Good morning, everyone. Welcome to the AAPMNR General Rehab Research Spotlight. I am Angela Benninga, and I will be serving as the moderator for this session. We will be having presentations by four different research participants today. We'll wait until the end to take any questions. So if you have any questions that come up as the presenters are presenting, just feel free to either send them to us via the chat or jot them down, and we'll address those questions at the end. I want to remind everyone that this session is being recorded, so if you can please mute your mic so that we have limited feedback from participants. And then again, just submit any questions you have via the chat or jot that down and let us know at the end of the presentation if you have any questions. So without any further ado, I will introduce the first presenter, Brock Mars, who will be speaking on body weight support system. Thank you, Dr. Benninga, and thank you to the AAPMNR Organizing Committee for inviting me to present today. My name is Brock Mars. I'm a fourth-year resident in physical medicine rehab at the University of Kentucky in Lexington. My co-authors for this work include Valerie Gibbs of Baptist Health Lexington and Dr. Lumi Sawaki. Dr. Sawaki is now an employee of the NIH and has asked that I provide the disclaimer that this work was performed while Dr. Sawaki was an employee of the University of Kentucky. The opinions expressed in this work are the author's own and do not reflect the view of the National Institute of Health, the Department of Health and Human Services, or the United States government. Next slide, please. Inpatient rehabilitation of acute post-surgical below-knee amputees is known to improve patient outcomes, but there is room for improvement. The acute post-surgical amputee is one who comes to the inpatient rehabilitation hospital directly from their amputation admission. The surgical wounds are still healing. The shrinking and shaping process has not begun, and they do not have a prosthetic. Patients are often lacking confidence and fearful of falls resulting in injuries to their residual limb. This fear can limit the patient's participation in such a way that they do not fully realize the benefits of their inpatient rehabilitation stay. Further, the therapist is often focused on fall prevention rather than the patient's rehab activities. In many cases, more than one therapist is required to assist the patient. A dynamic body weight support system such as the one demonstrated in the figure shown might be a solution for improvement. These systems place the patient in a harness tethered to an overhead motor on a track. The user can dial in the desired percentage of body weight support. The system provides equivalent support throughout all activities. This limits fall risk, thereby freeing up the patient and therapist to focus on the specific task at hand. Next slide, please. The objective of this retrospective cohort pilot study was to examine and evaluate the role of a dynamic body weight support system in the functional outcomes of acute post-surgical below-knee amputees in inpatient rehabilitation. 22 acute post-surgical patients were identified as having participated in inpatient rehabilitation at Cardinal Hill Rehabilitation Hospital in Lexington, Kentucky. Of these 22, three patients utilized the dynamic body weight support system during their rehab training. Since this was a retrospective analysis, not all patients utilizing the dynamic body weight support system received the same amount of time with the system. The system itself was fixed in one therapy gym. There, the patient was able to work on mobility, transfers, and ambulation. The total FIM score and motor FIM score were identified as the outcome measures for this study. All data used in this study was collected from the records of Cardinal Hill Rehabilitation Hospital. Next slide, please. The patients that did not use the dynamic body weight support system during therapy increased their total FIM score by an average of 54%. Similarly, these same patients showed an average increase in motor FIM score of 76%. Alternatively, the patients that did utilize the dynamic body weight support system during their therapy increased their total FIM scores by an average of 85% and their motor FIM scores by an average of 117%. This pilot data suggests that a dynamic body weight support system can meaningfully improve the rehabilitation performance of acute post-surgical below-knee amputees. Additional data and prospective studies will be needed to assess the true significance of these findings. Further, metrics like post-amputation injury and time to prosthetic would also be useful to examine. In addition to positive patient outcomes, a dynamic body weight support system can also impact other areas of patient rehabilitation. For example, systems like these can reduce therapist burden and prevent therapist injury. These things warrant study in the future. In conclusion, the dynamic body weight support system is a tool that has promise for improving the inpatient rehabilitation of the acute post-surgical amputee population. Thank you for your time. If you have any questions, please put them in the chat and we can address them after all the speakers have presented and I'll give it back to Dr. Benninga. Thank you. Thank you, Dr. Mars. Next up is Kirill Alekseyev on the benefits of acute rehabilitation in our current COVID pandemic. Good morning. My name is Dr. Kirill Alekseyev and I am the medical director of Post-Acute Medical Rehabilitation Hospital of Dover and below are listed all the contributors and all the authors, including the therapy team, internal medicine team, as well as the nurses that contributed to the study that we took one year to do. So the design was observational prospective study that followed 60 patients from admission into acute medical rehabilitation hospital from the beginning of the pandemic of March 2020. And we did one year study ending in March 2021. Data was collected, analyzed to determine the benefits of acute rehabilitation COVID-19 patients in addition to the change of the current treatment guidelines related to COVID-19. Next slide, please. So the methods, this was a prospective study and the data was collected including the following admission date, length of stay, ability to tolerate treatment and therapy and which date it took place, presenting symptoms, treatment needed, limitations, complications, GG score admission and GG score discharge. The total population that was included 33 males and 27 females and all were greater than 60 years of age. The self-care and mobility section was used to help determine the level of disability and indicates the amount of assistance that the patient required to perform the activities that they were living. Next slide, please. So the results, the top five presenting symptoms among all the 60 participants were shortness of breath at 72%, fatigue at 36%, weakness 25%, fever at 23% and cough at 22%. The top four limitations were noted fatigue at 83%, weakness 48%, shortness of breath with activity 40% and endurance at 12%. Top five complications that the patient presented was pneumonia 40%, shortness of breath 32%, kidney injury and chronic kidney disease 23%, fatigue at 13% and CVA 10%. The overall average increase in GG score for the entire data of 60 patients was 29.5 with a standard deviation of 16.11. Patients that needed less than 10 days of acute rehabilitation had an average of GG score increase of 34.2 with a standard deviation of 10.6. And patients that required a length of stay from 11 to 20 days of acute patient rehabilitation had an average of GG score increase from 26.5 with a standard deviation of 18.5. Now with that being said, I want to focus on the next slide, please. There are two different charts here. First graph indicates admission GG score versus discharge GG score and this graph compares the patient's admission GG score to the discharge that determined that the Pearson's correlation coefficient was 0.817 with T statistic was 10.79 and P value of 1.72. And according to our data, it was noted that a strong positive correlation in addition to a highly statistically significant P value. And the second graph right below indicates data in acute rehabilitation compared to differences in GG scores of discharge. And the discharge GG scores is in blue with increase in order from the number of days in green. And the patient was in acute rehabilitation for those patients required 10 or fewer days again those 27 patients with an average GG scores increase of 34.2. And for those required anywhere from 11 to 20 days, which is 33 patients, the average GG scores increase was 26.5. Now with that being said, I want to focus that just because the longer length of stay in acute rehabilitation did not really correlate to the functional improvement from the charts. And the reason being is the first half is when the pandemic first took place, patients were coming much more complicated after long hospitalizations, intubations and things of that nature required a longer recovery time in order to get their functional gains. But the second half of the study when patients having less significant symptoms and required less hospitalization time, they were able to get their functional gains a lot quicker. Overall, although the average was 29 of the overall increase, again, those were the differences as to why longer length of stay did not correlate to such a drastic increase, but all patients across the board increased and improved in functional gains competitively. In regards to treatment guidelines, I want to mention that there was a lot of differences in treatment since we first started with pandemic. So initially, viral pneumonia is not known for steroids treatment. So there's some internal medicine physicians that tried steroid treatments, which was published in recovery article in the World Health Organization, which showed steroids were effective in viral pneumonia, which helped us with the treatments because initially we had really no standard of care and treatment for COVID-19 initially. And with that being said, steroids now have become the standard of care and for the COVID-19 and we are utilizing them and therefore patients are having improved functional outcomes in terms of respiratory issues, and also they're able to have improved mortality and morbidity. Also initially we're using convalescent plasma, which shown that there was really no significant benefit. And now pharmaceutical companies have compiled Regeneron, which we're using in the treatment as well right now. And also initially we're using things like, you know, medications like Clonil and some anti-HIV medications, which we're no longer using, but now we are using Remdesivir, which is also helping with morbidity and mortality. So there's been a lot of treatment changes across that year of study that we have seen. So patients now are coming in with less complications, able to tolerate therapy better, and get more functional gains as the outcome. And one thing to take away from this is, in order to get patients ready for acute and patient rehabilitation, therapy has to be started early on as possible. So even in ICU settings, bedside therapy, PT and OT is very crucial on limited capacity, whatever the patient is able to tolerate to get them ready for rehab and get them back to high level function and regain their independence. So thank you. I'll answer any questions at the end of the session, and thank you for your time. Thank you very much, Kirill. We will transition now to Alexandra Fry, who is going to present her research on the differences, the validity and reliability of FIMS scores and the CARE tool. Hi, I'm Alexandra Fry. my presentation is on comparing the reliability and validity characteristics of the FIM and the Care Tool, like how do they stack up? So here I have a poster, there's a QR code on the bottom and the middle, and that's where you can like take a picture so you can have it for later. And also you can like zoom in that way too, since it's probably pretty small font here. Anyways, I'll go ahead. So the FIM score and the Care Tool scores are two very important scores that we use to assess patient's function in rehab. The FIM, the Functional Independence Measure, was the gold standard in the past, but it was replaced by the Care Tool, which is the Continuity Assessment Record and Evaluation in October, 2019. Now, literature examining the measurement properties of the care item set are limited, and there's not really any published studies comparing the reliability and validity of the FIM and the Care Tool functional skills together. There are several literature studies out there showing the reliability and validity of the FIM, but the Care Tool is lacking. And our study aimed to address this gap in the literature because they weren't compared previously. So we expected strong relationships to be there between mobility and self-care scores for both the FIM and Care Tool. Both instruments would expectedly be predictive of length of stay, and then the FIM cognitive items would also have the weaker relationships with the Care Tool. And so our methods were basically, we had a prospective study with 3,387 participants that were given both the Care Tool at admission and then the FIM at admission and discharge between 2016 and 2019. And on the bottom left, you can kind of see the Table 1 and Table 2 that we had as far as the observed scores that we had for FIM and Care Tool. And then also on the Table 2, you have the demographics. So it's kind of evenly broken up between males and females and Caucasian and African-American were the predominant races. And as far as marital status, marriage was more common and the average age was about 66. So in the middle, that graph there, you have the FIM and the Care Tool scores at admission and discharge. And so this was a basic graph to show how much the admission and discharge Care Tool scores and FIM scores actually correlated with each other. So you can see the diagonal line along the center shows one, that's a perfect correlation between both of them. But as you go kind of lighter blue, you'll see less and less of a strong relationship. And so you can kind of see those there. That LOS at the bottom is a length of stay. So that wasn't very predictive on there. And you can see something like on the bottom right of that graph, the FIM motor and then the discharge FIM score were pretty strong. So that's saying that the FIM motor was pretty reliable. Okay, so for the results section, so we found a statistically significant correlations actually between the FIM and the Care Tool as we expected with the strongest relationships between the FIM motor scores and the Care Tool mobility scores ranging from about 0.76 to 0.84 with a P of less than 0.05. The FIM cognitive scores were correlated with the Care Tool scores, but at a lower overall magnitude ranging from about 0.24 to 0.52. And regression analysis showed FIM and Care Tool functional skill scores were actually predictive of length of stay with FIM cognitive skill score comparatively as predictive as the Care Tool scores. And then the motor and the mobility scores were consistently the strongest predictors of the length of stay. So you can see on the chart that we have there for model one, two, and three, we kind of just tried to see the relationship. And so for model one, you have the FIM with a cognitive and motor. For model two, you have the Care Tool with self-care mobility. And the model three is kind of comparing to see if there was like a strong model if you add the FIM cognitive to the Care Tool self-care and mobility to see if the FIM cognitive would actually improve the scores by adding it in as a separate model altogether as like a theoretical one. And so you can see the adjusted R-squares on the right side of that chart didn't vary too much for model one, two, and three, although model three is higher. So based on that, so for length of stay predictions, we can continue to use this Care Tool as an adequate measurement as we predicted initially. But cognitive assessments may require other tools in addition to the Care Tool because that like 2019 was slightly higher showing that it does slightly improve the Care Tool when you add to it. So in conclusion, the Care Tool is a valid and reliable instrument for rehabilitation functional assessment that is comparable to the FIM score. And cognitive variables measured by FIM were meaningful but are not accounted for in the Care Tool functional scales. All right, I'll bring it back. Ready for presenter, Matthew. Great, thank you very much, Alexandra. And now we will move on to Dr. Matthew Tay, who will be presenting on the axillary web syndrome in Asian women after breast cancer surgery. Thank you, Dr. Benninger for the introduction. So I'm Matthew, a psychiatrist from Singapore, and today I'll be presenting on axillary web syndrome in Asian women after breast cancer surgery. Next slide, please. So breast cancer surgery is the main treatment of breast cancer, and it's usually combined with sentinel-lymph node biopsy or axillary-lymph node dissection. And this aids the surgeon and oncologist to decide what type of surgery or chemotherapy to proceed with. However, these types of axillary surgery can result in axillary web syndrome. So what is axillary web syndrome? It's believed to be the most common type of surgery in Asian women after breast cancer. It can be due to the interruption of axillary lymphatics or the development of thrombosed lymphatic vessels after surgery. However, the exact pathology is still unknown. This condition is characterized by the presence of cording, which are often present in the axilla, which can be seen in the top right picture. This cording can also extend down to the elbow, seen in the below right picture. So as you can imagine, this cause can result in pain, limited range of motion, functional impairment of the shoulder joint, and reduced quality of life. However, this condition is traditionally taught to be self-limited and self-resolving within three months. Hence, no treatment is usually provided. However, there's emergent evidence that axillary web syndrome can persist beyond three months, and treatment might be required if it persists. Beyond three months, however, breast cancer survivors who have recovered from their operation, and the cancer surgeons or oncologists may not be looking out for this condition. These patients may also be undergoing outpatient rehabilitation at this stage. And although Western data has been published, studies in Asian patients are limited. Hence, our study aim was to investigate the prevalence and association of axillary web syndrome in outpatient cancer rehab center. Next slide, please. So for materials and methods, this was a cross-sectional study of Asian women between 2017 and 2019 in Singapore. So this was conducted at the Singapore Cancer Society Rehabilitation Center, which is a national cancer rehabilitation center. The inclusion and exclusion criteria as mentioned. All recruited patients were examined by both a physiatrist and a trained physiotherapist, and the diagnosis of axillary web syndrome was made clinically. Other data was also recorded, which included restriction in the range of motion, which is defined as a difference of 10 or more degrees compared to the contralateral shoulder, or the presence of pain defined as a numerical rating pain score of three or more. Next slide, please. So this table shows the clinical characteristics of our study population. So we recruited 111 patients altogether, and we found that 32 patients were diagnosed with axillary web syndrome. So this was a predominantly Chinese cohort, and there were patients both less and more than 50 years old. Patients also presented at one to five years post-surgery with this condition. These patients also had various types of breast cancer surgery, including breast conserving surgery, simple mastectomy, and simple mastectomy with reconstruction. Patients also had both centellar limb biopsy or axillary limb dissection performed. They also had various stages of cancer, and some also had concurrent arm pain or lymphedema. Next slide, please. So to recap our main findings, we found that over a quarter of our patients were diagnosed with axillary web syndrome. And although a majority presented at one to two years post-surgery, there was a significant minority, nine patients, sorry for the typo, who presented with axillary web syndrome at three years or more post-surgery. As expected, more patients with axillary web syndrome had functional limitations in the shoulder flexion compared to those without axillary web syndrome. However, we did not find any difference in pain or lymphedema between the groups of patients with or without this condition. We also performed a multivariate logistic regression, and this showed that significant associations with axillary web syndrome were a younger age of less than 50 years old, and the presence of axillary limb node dissection. So to conclude, firstly, axillary web syndrome can present as a late post-operative breast surgical complication, and this may be due to under-diagnosis by doctors. Also, non-rehab doctors may not recognize this condition due to unfamiliarity resulting in delayed treatment. Second, this has clinical implications for rehab providers, as we need to pick up this condition early for suitable treatment, such as manual therapy. In fact, this condition, if untreated, can result in functional limitations, as shown by the reduced shoulder range of motion reported in our study cohort. Thirdly, axillary web syndrome with axillary limb node dissection is a significant association, probably due to it being a more invasive surgical intervention. Additionally, younger age has also been reported as a risk factor for axillary web syndrome in previous studies. So I thank you all for your time. That's the end of the research spotlight presentation, and I'd like to pass the time over to Dr. Benninger. Thank you very much, Dr. Tay. It was very interesting research. Okay, now that all four presenters have been able to go, wanted to open it up to any questions. I know we got one for Dr. Mars after his presentation. Question for Dr. Mars, if he's going to pop in. There we go. Were they in body weight system on one leg, or did you have some sort of protective prosthesis, eye pop, et cetera? For this set of data, all these patients were on one leg. The surgeons in this area that typically feed into our rehab hospital have, for whatever reasons of their own, tend to place patients in soft removable post-operative dressing. So that's typically what we see when we come over. It would be ideal to get them into some sort of a rigid removable, even a weight bearing. Even one that's non-weight bearing would be better than nothing at all. But a big portion of what this study is kind of looking at is trying to help these patients to protect their residual, to present those post-op complications. And I think the body weight system allows them to focus more on their movements as opposed to the fear of falling. So that's what we were kind of going after. But yes, the short answer is they were not, they were not in any kind of protective dressing. Thank you. That's a great question. Another question for Dr. Matthew. What can be done to prevent AWS? Sorry. Thank you for the question. So some studies have shown that as more lymph nodes are removed during the surgery, there's a higher risk of AWS. Additionally, if it's an auxiliary lymph node dissection versus a sentinel lymph node biopsy, this has a higher risk of auxiliary Rett syndrome. However, these factors cannot be controlled. Usually it's decided by the breast surgeon. So I think what can be done from our rehabilitation perspective is to detect the condition early. So what happens is that these patients are not detected early and they go on with this condition for a long period. The good thing is that once it's detected, the treatment is actually very, very easy. So usually just manual therapy, range of motion exercises, and these patients usually get excellent results with this physiotherapy. So as I think prevention is not really something that we can aim for, but early detection, early treatment would be the best way to go forward. Great question. Thank you. So it's unique as a rehab doc to be able to interact with our surgeons before surgery. So a pretty rare occurrence there, but it would be nice for sure. I think it would benefit the patient significantly. I don't see any other questions currently in the chat. Is there, give anybody a couple of seconds here if they want to type something in or if any of the presenters have another little tidbit they want to share. We've got a few minutes left before the session's complete. We're just going to ask Kirill, if you would, since you kind of took a long look at post-COVID recovery, you know, what are the biggest complications that you see in your patients that are coming out of rehab that have done well in rehab, but are still, those complications that are still lingering on? Sure. That's a good question. Thank you. So some of the biggest complications coming out of rehab, mostly in the first half of our research, when the patient's coming in significantly more ill, before we had proper treatments and things like that, is they still are suffering with significant kidney injuries. When they, you know, some of them had to be in dialysis, some were able to get all dialysis, but that's one of the biggest complications. For the second half, where the symptoms weren't as significant, you know, and the treatments have been better, a lot of neuropathy is still an issue, leaving the ones that presented with, you know, especially lower extremity neuropathy, kind of limiting, you know, effect balance, even though the trend is, you know, improving and the function is improving, neuropathy actually has been somewhat of a barrier, but it is effective with outpatient treatments once, you know, they leave and continue with outpatient to be working on some of the techniques and, you know, minimizing, you know, some of those symptoms. So that's kind of one of them. Thank you for the question. Appreciate it. Okay, I do not see any other questions popping up in the chat, so I want to thank all the presenters for their excellent research and being willing to submit it to the AAPMNR session to be able to share with all of us, we really appreciate that. And I will turn it back over to the AAPMNR.

body weight support system

rehabilitation in COVID pandemic

validity and reliability of FIMS scores

CARE tool

axillary web syndrome

Asian women

breast cancer surgery