have very unique barriers. They're not the same as the general population in the United States and they seem to correlate with exercise time, which indicates that they may have an impact on people's ability to exercise. This means that this is most likely clinically relevant and clinicians can address these barriers by forming individual plans with patients to help them exercise by addressing the things that might be stopping them. Some things like chronic pain, when we improve our pain management strategies, we can enable patients to exercise more. When we talk about pain attitudes, patient education and reassurance that exercise is safe and not harmful for them can really empower them to be able to exercise and improve their own health. We can provide equipment to help them with stability. We can provide resources to help people who struggle to be able to exercise due to lack of access. And we can think about tailored individualized plans based on each patient's barriers, understanding that they're unique in their own means. With all of this, our hope is that this will spur clinicians to really get to know their patients because we have such incredible potential to improve people's quality of life and their functionality by addressing the barriers they face to exercising. Thank you so much for your time. I really look forward to meeting everyone and answering your questions. Hi, my name is Natalie Webster and today I will be talking about shoulder pain in persons with major upper limb amputation who use prostheses. Understanding shoulder pain in persons with major upper limb amputation is important because most individuals who sustain this level of amputation do so as a result of a traumatic injury in early to middle adulthood and have a long post amputation life expectancy. These individuals are potentially at an increased risk of shoulder pain due to overuse in their non-amputated limb and the compensatory movements they use to operate their prosthesis in order to complete daily living activities. The objective of my study is to describe the frequency and severity of shoulder pain in persons with unilateral major upper limb amputation and determine the association between the shoulder pain, the participant, the type of amputation, and the characteristics of the prosthetic device. The study utilized a cross-sectional study design and participants were recruited nationally from people living in the community. The 112 participants in the study included persons with unilateral major upper limb amputation who actively use a prosthesis. During in-person study visits the participants were assessed and data was collected on the participants demographic amputation and prosthesis use history and a direct physical examination was also performed. The main outcome measurements of the study were collected during in-person visits and included self-reported and functional performance measurements to quantify dexterity and activity performance. Shoulder pain was classified as either present or absent at the time of the in-person assessment and participants were asked to rate their pain intensity on a 10-point scale, 10 being the worst pain. The prevalence of shoulder pain was described by the type of prosthesis and whether the pain was on the same side or opposite side as the amputation. Bivariate analyses were used to compare frequency and intensity of shoulder pain by amputation level and the mean quick dash score of those with and without shoulder pain was compared with a t-test. So the prevalence of shoulder pain was 31% with 15% of participants reporting ipsilateral pain, 25% of participants reporting contralateral pain, and 10% of participants reporting bilateral pain. Pain intensity was rated moderate on both the ipsilateral and contralateral sides with the mean scores of 4.9 and 4.2 respectively. Pain intensity was not statistically different by amputation level. Shoulder pain was more prevalent but not significantly so in those with transhumeral level amputation with a rate of 31% compared to those with transradial level amputation at a rate of 29%. A significant difference was found in the mean quick dash scores of participants. Individuals that reported shoulder pain on average scored higher on the quick dash assessment which indicated higher disability than participants that reported no shoulder pain with a p-value of 0.002. These results were consistent between the participants using body power prosthesis and myeliatric prosthesis with p-values of 0.01 and 0.02 respectively. As you can see in the graph on the top right, 40% of participants using a body powered prosthesis reported experiencing shoulder pain while only 15% of myoelectric users reported pain. Body powered users also experienced ipsilateral and contralateral pain at higher rates than myoelectric users. The graph below shows the prevalence of shoulder pain by years since amputation. As you can see the prevalence of shoulder pain increased as time since amputation increased with 48% of participants whose amputation occurred more than 20 years ago reporting pain while only 18% of participants whose amputation occurred less than 20 years ago reported pain. From this study I was able to conclude that shoulder pain is a common condition in persons with major upper limb amputation that use active prosthesis and that shoulder pain was more frequent in the shoulder contralateral to the amputation in persons with transhuman level amputation and in persons who utilize a body powered prosthesis. The prevalence of shoulder pain appears to increase over time following amputation by and shoulder pain appears to be negative to negatively influence activity performance as measured by the quick dash assessment. Based on the findings of this study I recommend that clinicians be aware that individuals with major upper limb amputation who use a prosthesis are at increased risk of shoulder pain and that the shoulder contralateral to the amputation appears to be a great at the greatest risk especially in those that use a body powered prosthesis. It also appears that the risk of shoulder pain increases over time and can potentially impact the functional performance of the participant. Thank you. Excellent. Thank you so much for these fantastic presentations. What I can really appreciate is that each of you hit upon an issue that really has the ability to impact the field considerably, which is why your research was selected for the greater presentation today. For those of you who are providing some questions on the chat box, we really appreciate it. If during this question and answer period goes forward and we have some connection issues, bear with us, we will work through it and we will get to your questions as soon as possible. So with that in mind, what I'd like to do is welcome back all of our presenters here, and we have some questions that popped up on the chat box that we'd like to get to and we'll address each of you individually. We have one question that refers to the chronic pelvic pain study. Appreciated the quality of the work. And the question was, were there any data regarding inter or inter-relator reliability collected on this diagnostic evaluation? And it's not sure based on the talk, whether or not there was a single provider performing these evaluations. Could you kindly comment on that? Sure, can you hear me? Yes. Great, so there was more than one provider who was doing the evaluation and treatment in this case. They were all physiatrists and all at an outpatient pelvic rehab specific practice. So trained in those techniques of evaluation and treatment. And we did not collect any data on inter-relator reliability for the diagnosis of trigger points or the TINEL sign. I think that overall the trigger points from what I've seen in the literature have low inter-relator reliability in general. I don't know specifically about the pelvis. I think it's a very difficult area to study because it's a clinical diagnosis. There's no specific thing that we can see on imaging or other diagnostic testing. Thank you for the answer. So if you were to redo the study or do a second phase, would you, do you believe that that would be an important part to add as part of that study design as a prospective one? Yes, I think it would be very interesting to look at inter-relator reliability among the physiatrists doing the exam. And I think that that could give us some information about how well we're diagnosing these problems to begin with. Excellent. And then to further target the treatment. Excellent, thank you. I agree. All right, there was another good question talking about, I believe it's to you, Brian, asking about the, were there any wound problems or differences in wounds based on the treatment that were provided in the three groups that you studied? So as to wounds, it wasn't something we specifically looked at in our study. Going back to the orthopedic journals we looked at, that was one of their big selling points when it came to using aspirin over a NOAC or one of the heparins is that you have a higher incidence of wound-related issues, infections, hematomas, if you do use a heparin or one of the NOACs. But going back to my answer for that is that isn't something we unfortunately looked at in our specific study. So maybe I could add just a question to that after listening to your presentation, reviewing your abstract. With respect to the patients that were referred to the inpatient setting where you were, is there anything else that could potentially explain really the big difference between the aspirin users versus otherwise? Because these patients came from various other locations, correct? Yes, that is correct. I mean, the approach for the hip fixation could have some role in how bad the trauma was beforehand. But I mean, one of the things that we mentioned in our study as well is that we didn't take into account the doses of whether it's heparins or the aspirin. Some patients came on 325 of aspirin twice a day and some came on the baby aspirin, 81 milligrams. So that wasn't something we specifically took into effect, but that could also influence the results we had. Yeah, excellent. Okay, thank you very much. There was another question that had come through as well. The question was also related to you, Brian, as well. Was evaluation for DVT prospectively evaluated in all patients or only in clinically symptomatic patients? In our study, any patient that came in with aspirin, we would get a lower extremity duplex on admission as well as follow it weekly. The reason we did that is because we found this increased incidence of DVT in these patients. So we wanted to keep an eye on it. As for the patients on the heparins or the NOACs, we really only looked if they had symptoms that were concerning for a DVT or a PE, and then we would go looking, but not beyond that. Okay, all right. There were a couple of questions that related to the upper limb amputation study in prosthesis users, and the questions came about in terms of dominant handedness. Was there any relationship that you found with your data? Can you hear me? Okay. Yes. Okay, yeah, dominant handedness was something that we wanted to look at. Unfortunately, we didn't have data on dominant handedness before the amputation occurred and after for all the participants. So that was something that we considered looking into in the next aim of the study as it continues, but that's not something we looked at in my specific part of it, because we didn't have it for all the participants. Understood. And a follow-up second question came in for that study as well is, was the number of hours of use also considered as part of the statistics? Yes, we did break it down by the number of hours that the participants used their prosthetic devices, and there was no statistical difference between their pain and the hours that they wore the device. So yeah, or significant difference. Okay, thank you very much. I'm gonna scroll up here to take a look at... Okay, those are time-related and handedness. And okay, I have maybe a question for Alberto, and that was in response to the different interpretation of what factors in terms of adherence, what do you think an interpretation could be with respect to the stroke versus the multiple sclerosis on the thumb and palm versus the stiff extended knee? Do you think there are lifestyle factors for these patients that might be contributing to their adherence related to this? Yeah, I don't know that I would say it's a lifestyle. It's definitely a clinical presentation. We know that patients with multiple sclerosis tend to present more commonly in a paraplegic manner rather than a hemiplegic. And so that may have affected their ability to tolerate the treatment. Where the thumb and palm is much more prevalent in those patients with a stroke and is something that is very bothersome to them. And so being able to address that does increase very much the likelihood that they will continue with their treatment. Right, right, excellent. I also did have a question for Ms. Victoria. Again, excellent presentations for everyone and exercise is medicine is near and dear to my heart. With respect to potential barriers, I don't know if part of your survey addressed the possibility that prior to their amputation for whatever reason that might be, if somebody was previously active or an avid exercise prior to their amputation, were the barriers different or did they have different factors that may have contributed to your findings? Yeah, this is definitely something we considered. Can everybody hear me okay? Yes. At the beginning of the study, we had thought about whether we should include people's prior level of activity and even maybe whether we could consider the activity level of people they lived with or people they were close to. But we got to a point when we had a very, very long survey and that was something that kind of got taken away in order to focus on the barriers. But I think it would be very interesting to look at in a larger study. Excellent. Okay, it looks like we had another question come in here. It looks like, I assume that this is directed, I think, for you, Brian. How much do comorbidities such as diabetes or weight affect the patients as relatively healthy patients may have gone home from acute care? Am I addressing this question to the right person? I would assume so. Okay. I guess I can't say for sure. Obviously, with any comorbidity that's gonna affect the vasculature, you're gonna have an increased risk of DVT. Diabetes was not explicitly in our exclusion criteria, but we did have, whether they had a history of DVT, PE, cancer diagnosis, or a prothrombotic state in the past, the patients with diabetes likely had a higher risk of DVT. And I wish I had the data stating if it was, if they were put on a higher dose of anticoagulation or they were put on a heparin rather than an aspirin, because that could be useful information too, but unfortunately, I don't have that information with me right now. Okay, okay, excellent. I think there was another question here coming in for Ms. Emma, I believe. And I think the question was, have you considered pelvic congestion syndrome? So, that's not something that we specifically considered. Most of the patients in this study, or I guess I should say the average duration of symptoms for most of these patients was six years or more. So, they had been through multiple diagnoses and treatments with the most common being endometriosis. We don't have recorded that pelvic congestion syndrome was one of the common etiologies or comorbidities in these patients. It's definitely something to consider because it does cause tenderness on exam. So, something to look at more closely if we ever do another version of this. Right. And to maybe piggyback a question related to that was, I noticed that part of the title and the way the study was described was talking about a more diverse population that you were trying to study in this particular report. Is part of your analysis, were you factoring in ethnicity or race? And if so, were there differences in responsiveness to treatment based on that factor? That's a really good question. We did not factor in ethnicity or race. It didn't look specifically at that data. When we're talking about a more diverse population, a similar study had been done with only 16 patients, all endometriosis. And in this case, we're used 100 patients with multiple etiologies of their pelvic symptoms. But that's really interesting to think about how race or ethnicity factors into treatment. Yes, and the reason I bring that up is that we know that pain does affect different ethnicities differently. So, I was just curious if that was part of what you were considering. That would be very interesting. Yes, it would. Let me just track through the questions to make sure I'm covering everybody's here. Okay. Maybe a question for Victoria. And that is, I'm assuming that the instability that you were talking about or the perceived disability for persons with amputation refers to stability during load-bearing. Is that correct? So, it was within the survey, I believe the wording we used was, I feel unstable or I'm afraid of falling or off-balance. And so, it was kind of subjective based on if people perceived they were off-balance. We did not specifically ask whether they were load-bearing in those instances. Okay. And that's okay. That's great to have the perceptions in there. Out of curiosity, what were the most common locations of pain? In mine? Yes. Yes, so we measured the two different types of pain, both phantom limb pain and residual limb pain. And since most of our participants out of the 124, only three had upper limb amputations. And so, these were all lower limb amputations. So, these would have been pain in one or both of the lower limbs, either in the existing limb itself or in the phantom limb pain. And we didn't see significant changes in the limb pain with the exercise time, but we did know that their pain was one of the number one barriers to exercise that they listed. Okay. Okay. I also have a question for Alberto. In reference to the treatment, and I may have missed that as part of your presentation, but in terms of the boncholineum treatment, did people receive both lower limb and upper limb treatments depending on the stroke effects? Yes, they could have received treatment according to their clinical need. There was, this was an observational study. So, patients were allowed to be treated in whatever clinical fashion was necessary. And out of curiosity, I didn't remember seeing this in the analysis, but was there better adherence if more sites were done? So, both upper and lower, as if they were getting more of a benefit from the treatment? That's a great question. It doesn't seem to be a correlation between the number of sites. It does tend to be more focused on, did their problem presented in a way that interfere with ability to do something specific. And so, goal attainment is really a good link to that. Understood. That makes perfect sense. I wanna make sure I'm not missing any more questions here. All right. Are there any more on the chat box I can address? I think we've covered all of them here. So, may I add a comment? Yes, please do. I wanna, first of all, thank you for coordinating this session. You did a great job in keeping us all on track. The other is, at least on my screen, I have, to my right, four young individuals who are fantastic growing physiatrists in the field. And so, I wanna congratulate them for their work. It is an honor to be here standing next to them. I'm standing, maybe you're sitting, but I'm standing next to them. It makes me clearly see that the future is bright for the field. And that, you know, the guy with no hair is standing here next to you. Just because, you know, we all put our papers in and some committee look at them in a manner that made sense. So, congratulations to you all. Yes. And I echo the sentiment exactly. I wish we could be here in person and to see the audience and the viewers who are putting questions in on the chat line. I really appreciate it. The stories that all of these investigators here are telling are very important. And I really look forward to seeing them in print. And I hope to meet you all in person sometime soon. Congratulations on the fine work. This was really a pleasure. Thank you also for the IT folks who are in the background keeping us on track as well. Thank you and good luck. Thank you.

rehabilitation

chronic pelvic pain syndrome

trigger point injections

hydro dissection

thromboprophylaxis

deep vein thrombosis

post-operative hip fracture patients

onabotulinum toxin A treatment

shoulder pain