Good morning or afternoon everyone. I'm Dr. Joseph Borris from the University of Missouri. I'd like to welcome you to the 1905 session of Research Spotlight for General Rehabilitation. We will be continuing with our presentations for the next several minutes. A few housekeeping items. Please be advised that we will be recording this presentation for archival purposes. Please mute your microphone if you are not speaking. If you wish to be heard, please use the raise hand function. You may also ask presenters using the chat function. Tech support can be reached via chat function. Browse over and search for the AAPMNR producer. Please contact us with any tech issues that you may have. We'll go ahead and start our first poster presentation now. Dr. Derek Bui from UCLA will be presenting a comparison between in-person versus telemedicine ordering frequency of MRI lumbar spine for radicular symptoms. Thank you, Dr. Bui. Thanks, Dr. Borris. Thanks for having me here, everybody. Good morning or good noon. Again, I'm Derek Bui. I'm a PGY3 at UCLA VA program. Again, my title is a comparison between in-person and telemedicine ordering frequency of MRI lumbar spine for radicular symptoms. My colleagues and peers involved with this project were Drs. Alano, Schultz, Ashfack, Bernard, and Chang. The objective of this study is that the COVID-19 pandemic has accelerated the use of telemedicine, although there's limited information that demonstrates if telemedicine affects medical decision-making. This study aims to demonstrate differences in ordering frequency of MRI lumbar spine for radicular symptoms between in-person and telemedicine visits. The methods of this study, this was a retrospective cohort study involving 1,322 patients with back pain. These low back pain patients were found using ICD codes with the aid of a medical record specialist. These patients were comprised of male and female veterans from the West Los Angeles VA Outpatient Physical Medicine and Rehabilitation Clinic. These patients' medical records were reviewed and only initial visits with radicular symptoms were included. Radicular symptoms were determined by reviewing the history of present illness and also the assessment and plan. With this criteria, there were 281 new consults diagnosed with radicular symptoms. Out of the 281 new consults, 212 were in-person and 69 were telemedicine. And the 69 telemedicine visits can be further broken down into 63 telephone visits and six video visits. And so then the MRI lumbar spine ordering frequencies were reviewed for the total of the 281 patients. The setting for this study, again, as previously mentioned, this was a multi-campus outpatient physical medicine rehabilitation clinic. The results of our study, so it showed that 61 of the 212 in-person visits resulted in an MRI. That equates to 28.77%. Meanwhile, 21 of the 69 telemedicine visits resulted in an MRI. So that equates to 30.43%. Again, I'll be discussing the results in graph form. You can see that there are two graphs. The first graph is titled total number of visits for each visit type. This graph demonstrates that there was a large difference between the two groups, in-person and telemedicine visits. It shows that there was, again, a large difference between the total number of visits. However, if you look at the second graph, which is titled percentage of visits with new MRI ordered, the in-person and telemedicine percentage of visits with new MRI ordered, the values were much closer. So the conclusions of our study, well, this is the first reported data to our knowledge that demonstrates the ordering frequency of MRI lumbar spine for radicular symptoms between in-person versus telemedicine visits. There was a minimal difference in ordering frequency between in-person, 28.77%, versus telemedicine visits, 30.43%. This may suggest that telemedicine is a reasonable alternative to evaluate low back pain with radicular symptoms. However, we do recognize the limitations of the study, mainly that there was a disproportionate sample of in-person compared to telemedicine visits. And additionally, the telemedicine visits were made up of telephone and video visits, which may require separate categories to fully evaluate differences in ordering frequency compared to in-person visits. That concludes my presentation. Thank you so much. We're at the five-minute mark. We could entertain chat or questions until the seven-minute mark. If not, we will move on. Our next case is presented by Dr. Dan Nguyen from Sunrise Health Graduate Medical Education Consortium, Mountain View Medical Center. The title is A Retrospective Cross-Sectional Analysis of Inpatient Falls to Evaluate National Trends and Risk Factors Using Data from the Nationwide Inpatient Sample. Hey, everybody. Good morning. Like Dr. Burris said, my name is Dan Nguyen. I'm a fourth-year PM&R resident at Mountain View Hospital based in Las Vegas. Thank you for inviting me here to talk about my research poster. So my poster is very descriptively titled A Retrospective Cross-Sectional Analysis of Inpatient Falls to Evaluate the National Trends and Risk Factors Using Data from the Nationwide Inpatient Sample. I chose to explore the topic of inpatient falls because of the monumental personal and societal consequences that are associated with them. Although it may not seem like the most exciting topic that you may hear about today, and you probably won't see any episodes of Grey's Anatomy about inpatient falls, physiatrists know that falls can be very detrimental, not only in the community but also in acute care, and also can hinder patients' progress in inpatient rehab. Inpatient falls are the most common inpatient accident and occur in 2 to 17 percent of acute care patients. Furthermore, 30 percent of falls result in physical injury, and 4 to 10 percent lead to serious injury, including fractures and head injuries. These falls can lead to functional decline, longer hospital stays, increased disposition to long-term care facilities, higher costs, and long-term disability. In our study, our primary objective was to investigate the temporal trends of inpatient falls and the comorbidities and diagnosis codes that are associated with them. In order to accomplish this, we mined data from the Nationwide Inpatient Sample of the Healthcare Utilization Project from the year 2013 to 2015. For those unfamiliar with the Nationwide Inpatient Sample, it is the largest publicly available all-payer inpatient healthcare database designed to produce U.S. regional and national estimates of hospital stays. So, unweighted, it contains data from 7 million hospital stays each year. Weighted, it contains over 35 million. In our study, the patients in this database were identified using the ICD-9 code for inpatient falls. The data that we obtained shows that inpatient falls trended slightly upward from 2012 to 2014, rising from 2.64% to 2.74%. The most significant risk factor was a patient that experienced a fall in a prior admission or had an injury code as their primary diagnosis, which indicated that these patients were 4.2 times as likely to experience a fall during admission. Other risk factors identified were mental disorders, nervous system disorders, and what was categorized as signs and symptoms of ill-defined conditions. Comorbidities identified with increased risk factors were coagulopathies, electrolyte disorders, and pulmonary circulation disorders. So, understanding inpatient falls and the risk factors associated with them is important to devise and implement strategies to reduce inpatient falls, especially among the geriatric population. With the data gleaned from this retrospective study, we can explore quality improvement initiatives to reduce the risk of most vulnerable populations. Moving forward, we could implement increased precautions for patients with conditions that put them at additional risk, and we can also address and optimize the care of the comorbidities that are associated with increased risk of falls. We also plan to expand our data set from the 2013 to 2015 time frame to the NIS data from the past decade to get an even clearer picture of these correlations. And that concludes my presentation. Thank you again for having me. Thank you, Dr. Nguyen. So, our next presenter is Dr. Radhika Mann from University of Pennsylvania PM&R Department. The topic is Identifying Barriers and Motivators to Breast Cancer-Related lymphedema self-management programs, a case series. Thank you, Dr. Mann. Thank you, Dr. Burris. And hi, everyone. Thanks for joining today. I'm Radha Kambiani. I'm one of the current PGY-4 residents at University of Pennsylvania. And firstly, I'd like to thank my co-authors, Dr. Frances Schofer, Dr. Serena Banas, Dr. Michelle Johnson, and of course, Dr. Jasmine Zhang. I will be discussing, like Dr. Burris had mentioned, a case series on identifying barriers and motivators to breast cancer-related lymphedema, self-management programs, and why this is important to us as physiatrists, specifically focusing on the cancer rehab population. So as a background, breast cancer is the most common type of malignancy among the female population. And a common complication seen in this population is breast cancer-related lymphedema, or BCRL. Lymphedema affects up to 250 million people worldwide, and its prevalence is only continuing to grow with an increase in cancer survivors each year. Comprehensive decongestion therapy, or CDT, which includes manual lymphatic drainage, or MLD, is the gold standard of treatment for patients with breast cancer-related lymphedema. And CDT typically comprises of MLD, bandaging, skincare, exercise, and maintenance compression. CDT is divided into two phases. The first decongestant phase focuses on reducing the edema to a stable size, and the maintenance phase sustains the volume at a reduced level to allow for daily functioning. Individuals suffering from lymphedema undergo CDT or a variation of CDT, which is then followed by a self-management regimen that can be performed daily from home. However, despite these formal therapy courses, some patients continue to suffer from uncontrolled lymphedema. Thus, the adherence to these self-management programs is questionable, and the barriers to compliance are likely multifactorial. So this study seeks to better understand the patterns to strong and poor compliance in this population. This case series assesses participants who are currently undergoing specifically strength after breast cancer program or SABC, or have recently completed the program, which was led by a certified lymphedema therapist. And SABC is based on the physical activity and lymphedema trial, which showed that progressive weight training for one year reduced lymphedema symptoms and exacerbations, as well as improved strength and body image and prevented an overall decline in physical function. So in this study, 14 women between the ages 18 and 65 with breast cancer-related lymphedema affecting the upper extremities were asked to participate from September, 2020 through April, 2021, and patients with active cancer, infection, or clot in the affected limb were excluded. Patients with a primary form of lymphedema, lymphedema of the lower extremities, or stage three lymphedema were not included in the study as well. These women received electronic surveys via RedCap measuring the degree of compliance with each component of their self-management program, specifically MLD, home exercises, and compression garments. And the degree of compliance was indicated by less than, same amount, or more than the amount of time prescribed by their therapist. We found that eight of the participants had one upper extremity affected, one had bilateral upper extremity involvement, and three with other areas involved, primarily being their breast and or chest wall. And majority, about seven of the participants had stage one lymphedema, one had stage zero, and one had stage two. Almost all of the participants reported pain in the affected limb as well as heaviness. Additionally, these women were asked reasons for strong compliance, poor adherence, and what additional resources would improve their compliance. And what we found is that majority of the patients reported motivating factors in strong compliance as desire to improve swelling, of course, but also pain, strength, and function in the affected limb, as well as reducing the burden on loved ones. Poor compliance was largely due to pain in the affected limb, lack of motivation to keep up with the program, insurance delays in obtaining the compression garments, and discomfort from tight garments. Majority of patients reported the availability of additional visits with lymphedema therapists and additional telehealth visits with cancer physiatrists would improve their compliance with home lymphedema programs. And these would essentially serve as refresher courses with therapy, as well as allow for ongoing discussions with their provider on how to reduce their symptoms and optimize the improvement in their lymphedema. And currently, insurance is a limiting factor in obtaining additional lymphedema-focused therapy sessions. Some also reported the ability to obtain properly fitting compression garments in a timely manner would assist in improving compliance, which was also largely limited by insurance. This case series serves as a small size study that gives us a general idea of compliance to breast cancer-related lymphedema home programs and serves as a starting point to further improve the overall chronic management of lymphedema. Further studies objectively measuring lymphedema in patients over a longer period of time following implementation of refresher courses led by certified lymphedema therapists and additional follow-up visits with cancer physiatrists will provide us a better understanding of possible benefits in timed intervention in their care, and ultimately, optimizing the overall trajectory in their lymphedema management. Thank you all for your time. Thank you, Dr. Manning. So we will move up the next presentation. This presentation will be performed by Dr. Oksana Witt out of Virginia Commonwealth University Department of Physical Medicine and Rehabilitation. The title of this poster is Outcomes Associated with Concomitant Lower Lymph Amputation in Persons with Major Upper Lymph Amputation, Results of a National Survey. Thank you, Dr. Witt. Thank you. Hi, my name is Oksana Witt. I'm a PGY-3 at PM&R Virginia Commonwealth University residency. I'm presenting our study with Dr. Webster, Dr. Resnick, and Mr. Borgia on the results of a national survey on the outcomes associated with concomitant lower lymph amputation in individuals with major upper lymph amputation. First, I would like to start by giving a wholehearted thank you to our team. Also, I have no disclosures. Thank you. There are 1.6 million people with amputations living in the United States as of 2005, and 185,000 new amputations per year. It is projected that the number of people living with the loss of a limb will more than double by the year 2050 to 3.6 million. The challenges faced by individuals with amputations are amplified for those with multiple limb loss, and there's limited data on their functional outcomes. Our study was based on the National Telephone Survey of 808 U.S. veterans with major upper lymph amputations with and without concomitant lower lymph amputations who received care at the VA between 2010 and 2015. Our objectives were to describe demographics and determine the association between concomitant lower lymph amputation and the measures of pain, prosthesis satisfaction, quality of life, and independence by comparing two groups. Those with upper lymph amputation only, 706 people in that group, and those with upper lymph amputation and any lower lymph amputation, 102 people in that group. We used t-test and chi-squares tests to identify any significant differences in characteristics and outcomes between the two groups. Next slide, please. Thank you. As you can see in the table on the left, individuals in both groups were very similar in terms of demographic characteristics, with the exception that those with concomitant lower lymph amputation were slightly younger on average, 60 years old versus almost 64. And for individuals with upper lymph amputation only, the most common etiology for upper lymph amputation was accidents, 67%. The most common etiology for those with concomitant lower lymph amputation was combat injury, 52%. Of note, individuals with bilateral upper and lower amputations, for them the most common etiology was actual infection, 83%. There was no difference between the two groups in terms of upper lymph prosthesis use or type of upper lymph prosthesis, as can be seen in the figures on the right, the top and the bottom ones. Of the veterans with concomitant lower lymph amputation tended to wear an upper lymph prosthesis for longer periods of time per day. You can see in the middle figure that there was no difference overall and no difference in prosthetic satisfaction. Next slide, please. Thank you. As you can see in the figure on the left, phantom pain was significantly lower in those with concomitant lower lymph amputation however, we did not find any differences in measures of non-phantom pain outcomes between the two groups. As you can see in the table on the right, there was no difference in perceived disability measured by Q-dash, quality of life measured by VR-12. Oh my God, this is so confusing. Or independence in the population with the concomitant lower lymph amputation despite the high frequency of transfemoral level amputations, which was about 67%. Also overall, we did not find significant differences between the two groups. These results are important since our study involved a large cohort of veterans with upper lymph amputation with and without lower lymph amputation. And the results provide clinicians a greater appreciation of the similarities and differences between the two groups in relation to amputation characteristics, pain, prosthesis utilization and satisfaction and functional outcomes. Thanks for letting me share this with you today. If you have any questions, please drop them in the chat. And if you have any questions, ideas later on, please feel free to contact me. Also be sure to check out our poster in the gallery. Again, thank you for your time today. Hope everyone has a great weekend. Thank you, Dr. Witt. So this is the end of our presentations. I wanted to open up the floor. If we have any questions for any of our presenters, happy to entertain those. We have a raised hand, we have a chat area. I will ask a question to Dr. Maney, if I could, please. Then the physical therapy programs, I may have missed something there, but were there specific types of exercises that you included in this study? And if so, could you give a few examples of that? And if you don't have that, that's fine, of course. Yeah, thanks for that question. So it's actually part of this like formal SABC program. And so there's a certain criteria for that, for who can actually enter that. And then once they're in it, the certified lymphedema therapist kind of go walk them through certain firstly stretching type range of motion. So a lot of it is kind of working on scapular stabilization type exercises, shoulder as well, since that is also an area for these patients that tend to have more injuries in this area. And then kind of over the course of several weeks, progress to more strengthening exercises. So it starts out more with stretching range of motion. And then over the course of like, I believe one to two months, can kind of go up to more rigorous exercises. Okay. Thank you. I have a question for Dr. Witt. We have, let's see here. Dr. Bowie, a modified physical exam compared with inpatient visits and assessing radicular symptoms. A question about that. I don't know that Dr. Bowie is with us. Hi. Yes. Hey. Yeah. Thank you for the question, Dr. Nguyen. So in terms of whether or not there was a modified physical exam compared to inpatient visits, I think the question would probably be modified physical exam compared to outpatient, because this was all in the outpatient setting. Yes, to a degree. It wasn't consistent though. So when I was reading the encounter, the telemedicine visits, whether it be video or telephone, there was a degree, certainly limited. So whether it be kind of, Hey, can you perform a slumps test over the telephone? And so the reported answer would be yes, I do feel radicular symptoms down my leg, or it would be, can you perform the slumps test via video? But yes. So there was a limitation in the sense that the provider could not actually perform the same level of objectivity. As if they were in person. But yeah, so that was kind of. The overall, like the idea behind the project. Is whether or not, can you provide. A similar telemedicine fiscal exam. And does that affect the medical decision-making to ordering MRI lumbar spine? Great. Question I had for Dr. Witt just about the types of upper limb prosthetic devices that were. In this patient sample here that you had, I may have missed that, but I was just curious if they were my electric or manual operated devices, or if there was a division of those. Yes. If you can see. It's going to be on. The third slide. So one of the. Figures we do have. Figure on based on the primary prosthesis type. And then. Body powered. My electric or hybrid. We put them together. Cosmetic. And then other or unknown since we did. The study was based on the chart reviews. So it was. Whatever it was. I tried it there. So, yes. Thank you. Okay. Chats questions. It looks like we're in a pretty good place here. So I think the presenters for their time and their expertise and their presentations, you guys did a great job with those. So very much appreciated. And I hope everyone has a great. Rest of the meeting. Thank you all. Thank you.

telemedicine visits

MRI lumbar spine

inpatient falls

breast cancer-related lymphedema

lower limb amputation

upper limb amputation