Everybody, my name is Kevin Vincent. I'm the moderator of the session. Our session is the Research Spotlight on General Rehabilitation. So with that, let's get to our first slide. We have a couple of housekeeping notes to make sure of, just to make sure everybody knows that we are recording this session. And please mute your mics while you're not on the microphone or speaking. If you need to be heard or anything, please raise your hand. We will do a question and answer component at the end. Use the chat function. We will look into the chat for the questions and I'll read those to the person that you would like to have answer it. And if you need any issues from a tech support standpoint, please use the chat function. Browse over and search for the APM&R producer and contact with any technical issues. So with that, let's actually get our session started. Our first presenter is Dr. Ilyescu, who's going to be talking about athlete identity and common benefits and barriers to sport participation amongst adaptive teen sports participants. With that, I will turn it over to Dr. Ilyescu. The floor is yours. Thank you so much, Dr. Vincent. Hi, I'm Daniela Ilyescu, and I will be presenting today kind of the work that our team has done from Nationwide Children's and Ohio State University, both in Columbus. So for the background, it's well known that in the able-bodied population, there's a lot of physical, psychological, and social benefits to participation in sports. However, those with physical disabilities might not be able to take advantage of these benefits because of some of their barriers. And in addition, they may often not identify as athletes because they're not viewed as so by the general population. So what we wanted to do with this project is we wanted to kind of dive deeper into seeing from the qualitative standpoint, what are the themes that influence the participation of athletes with spinal cord injury and other disabilities in adaptive sports? And we also wanted to look at their self-identity as athletes. So this was an IRB approved study. It was a cross-sectional qualitative interview. We interviewed different participants at both practices and tournaments. There are a total of six different team sports that are represented here, and a total of 42 participants. Some of the sports are sled hockey, wheelchair rugby, bocce, wheelchair basketball, blind soccer, and goalball. Out of them, 32 were male, 10 were females, aged between 10 to 48 years old. And they've had various physical disabilities. The most common was spina bifida, followed by cerebral palsy and traumatic spinal cord injury. So this image shows the themes that came out out of this qualitative research. So first of all, you can see, which is expected in the general population and throughout literature for adaptive sports, that there's a multitude of social benefits, physical benefits, and mental health benefits that were identified. In terms of the barriers, the main one mentioned were medical setbacks due to procedures for their disability. Also finances was a big one that was mentioned. In addition to transportation, not being aware that they could play adaptive sports and time commitment. And actually quite a few of them did mention that they didn't feel like they had any barriers to participation. What we found is a lot of them mentioned that once they were able to try the sport, then there was no going back. They wanted to keep going. And some of the factors that allowed them to try the sport was the organization having the equipment available and offering the opportunity for them to just try and see what the sport is like. In addition, there are several other motivators that helped them begin involvement. Those are largely family, role models who are already playing the sport, having love for the sport already, and also local organizations that made them aware of the sport and medical professionals, including therapists, physicians, and so on. Now, in terms of the benefits overall, what they mentioned, majority of them said they enjoy connecting with friends with similar disabilities and capabilities who encourage them, who serve as role models and make them feel included like they're part of a family and also feeling like they have fun playing a sport they love. In addition, the mentorship provided by coaches and teammates allowed them to feel like they're in competitive environment or they feel like they can achieve. And this really keeps them coming back. Now, in terms of the reason for athletic identity, actually 40 out of 42 participants mentioned that they do identify as athletes, which was 95%. Some of the reasons they mentioned is first playing a sport, playing it for a significant length of time, and also feeling like they're putting effort and they're in a competitive environment. So all of this leads to us saying that despite encountering barriers to participation, such as frequent travel, expensive equipment, having a lot of medical procedures, the majority of our participants mentioned that the overpowering benefits of participation allow them to thrive and to identify as athletes. Now, there was also a quantitative component to our research, which we just had a manuscript submitted and I will talk more about that also. So that was just a teaser, but thank you very much for your time. Thank you. Thank you very much. Okay, so thank you for the presentation. We're gonna move on to our next presenter who is Dr. Messiano, who's gonna be talking about activity limitations after a fall injury. Dr. Messiano, the stage is yours. The study objectives of this is to quantify the activity limitations of individuals after a fall injury. We also wanted to investigate the interrelationship of activity limitation status with muscle performance of these individuals. And lastly, we wanted to establish the association between activity limitations and the body function changes of these individuals, such as anxiety, depression, fatigue, sleep disturbance, and pain intensity. The study design is a retrospective cross-sectional study in a PM&R clinic with 23 individuals, 11 males and 12 females, with a mean age of 52-55 for females and males. The main outcome measures that we utilized to quantify activity limitations were two types. First, it's the capacity qualifiers, and the second are the performance qualifiers. Under capacity qualifiers, we utilized the six-minute walk test for gait speed, the 30-second chair rise test for power endurance, the dynamic gait index for balance, and dynamic gait measure. For performance qualifiers, we utilized the PROMISE 29 version 2, the physical function subscale, and also the pain disability questionnaire functional status subscale. For muscle performance measures, we explored strength by dynamometer testing, lower extremity power endurance by timed up and go and distance, and balance by the Berg balance scale. Now for the body function measures, we utilized the PROMISE 29 subscales for respective body functions. The mean scores, as you can see, are, as you note, the PROMISE scores are in T-scores. For the TUG or the timed up and go, the Mann and Whitney test showed no differences, and the correlations for the dynamometer test, which deferred by sex, had no significant association with activity limitations. So what we found was we saw some significant correlations of the activity limitation with body function changes, specifically fatigue and pain intensity. Significant correlations were also seen between activity limitation and muscle performance markers, as you can see down, such as your Berg balance, your, mostly in the Berg balance association. So what we concluded is that individuals after a fall injury tend to have severe activity limitations. They tend to be clinically slow and have moderately decreased lower extremity strength, balance, and power endurance. The activity limitations of this individual significantly correlated with their muscle performance and their body function changes. We support, the study supports the target of said muscle performance and body function markers as interventions for these individuals, and we recommend future investigations on activity limitations, muscle performance, in other post-traumatic syndromes. Thank you. Okay, thank you very much for that presentation. Our next presenter is going to be Dr. Thomas Kainbacher, back pain rehabilitation associated with changes in activity limitations and participation restrictions of the International Classification of Functioning, Disability, and Health. With that, I'd like to bring on Dr. Kainbacher and have him take the floor. Sir? Yes. Thank you, Dr. Vincent. For us as PMNR physicians, of course, it's important that the relevant ICF activity and participation categories are part of the upcoming ICD-11 soon. And the ICF is a reliable tool that describes the functional health and the environmental factors, and it's a language across all disciplines, and that's the reason why the WHO called on stakeholders to enhance its use in order to strengthen rehabilitation at all levels worldwide. However, such additional assessment might be unfeasible in a tight social security rehabilitation environment, and this was the reason why our group developed a computer-generated algorithm that predicts the important activity and participation categories from clinically and routinely used patient report and outcomes. In our case, this was the paroled Morris disability and the pain disability index scores. And the second study we performed was the assessment of the limitations and the restrictions in the important brief ICF back pain core sets along, meaning before and after comprehensive back pain rehabilitation, and it was possible without additional time burden for patients and medical staff. So what this algorithm does is it creates many randomly constructed classification trees, and it looks for those variables that optimally match and split the response variables into impaired and any kind of unimpaired. It cannot distinguish the different grades of impairment in the ICF categories, but it can summarize grade one through grade four as impaired. So it can grade two categories, one is the impaired one and the other one is the unimpaired one, as far as each of these important categories. So the study was a prospective cohort study, and the setting was an outpatient rehabilitation center, and the intervention comprised of six months of comprehensive outpatient back pain rehabilitation, that was strength training of core muscles, sensory training, stretching, psychological interviews, education, each lasted 90 minutes. It was performed twice weekly and for six months. And of course the assessment was done before and after the intervention, and the outcome was the percentage of patients with limitations and restrictions in important categories. As you can see on the slide, there's quite a difference in the impairment or in the percentage of patients with impairments before the intervention, as far as the activity categories are concerned. Like maintaining a body position was affected in 80% of the patient population, whereas walking was only affected in 30. And there was quite a difference also in the participation categories, it was 54% with acquiring, keeping, and terminating a job, and 62% with work and employment, others specified. If you look at the numbers for the changes that was observed along with rehabilitation, you could find that these differences were also quite different. There were 20% improvements, meaning that the percentage of patients with limitations in the maintaining a body position category was improved by 20%, and the improvement in the walking category was 40%, and it was quite similar in the participation categories. Looking at the functional scores, you see that throughout all different scores we find significant improvements as far as pain intensity is concerned, the ROND-MORIS score, pain disability, and also the lumbar extension strength improved significantly. So what can we conclude? First, the rate of impairment with limitations and restrictions in the activity participation categories for back pain only partly merits disability levels, and this is important because assessing problems in these categories is relevant for clinical practice for both goal setting and intervention planning. And of course, it's also important to know that this can be achieved with a computer-generated mapping algorithm, and it doesn't need any additional burden. So I thank you for the attention, and I'm happy if you have further questions. Okay, thank you very much, sir. We are moving quite well and moving right along to Dr. Uleg Reki from the University of Texas, San Antonio in Houston. So she is going to discuss lymphedema awareness and knowledge gaps in the Turner syndrome community, a survey study. With that, Dr. Uleg Reki, the floor is yours. Thank you very much. So I'll share my poster on the next slide. Thank you. So as a little bit of a background, Turner syndrome is a genetic condition involving a complete or partial absence of a functional second sex chromosome. Pathognomically, a core feature is this lymphedema. 97% of girls diagnosed in infancy, the key diagnostic thing that kind of indicated further investigation was the lymphedema. However, in childhood and adolescence, sometimes this is when it gets diagnosed, and even in that circumstance, 82% of those were keyed off by the presence of this lymphedema. So awareness and identification of lymphedema can mean an earlier diagnosis, earlier intervention and follow-up for these individuals with Turner syndrome. However, it's been estimated that only about 39% of those with Turner syndrome, that they actually have no knowledge at all of lymphedema and about 80% have some sort of awareness of it. Despite its prevalence, it's frequently undertreated. So with our study, we sought to investigate in our local Turner syndrome community with a cross-sectional anonymous survey, what their awareness was of lymphedema and their experience with it. So we had a 24 question survey and we distributed it at a couple of different places. So in Houston, there's this community event for these Turner syndrome community folks. So it includes the patients as well as their family members or their caregivers. And then there's also a adult comprehensive care center and an associated pediatric clinic. So surveys are also distributed in those settings. Our primary outcomes are the lymphedema prevalence and awareness. And then secondarily, we investigated the duration, treatment and sequelae of lymphedema, including some of the impacts on daily living. We had 41 surveys included or returned to us. About half of them were completed by the patient themselves. So the average age for the patients completing the survey was about 26 years, 27% were completed by the caregiver. And then there were about 20% that didn't say whether they were the patient or the caregiver completing the survey. And then one instance where they completed it together. As mentioned, some of these patients have an experience with lymphedema very early on from infancy. And so they might not recall their experience with lymphedema, however, their caregiver might. So in those circumstances, the caregiver was likely to fill out the survey. Approximately 75% reported actually having heard of lymphedema, but only 27% had discussed lymphedema with a healthcare provider. So that leads us to the question of where are they hearing about it and what is their knowledge level about it? So we were just superficially getting information about how they heard about it and where have they heard about it, and then what their experience was. But future studies, we hope to delve into more like what is it that they know? Maybe they're learning from the internet, from friends, colleagues, other patients, social media, but only about 27% had discussed it with their healthcare provider. 22% of those responding said that they'd actually received a diagnosis of lymphedema and the median age of that diagnosis was two years. Half of those with lymphedema reported resolution, median duration being a little greater than four years. There was one individual that said they had received a diagnosis, but then they didn't have any other additional information regarding their lymphedema experience. So for that reason, we excluded them from the pool of responses there. About 33% or a third of them with lymphedema had received some sort of treatment, so only about a third of them had received treatment. And then of those, not all of them actually experienced resolution overall. Interestingly, the way that the question was worded was, has your lymphedema slash swelling resolved? And there were five individuals or about 15 to 16% that had said, no, it had not resolved, but they also denied ever having a diagnosis of lymphedema. So perhaps they had experienced it, but they were not diagnosed with it or they were not aware that they were diagnosed with it. Similarly, we asked about those who might have experienced sequelae of lymphedema, including like cellulitis or skin infection. And there were several that had said, well, they'd had cellulitis or skin infection, but they had never had a diagnosis of lymphedema. Those don't have to necessarily be together, but that's just kind of food for thought as maybe there was another underdiagnosis in that situation. But half of those that had had a diagnosis of lymphedema did endorse having had some cellulitis or skin infection. Only one respondent had said that they'd had difficulty walking because of their swelling or their lymphedema, but nobody reported issues with dexterity, writing, other activities of daily living, laundry, anything like that. So overall, this just kind of sheds light on the fact that as healthcare providers, we have a big role in trying to discuss lymphedema with our unique patient population. Turner syndrome is very much a unique population. Not all puminar physicians will encounter these folks, but when you do, it's important to think about these things like lymphedema and certain treatments for it. Most of those who had been, you know, all of those in this study who had been prescribed some sort of lymphedema therapy or treatment were compliant with it. There was one individual whose lymphedema had not resolved, and she had noted in the margin of her survey that she'd been encountering lymphedema and dealing with it for more than 17 years without resolution. The things that these folks were trying were the compression garments and some of the pumps, but there were other things that hadn't been explored yet and maybe would have been worth exploring. So overall, this just highlights the facts that we as healthcare providers play a really big role, and in future studies, we hope to investigate more about what sort of knowledge that they actually have, not just are you aware of it, have you heard about it, but what is it that you know about it, and finding more opportunities for education. Thank you. Okay. Outstanding. Thank you very much for that presentation. We are on to our final presenter of the session, and then we'll open the floor up for questions. Our next presenter is Dr. Heather Vincent. She is going to be talking about specific joint patterns and muscle strengthening activity predict four-year risk for multiple falls in older adults. So with that, I'll turn the floor over to Dr. Vincent. Thank you very much, and thank you all for bearing with my voice today. The first thing I would like to do is give a special thanks of gratitude to our veterans and our military service personnel on this special day. Thank you. For this particular project, this was actually driven by some clinical observations and questions that we are observing that falls are more common among older adults and those that have chronic osteoarthritis pain than those who don't have osteoarthritis pain, particularly when the lower limb is involved. Emerging evidence in the literature is showing that in addition to single site pain, the addition of more joint sites leads to recurrent falls over time. But it's unclear, first of all, what specific joint patterns, not just the number, which leads to the greater risk for multiple falls, and second, whether or not regular participation and muscle strengthening and or endurance activity can mitigate this fall risk over time. And so our purpose is we're to first determine whether or not there are specific patient subgroups at specific risk for multiple falls over a long-term period of four years based on pain site location and pain site combinations, and then secondly, whether or not habitual activity and muscle strengthening and endurance can mediate or contribute to the number of falls over time. And so to answer this question, we needed a very large sample size, and so we leveraged the Osteoarthritis Initiative dataset, which included complete data for over 3,300 people for which we could answer this question. So once we had our initial sample pool to work with, we stratified these patients into 30 different groups by either single joint pain in the lower body or back or neck, and all five sites of pain, the ankle, knee, hip, back, and neck, and all various possible combinations of two to four of these five particular sites. And so very simply, we wanted to look at the annual number of falls, the total falls reported over a four-year period, and we categorized those into single falls or multiple, which was two or more. Our secondary outcomes included this patient-reported participation in weekly activity involving muscle strengthening and or endurance using the physical activity scale for the elderly or the PACE score, where a score of zero represented no participation and a score of four represented nearly daily participation in several hours or more. So our statistical procedures included binary logistic regression to determine the presence of multiple falls, yes or no, by year four. And we put in a series of covariates, including a wide variety of social determinants of health and some testing that can also modify these outcomes, including changes in weight and pain medications. Secondly, we performed a linear regression model to determine the total number of falls over a four-year period. And again, after entering those specific covariates and joint pain group, we entered in last the hours of muscle strengthening and endurance last. And what we see in Table 1 is simply the characteristics of our patient population, fairly typical for those that fall into the region of osteoarthritis pain, approximately 62 years of age, about 58% female, and a variety of racial and ethnic backgrounds, 22% of which who were living alone at the time that these measures were taken. In Table 2, we tracked a baseline, and over a period of that 48 months, what happened to body weight? And if you look at the average cohort body weight, we see that the values really didn't change. However, if you look at the range within each person, the range was quite large. Some individuals lost up to 40 kilograms, where others gained nearly 37. So among this group was the wide variation, which is why we put this body weight change in as a covariate. We also placed in pain medication use, whether those people were using pain medications or not, yes or no, we simply reported here as a percent of the population. And then changes in the PACE scores from baseline to 48 months. And again, while the average scores do not show a significant difference in terms of change, there was significant variation within the population. So looking deeper beyond means is critical when we try to determine risk for adverse events in this population. So Figure 1 shows us that across this 48-month period, there's a fairly consistent presence of fallers. So those who had repeat falls starting at baseline from the year prior all the way through month 48, there's a consistent group of people who had repeat falls. The red bars represent those who simply reported in the past year whether or not they fell. So they could have fallen once or more, again, a very consistent prevalence in this population. So who are these people? Who are these individuals who are at greatest risk for this happening? So in our results, Table 3 shows the results of our binary logistic regression, and we report here the top five pain combination groups, which represented the highest risk for multiple falls. And so the odds risk for multiple falls over four years was 8.4 if an individual at baseline reported ankle, knee, and neck pain. This was followed by all joint sites with an odds risk of approximately 5.9, and then subsequently lower risk but very, very high odds with ankle-back, ankle and knee, and ankle-back and neck. Now, after we adjusted for all these covariates, these were the odds ratios that resulted. Single-site pain odds ratios were much lower, ranging anywhere from 1.05 to 2.1, clearly indicating that multiple sites is an elevated risk for falls. Secondly, linear regression was also performed to predict the total number of falls and to determine how muscle strengthening plays a role in mitigating that risk. Once we accounted for all of our covariates, the addition at the end of strengthening and endurance activity, this feature reduced the number of falls using the beta coefficient over the four-year period by approximately negative 1.28, which was considered significant. A small effect, but significant. And so from these data, what we can conclude is that falling multiple times over a four-year period is going to be a risk factor for patients that you might see at a baseline visit who have pain at more than one site, and that mitigating this risk might be achieved through daily incorporation of muscle and strengthening endurance activity. This does not necessarily mean purposeful exercise, but activities throughout the day that encourage strong muscle contraction and endurance. And these values are important, particularly those with osteoarthritis pain, 45 to 75 years of age. Thank you very much. I appreciate your time and look forward to answering any questions. Okay, thank you very much for all the presentations. I'd like to thank our presenters for all that great information, and also for our participants for being here during the session. At this point, we'd like to open up the floor to questions, if there is a question. If you could put that question in the chat, that would be most useful, and we'll find that question there. Or I think you could also use the raise the hand function. Any questions from the audience or from one of the other presenters to each other? No? I guess you guys were just so explanatory, you blew the audience away. I thought maybe Dr. Iliescu, since you made a teaser about a paper, I'd grab her and say what was in that paper that you want to talk about, but hold on. So, this is Dr. Kortewein, says, apologies, but missed a portion of the false talk. While it makes sense, this is stating a correlation and not necessarily a causation, correct? Is that for the first one or the other one? I mean, always correlation is not causation, but the last one, so Dr. Heather, that was for you. Yes, excellent question. So what this type of a study was, is looking at the relationships, this is not a causation. So what we tried to do was take out as many of the features that could be contributing to fall risk over time, including changes to body composition, medications, the social variables and so on. So yes, it is a correlation. Other questions from the audience? All right, outstanding. I want to thank everybody for attending the session. Looks like we're going to give everybody about eight minutes of their day back. Hope you enjoy other sessions as part of the meeting this year, and thank you very much for attending. Everybody take care.

rehabilitation

adaptive sports

activity limitations

fall injury

back pain rehabilitation

lymphedema

multiple falls