Welcome participants to the 2020 AAPMNR Virtual Annual Assembly. This session is Research Spotlight, Musculoskeletal and Sports Medicine. This is the best of research session. Each presenter has pre-recorded their presentation and has made time to be available for a Q&A today. Please save questions until the end. To post questions to the faculty, please type questions in the chat field on the left side of your screen. So first I'd like to welcome Dr. Patrick Schaefer, who is a Chief Resident at Mayo Clinic, Department of Physical Medicine and Rehab, and he will be presenting a study entitled, A Single Site Retrospective Review of Clinical Complications from Ultrasound-Guided Carpal Tunnel Releases. Hi, my name is Patrick Schaefer. I'm a PGY-4 Physical Medicine and Rehabilitation resident at Mayo Clinic in Rochester, Minnesota. I'm going to be presenting our project titled, A Single Site Retrospective Review of Clinical Complications from Ultrasound-Guided Carpal Tunnel Releases. I would like to thank my co-authors on the project, Drs. Stephanie Clark, Jay Smith, Jacob Sellin, and Jonathan Finoff. Some background on our research, carpal tunnel syndrome is the most common compression neuropathy and leads to an estimated 580,000 carpal tunnel releases performed annually for refractory or severe symptoms. The goal of surgery is to cut the transverse carpal ligament to reduce median nerve compression. Traditional open carpal tunnel release is safe and effective, but can be associated with large, sometimes painful scarring, pillar pain, and often a relatively prolonged recovery. As opposed to open carpal tunnel release, endoscopic carpal tunnel release has been reported to result in faster recovery, presumably due to less tissue trauma, but has a greater risk of postoperative nerve symptoms and theoretical risk of injury due to poor visualization of surrounding neurovascular structures. Ultrasound guidance has been used to perform carpal tunnel release with the goal of minimizing tissue trauma without sacrificing visualization of important at-risk structures. Over 700 cases of carpal tunnel release using ultrasound guidance have been reported in the literature with excellent results and no documented neurovascular injury. In addition, prospective studies have documented faster recovery following carpal tunnel release using ultrasound guidance compared to traditional open carpal tunnel release. The primary purpose of our study was to evaluate the safety of carpal tunnel release using ultrasound guidance during initial clinical implementation in 2017 and 2018. The methods of our study, all patients were treated with carpal tunnel release using ultrasound guidance by Dr. Jay Smith at Mayo Clinic between 2017 and 2018. All procedures were performed using a high-frequency linear array transducer, local anesthesia with or without monitored anesthesia care, and the commercially available SX1 Micronife. In terms of the procedure, figure one shows the small incision that is made to introduce the SX1 Micronife, which is typically closed using Steri-Strips. Figure two shows the SX1 Micronife, which has inflatable balloons to expand the safe zone for the procedure, and a retrograde cutting knife, which is deployed to cut the transverse carpal ligament. Figure three shows a longitudinal view of the carpal tunnel with distal left, demonstrating the SX1 Micronife subjacent to the transverse carpal ligament. The blue arrow shows the cutting knife, which is deployed to cut the transverse carpal ligament, distal to proximal. Figure four shows a transverse view of the carpal tunnel with ulnar right in the mid-carpal region, demonstrating transection of the transverse carpal ligament, which is demonstrated with yellow asterisks. The two balloons have been inflated and are represented by the circular anechoic structures bordering the central hyper-echoic portion of the device. The radial balloon has displaced the median nerve more radially, which creates more working space for the centrally located retrograde cutting blade, demonstrated by pink arrows to cut the transverse carpal ligament. This transverse view allows the operator to simultaneously visualize the device, blade, and surrounding neurovascular structures. Figure five is a similar view to figure four, with the yellow arrow representing the gap in the transverse carpal ligament following transection. Charts were retrospectively reviewed for complications as well as underlying medical comorbidities. The results of the study, there were 13 patients with 17 hands total who underwent elective carpal tunnel release using ultrasound guidance during the study period. Dominant characteristics are shown in table one on the next slide. 24% of patients had at least one prior corticosteroid injection with range one to three injections. 41% of procedures were performed on dominant hands. Nine patients had unilateral releases, while two patients had staged bilateral releases and two had simultaneous bilateral releases. There were no complications reported at a mean follow-up of 147 days and median of 74 days with range 13 to 687 days. In discussion, I mentioned that there were no complications found when retrospectively reviewing patients that had carpal tunnel release using ultrasound guidance in our study. The results add to the growing body of evidence supporting the safety of using ultrasound guidance for carpal tunnel release. And in conclusion, our results suggest that carpal tunnel release using ultrasound guidance and the SX1 micro knife can be performed safely by a physician with expertise in ultrasound guided musculoskeletal procedures. Thank you and I'd be happy to answer any questions. Thank you, Dr. Schaefer. Next up is Dr. Amos Song from Vanderbilt University Medical Center. Dr. Song is a fourth-year resident and chief resident at VUMC, and he will be presenting a study on characteristics of musculoskeletal ambulatory care visits in the U.S. from 2009 to 2016. Dr. Song. Hello, everyone. My name is Amos Song from Vanderbilt University Medical Center, a fourth-year resident there. I just want to take a moment to recognize everyone that has been affected either personally or professionally by the COVID pandemic, but I am thankful for having you join me today over this video. Our project looked at the characteristics of musculoskeletal ambulatory visits in the United States from 2009 to 2016. Musculoskeletal issues are one of the leading health problems worldwide. Up to 50 percent, up to half of Americans will report a musculoskeletal problem in their lifetime. And as you can expect, this has quite the impact on the American workforce. 2009 to 2011, musculoskeletal conditions cost the United States up to $200 billion, about 1.4 percent of the GDP. Up to 290.8 million American days of work were lost due to musculoskeletal conditions in 2012. But despite this large impact of musculoskeletal disorders, detailed data on the epidemiology, patient characteristics, visit characteristics, and treatment recommendations on patients who seek ambulatory care in the United States for musculoskeletal disorders is pretty sparse. So what we did was we gathered data from the National Ambulatory Medical Care Survey. It's a survey conducted by the CDC, and we looked at years 2009 to 16 for patients older than 18. The NAMCS is designed to capture information regarding ambulatory medical care services across all specialties in the United States. Physicians randomly assigned a one-week reporting period in which they fill out a patient record form. They capture this data on selected patient and characteristics. The actual data for this collection is conducted by these physicians that are specially selected by field officers from the NAMCS office. These physicians would then record this data using for every patient on at least 10 patients during the work day that they record their data. We were particularly interested in ambulatory care visits that covered musculoskeletal body regions including the spine, which included the sacroiliac joint, shoulder, elbow, wrist, hip, knee, and ankle. Some of the patient characteristics we were interested in included age, sex, race, and ethnicity, tobacco use, and obesity. Visit characteristics we explored were sources of payment, if it was a primary care visit or not, physician specialty, and if it was a new versus chronic problem. We also took a look at education, referrals for exercise, injury prevention, weight loss, stress management, and tobacco cessation. So now I'd like to take you to the results section. Here we see in figure one, which will be on your left, on the x-axis is year, again grouped in two-year periods that are averaged annually, and on the y-axis we have the average estimated number of adult visits per year. As you can see, spine up top is by far the most common encounter for musculoskeletal visits, followed by the knee, shoulder, wrist, and then ankle. Figure two, which is on the right, shows the rate per 100 U.S. adults, so again, years are on the x-axis again, and on the y-axis is the average estimated rate per 100 U.S. adults. And similarly to the prior figure, we see that spine is by far the most common, followed by the knee, shoulder, ankle, and wrist again. And a couple of other findings were of interest to us. We found that musculoskeletal visits were most common in the working age, ages 45 to 64. We found that orthopedic surgeons were, in fact, the most common provider who encountered these patients. And we also found that the spine and the hip were the most common body region to be prescribed opioids as well. In addition to that, we found that female patients made up to about 56 percent of all visits, so slightly over half, regardless of which body region was considered. Less than 15 percent of visits had some type of education or referral on exercise, weight reduction, or injury prevention during their visit. In terms of imaging, we find that the shoulder is the leader in MRIs that were ordered compared to other body regions, and in x-rays, the hip and the knee were the most common compared to the other body regions. We find that injections are most commonly done for visits regarding the knee as well. A couple of interesting points in terms of the trends. We see what appears to be a decrease, especially in 2015 and 2016, but I would caution against making too many interpretations about those trends in the time. We think this is largely due to certain sampling strategies that change, particularly in that year, that may explain that decrease there at the end. Finally, spine and hip, as mentioned, was the most common body region to be prescribed opioids, and this may be a target of intervention for providers who see patients with those issues. Finally, to compare to other non-musculoskeletal visits, for example, asthma, diabetes, and hypertension, studies that use the same NAMC dataset have shown that the annual average for asthma is about 10.2 million visits per year, diabetes at 113.3, and hypertension at 176 million visits per year. As you may see, these musculoskeletal disorders compared to, if not exceed, a lot of these more common medical issues. It really gives a comparison to other common medical disorders that patients face. Again, thank you for coming to this video talk, and I'd be happy to answer any questions. Thank you, Dr. Song. Next up is Dr. Michael Harper. Dr. Harper is a resident at the Medical College of Wisconsin in the Department of PM&R on a research-intensive track. His interests are in sports medicine and adaptive sports. He will be presenting on Concussion Management Program in Wheelchair Athlete Retrospective and History Database Review. Dr. Harper. Hello, my name is Michael Harper. I'm a PGY-4 Physical Medicine Rehabilitation resident at the Medical College of Wisconsin here in Milwaukee. My project is on the topic of concussions in wheelchair sports, and this project originated during the coverage of wheelchair lacrosse after I had observed athletes falling out of their wheelchairs and hitting their heads on the playing surface. As many of you know, there are clear guidelines for the assessment of concussion in able-bodied sports, and there was a concessive statement in 2016 on the topic, which developed the SCAT-5. Many components of the SCAT-5 have limitations when performing on wheelchair athletes, and Drs. Kisik and Wedborn outlined many of these limitations in their article, Concussions on Parasport. Particularly, there are challenges given pre-existing symptoms due to an athlete's comorbidities, potential for baseline cognitive impairments, and being unable to assess balance in the balance error scoring system as a wheelchair athlete cannot stand. There are several parasports where the risk of concussion may be elevated due to the high speed of play, physical impact potential, and lack of protective equipment. Unfortunately, there have been only a few articles on the topic of concussion in athletes with disabilities. For example, a search strategy developed on defined articles regarding athletes in concussion revealed 6,000 results, whereas one developed for athletes with disabilities in concussion only returned 60 articles. Additionally, the recent 5th International Consensus Conference on Concussion in Sport featured 202 oral and written abstracts, but only two were specific to athletes with disabilities. The earliest publication identified that discussed head injury and concussions in wheelchair population was in 1985 in a study that was used to identify wheelchair athlete injury patterns. They found that 2% of reported injuries were considered a head injury or a concussion, and another survey in 1994 focused on wheelchair users and found out that 57.4% of participants reported they had tripped or fallen from their wheelchair at least once. Of the injuries that were recorded, 50% were the head and neck, with 2.7% being classified as a concussion. In more recent years, there was a study on wheelchair basketball players that found 6.1% of athletes were diagnosed with a concussion over a single season, with 44% not reporting the concussion, primarily because they did not want to be removed from play. Those remarks are remarkably similar to able-bodied results. And then during the 2012 Summer Paralympic Games in London, the overall injury rate was 12.7 injuries per 1,000 athlete days, with 2.2% of the injuries being to the head and face and 5.7% being to the neck. During the same games, football 5-a-side for the visually impaired had the highest incidence of injury of all summer sports, with head and neck accounting for 25% of all injuries. At the Sochi 2014 Paralympic Games, more than 60% of alpine competitors failed to complete the course due to poor snow conditions, which led to a high incidence of injuries. Of all sit-ski alpine athletes, 37% suffered an injury, and 5% of those were to the head and neck region. And during the 2016 Rio Paralympic Games, team physicians reported 10 significant head and facial injuries, but concussion was not reported in any of these incidents, despite clearly suspicious video footage of concussion in these events. At the 2018 Pei Youqing Paralympic Winter Games, head and neck accounted for 4.8% of injuries, with 4 reported concussions. And in 2018, the Wheelchair Basketball World Championships, the overall injury rate was 68.9 injuries per 1,000 athlete days, and of those, 1% was to the head and 16% were to the neck. Based off of this information, we decided to kind of tackle some of the challenges in assessment of concussion in developing a wheelchair athlete concussion management program at the National Veteran Wheelchair Games in 2019. The protocol largely focused on assessment of concussion and obtaining baseline characteristics, utilizing concussion history questionnaire, a graded system checklist, the standardized assessment of concussion, which is a cognitive screen, and a wheelchair error scoring system, which is a modification of the balance error scoring system that can be used in the wheelchair users. In the 2019 National Veteran Wheelchair Games, we had 81 athletes volunteer for the baseline testing. And this study is a retrospective chart review on the 81 athletes concussion history questionnaire. The purpose of this review is to obtain better understanding of the occurrence of concussion in wheelchair athletes and their reporting history of their concussion. The concussion history questionnaire obtained basic athlete characteristics, stated the definition of concussion and asked if the athlete has suffered a concussion in the past. If yes, there's questions on asking when the concussion occurred and whether it was sports related. And if they reported their concussion, if they did report it, who do they report it to? And if not, why did they not report it? Out of the 81 veteran wheelchair athletes, 35, which is 43.2% reported a history of concussion in their lifetime. Of those athletes with a concussion history, 30 reported a history of concussion prior to the disability, 12 athletes reported suffering a concussion after the disability diagnosis, and 22 reported having more than one concussion. Out of the 30 athletes that answered whether or not they reported their concussion, 77% reported they did report their concussion at the time of injury, and physician was the most common answer. Those that did not report their concussion because they did not know what a concussion was, didn't think it was serious, thought it was part of the game, or just stated other. In conclusion, with 43.2% of veteran wheelchair athletes reporting a history of concussion over their lifetime, and 63% of those athletes having a history of multiple concussions, we have demonstrated that concussions do occur in the veteran wheelchair athlete population. We also identified that the physician is most likely person that the veteran wheelchair athlete will report a concussion to, and additionally, we identified areas of education for veteran wheelchair athletes that may yield higher concussion reporting. These include educating on the signs and symptoms of concussion, and the potential side effects, such as post-concussion syndrome, second impact syndrome, and chronic traumatic encephalopathy. Our group has also gathered a group of experts to discuss the challenges in the assessment of the wheelchair athlete. The first edition of this handbook will be largely based on expert opinion, given the lack of literature, but our hope is to foster and inspire future research projects on the subject. We currently need a better mousetrap to assess concussion in the wheelchair athlete, as each wheelchair athlete proposes their own unique challenges, given their disability. Thank you for taking the time to listen to my project. Well, thank you, Dr. Harper. Next up is Dr. Jonathan Kirshner. Dr. Kirshner is an attending physician at the Hospital for Special Surgery, and holds a faculty appointment as Associate Professor of Rehabilitation Medicine at Royal Cornell Medicine. He will be presenting his study on efficacy of ultrasound-guided glenohumeral joint injections of platelet-rich plasma versus hyaluronic acid in the treatment of glenohumeral osteoarthritis, a randomized double-blind control trial. Dr. Kirshner. Hi, good afternoon or good morning, depending on when you're hearing this. I'm Dr. Jonathan Kirshner, and I'm a physiatrist at the Hospital for Special Surgery here in New York City. And I'm gonna be presenting my study called the efficacy of ultrasound-guided glenohumeral joint injections of platelet-rich plasma versus hyaluronic acid in the treatment of glenohumeral osteoarthritis, a randomized double-blind control trial. So clearly that's a mouthful, but I hope you enjoy my presentation. I really would like to thank the Foundation for PMNR for supporting this study with the ERF Madison Grant and Harvest Terumo for donating the PRP kits. They had no role in designing, devising, writing up, analyzing the study. They just donated free PRP kits. I also would be remiss if I didn't thank my co-investigators Jennifer Chang, Andrew Creighton, Kristen Santiago, Mark Dundas, Nicholas Beattie, Dallas Kingsbury, and Richard Chang. So a little bit of a background on glenohumeral osteoarthritis. You know, why was this an important study to do? Glenohumeral osteoarthritis is a common thing that we see in our offices in physiatry and involves degeneration of the glenoid and humeral articular surfaces and is associated with osteophyte formation, subchondral bony changes, and synovitis. It's common in the elderly, in patients with previous shoulder injuries, specifically shoulder subluxations or rotator cuff tears. It's very common in our PMNR population and patients who use wheelchairs, those who are involved in sports involving overhead activities. And generally conservative treatments include activity modification, medications, physical therapy. And then when that doesn't work, perhaps different injections such as corticosteroid injection. When all this fails, the gold standard treatment for glenohumeral osteoarthritis is surgery. And that's typically a shoulder replacement or a reverse total shoulder replacement in those who have deficient rotator cuffs. Hyaluronic acid is an emerging treatment that's shown some efficacy in limited studies for treating glenohumeral osteoarthritis. It's considered off-label use for glenohumeral OA. However, I do practice in New York State and as per the New York State Medicare guidelines, we are allowed to use hyaluronic acid for use in glenohumeral OA but patients can only have two courses of treatment in their lifetime. PRP is suggested to have potential for treating glenohumeral OA but there are very few studies looking at PRP at glenohumeral OA and there are no studies as far as we know comparing hyaluronic acid to PRP. So considering the PRP is being used for many other joints, especially knee arthritis with some good emerging studies that have shown benefit when being compared to HA, that gave me the idea for this study to compare the HA to PRP for glenohumeral OA. So the aim of this study was to assess the efficacy of leukocyte-poor PRP versus hyaluronic acid in the treatment of patients with chronic glenohumeral osteoarthritis that is refractory to conservative management. The hypothesis was that ultrasound-guided glenohumeral joint injections of leukocyte-poor PRP would be more efficacious with respect to improving pain, function, and quality of life than glenohumeral injections of hyaluronic acid in patients with glenohumeral OA. We decided to use leukocyte-poor PRP because this tends to be more anti-inflammatory, whereas a leukocyte-rich can be more pro-inflammatory. Leukocyte-rich PRP also has monocytes and other cells that are high in PMNs or neutrophils that may release matrix metalloproteinases and other degradative enzymes that may exacerbate arthritis. So that's why we chose to use leukocyte-poor. It's certainly controversial whether or not leukocyte-rich or poor is better, and that's something that we could talk about further in the future. So inclusion criteria, patients had to have radiologically-confirmed osteoarthritis, so everybody had x-rays and then some form of advanced imaging. If they could do an MRI, they did an MRI. If they had pacemakers or other contraindications, they would have a CT. They had to have pain at least six out of 10 or greater because we wanted to see that there'd be a meaningful difference after treatment. And all patients had to have some transient relief from a diagnostic glenohumeral joint injection. So just because they had radiographic OA doesn't necessarily mean a patient's symptomatic from the arthritis, but all of our patients had to have some temporary relief suggesting that their symptoms were indeed coming from the arthritis. We excluded patients that had concomitant cervical spine conditions can often refer pain to the shoulder and make it difficult to ascertain whether the pain's coming from the shoulder or from the neck. If patients were allergic to poultry, they had a worker's comp case, or if they had psychiatric or somatoform disorders, they were excluded. Patients were randomly assigned to receive a single injection of the hyaluronic acid or the leukocyte-poor PRP. So in order to have equal volumes of medication, what we did is we took three vials of a two milliliter vial of HyalGam, that was the brand we used, and we put all three vials in at once. And we compared that to six ml of leukocyte-poor PRP so that the volume was equal and that wasn't a confounding factor. I performed all the injections and I was blinded. So I did not know what treatments the patients were getting. One of my fellows would help prepare either the PRP or hyaluronic acid and blind the syringe with black tape. So I didn't know what the patient was getting. The patient didn't know what they were getting. And anyone who did the assessments, typically this was done either by phone or by an online questionnaire, the assessor was also blinded. Patients received a little bit of local anesthetic subcutaneously, but no local anesthetic was placed in the joint to minimize any confounding effects that the local may have. Some studies show that local anesthetics may degrade or counteract the effects of the PRP. All patients had to be off of the NSAIDs for five days before the treatment and for eight weeks after. This is because the NSAIDs can impair the release of the growth factors from the platelets and impair the actual function of the PRP. We assess pain, but also we want to assess functional status. So we use some different evidence-based questionnaires that have been devised embedded in the literature to assess shoulder function. So specifically the SPADI or the Shoulder Pain and Disability Index and the ASES scale, the American Shoulder and Elbow Surgeons Functional Scale. And we administered these at one month, two months, three months, six months, and 12 months post-procedure. Right now we have data for 12 months, which is what I'm presenting now. The study did go to 24 months and we're looking forward to presenting that data in the future. However, preliminary analyses do show that there were no differences in the 12 month and the 24 month outcomes. So overall, we did a power analysis and we were powered for 70 patients. We enrolled 70 patients. 36 were assigned to the HA group and 34 to the leukocyte-poor PRP group. On average, we yielded about a three and a half times fold of PRP. So we were able to concentrate the PRP to about three and a half times the native concentration, plus or minus 1.6. So certainly the results may vary based on the concentration of PRP. Overall, these are our results. And so you can see here, both for the SPADI and the ASES, the charts are pretty similar. There was no significant difference in both groups, whether they received the hyaluronic acid or the PRP injection, but both groups had significant improvement from their baseline and they started to notice this significant change in about two months. You can see at two months, three months and 12 months, these results were significant. So in summary, the current and average NRS pain scores improved over time in both groups with no between group differences. Sleep quality and general wellbeing were unchanged throughout the follow-up period in both groups. Side effects were very uncommon and overall the rates were 3.9% in the HA group and 2.7 in the PRP group. Side effects were typically worsening pain after the procedure, which was transient, but there were no significant side effects in either group. And overall patients were very satisfied. We asked them, would they repeat this treatment again? Roughly 60 to 70% of patients within the HA group said they would and 70 to 80% of patients in the PRP group said they would repeat it also. Most of the patients had very severe arthritis and almost everybody was indicated for surgery. So overall, 7% or seven patients in the HA group and nine patients in the PRP group did go on to a total shoulder arthroplasty during the follow-up period, but there was no significant difference between the two groups. So in conclusions, we found that a single injection of either hyaluronic acid or PRP improved pain and functional outcome in patients with chronic glenohumeral osteoarthritis. There were no significant differences in outcomes between the HA and the PRP groups. Side effects were uncommon overall and most patients reported that they would repeat the study treatment again. So hopefully this provides alternative options for clinicians and patients with glenohumeral osteoarthritis who are looking to avoid surgery and haven't responded to other conservative care, including medications and physical therapy. These are some of the references and thank you so much for your attention. Thank you, Dr. Kirshner. That was very interesting. Next up is Dr. Michael Krell. Dr. Krell is a ATC resident physician at WashU and he's the academic chief resident in physical medicine and rehab at WashU. His current research projects include injury epidemiology. He will be presenting on understanding fatigue and timing of ACL injuries in NFL games with snap counts and game number at time of inquiry. Dr. Krell. Hi, I'm Michael. The title of our project was Understanding the Role of Fatigue and Timing of ACL Injuries in American Football, Utilizing Snap Counts and Game Number of Injury. ACL injuries are one of the most common devastating long-term injuries experienced by athletes of all ages in sports. There is an increased scrutiny over the last decade to further understand these injuries. According to Dotson et al, the number of ACL injuries appears to be increasing mainly in pre-season and off-season activities, while the number of in-game ACL ruptures in NFL games was relatively constant from 2010 to 2013. Johnston et al performed a video injury analysis of ACL tears in American football athletes and found that most ACL injuries in the NFL from 2013 to 2016 occur through a non-contact mechanism, except for offensive linemen that experience about 80% through a contact mechanism of injury. There have been several theories that have been postulated about the role that fatigue plays and how significant it may be in ACL injuries. Fatigue is kind of a generic term that can be interpreted in different ways. Fatigue may be described as a sudden spike of activity through the course of a game or practice. It may even be a cumulative effect through the course of a game or practice. For our study, we utilized and continued from previous studies the term within game to describe this type of fatigue, whereas fatigue may also be considered a neuromuscular response from the cumulative effects throughout the entire season or a long intensive off-season training program. And we continued to use the terminology for this within season. So one common theory about this role that fatigue plays in ACL injuries describes the deleterious biomechanics that are associated with fatigue. And it's previously been associated with increased changes of knee sagittal plane asymmetry, abduction angles and moments, as well as an increase in vertical ground reaction forces. All of these biomechanical changes contribute to stiffer landing mechanics and poor energy absorption. This would correspond with an increase in ACL injury risk. Although this principle is not universally accepted in the literature, a recent review by Zhao et al found that there was no difference in the distribution of secondary ACL injuries across each quarter of game time or a quarter of the season, kind of looking at that fatigue component for these secondary ACL injuries from multiple sports that was unable to include American football. So one of the major limitations to evaluate fatigue in American football is that there's no clear mechanism to measure time. Although GPS monitoring systems and other emerging technologies continue to be trialed, there are no current universal guidelines on how to interpret the data and are simply not economically or logistically feasible at all levels of football. One way to address the issue may be to utilize snap counts to measure the number of plays an athlete actively participates within. So the purpose of this study was to establish the potential role of measuring fatigue and ACL tears in American football, both within game and within season by using and evaluating these ACL injuries with the total snaps played in the game of injury and the game number of injuries. So for our methods, the ACL injuries that occurred in NFL regular season games over eight years from 2012 and 13 to the 2019 and 20 seasons were documented. Potential ACL injuries were identified through mandatory published weekly injury reports, local news articles, and player interviews. Official NFL game reports and information was collected and descriptive statistics for ACL tears were identified by snap count and game number of injury. We utilize histogram plots to evaluate the distribution of these ACL tears by the variables of interest. And just for reference, the bye week each team has during the season was excluded and resulted in just the games being numbered one through 16, mainly for the fact that bye weeks are not evenly distributed in the season. So during these monitored NFL seasons, we were able to identify 182 in-game ACL injuries. The descriptive statistics are listed in the table in the third column at the top. The median regular season game of injury was number seven, and the data was slightly skewed towards earlier in the season. For total snap count, the range of snap count during the game of injury was from one to 79 snaps with a median total snap count of 20 at time of injury. We were able to kind of utilize the snap count for the game because in most instances, ACL injuries result and the player is unable to continue playing. And so this was an assumption that we made with the data. This data was non-parametric and was also skewed towards injury occurring at a lower snap count within games. So to complete statistical analysis of the snap count data, a square root transformation was performed to attempt to normalize the data. And as can be seen in column two, the graph of total snap count and regular season game of injury is documented. This was completed to evaluate for any association between within game and within season cumulative fatigue, utilizing a line of best fit. So the findings from this initial study demonstrate that in general, ACL injuries occurred slightly earlier within game and within season. However, this initial data has not fully been evaluated and there are potential confounding variables. Also, since this was the initial analysis to utilize snap counts, further monitoring should ensue to confirm the small slope from the graph demonstrating column two of 0.033, that it is truly indeed flat. And for our purposes at this time, we did not deem that it was clinically significant. So regarding future directions, the next steps will involve analysis of the snap count of players that sustained an ACL injury in the games preceding their injury to the snap count from the game of injury. This will help to identify when the injury occurs compared to the usual participation of an individual athlete. It will help us to eliminate any confounding variable where the position that the athlete plays could contribute. Different positions within American football have different typical snap counts in an individual game. So these analyses will likely be more worthwhile and have more clinical significance compared to this current data being presented. Another analysis will be to include a video review to evaluate the mechanism of injury of all of these ACL injuries when the snap count occurred. This will be important to identify if there's any association with a specific mechanism of injury with the actual timing of the injury and then also when it occurred in the season. So this initial data is really just the stepping stone to our future interest in this topic. Well thank you Dr. Krill. We have the Q&A session now. I'm happy to see all of you live. And there are some questions that did come up in the chat session so I'll just go ahead and get started with those as well as a couple of questions. The first question that came, I'll just go in order, was for Dr. Song and this basically revolves around the issue of were you disappointed by the fact that orthopedists are consulted more often slash earlier for management of MSK injuries as opposed to podiatrists? And do you have any data on what percent of patients seen by ortho actually ended up having surgery? So I want to say thank you to Emma for this question here. So I'll tackle the first one. We did not have data of the how many patients actually under that underwent surgery weren't able to follow these patients. And so we unfortunately don't have that data. We do know that about five percent of visits, depending on the body part, were seen as a pre-surgery visit. If those patients actually ever ended up getting surgery or not is unclear. And to answer your second part of your question, are there any ideas on how to increase referral to PM&R as a first line for MSK issues? I think ultimately this is going to be a partnership with our orthopedic colleagues and a systems-based solution where we really have to be able to demonstrate really value-based care that we can provide efficient non-operative care that would benefit both us and our surgical colleagues as well. Much easier said than done, but I believe that there are institutions that have been able to install that. I think that leads really well to Dexane's question here. Are there any ideas on how patients could be educated about the role of physiatrists? I think by being first line for some of these musculoskeletal issues, I think which we are very well suited to do, I think that would be probably the best way to do it, to continue to deliver high value care, good communication with the patient, as well as our operative colleagues. Thank you, Dr. Song. I have a few questions for Dr. Kirshner in the chat box. The first one is, were you drawing blood from all patients? I guess this goes to the idea of, were the patients who received hyaluronic acid, were they blinded to the fact that they didn't get PRP? Thanks so much for the question. You know, we definitely took that into consideration. All patients underwent a sham blood draw. So the patients in the HA group didn't necessarily have blood drawn, but we took a sharp and held it to the antecubital fossa. We waited approximately a minute, minute and a half, which is how long it would take to draw blood. We even used verbal cues to tell the patient to pump their fist. We put a tourniquet around their arm to try to mimic the whole blood drawing experience. We put a Band-Aid on and told them not to remove the Band-Aid for a few days. So while we can't perfectly blind, we didn't think it was necessarily ethical, nor did the IRB approve actually drawing blood from the HA group. So, Dr. Kursa, in particular, did you actually poke the needle in the patient and just not draw the blood? We held the needle against the skin, but didn't actually draw blood. Okay. I think the second question is also for you, which is, were the outcomes different from the PRP or HA injections in those that ended up having surgery? No, there was no significant difference in the groups going on to surgery. Overall, we were sort of surprised at the low rates of surgery considering the severity of the patients. But it didn't matter whether or not they had HA or PRP, that wasn't statistically significant. Okay. And there's another follow-up question, not a follow-up, but another question here for you. Could you tell us which HA was utilized in the study and how much PRP was injected? Sure. So we used Hyalgan, which is a Phidia product. It's a lower molecular weight hyaluronic acid. It's been around for several years and I happened to use that in my office and hadn't had a lot of side effects. I chose that partially for cost reasons. Again, I have to really thank the Foundation for PMR, ERF Medicine grants. We wanted to keep everything under budget. And so for cost reasons, we were able to use those three Hyalgan, take the three vials, inject it all at once. And that way it was the same amount of volume as the leukocyte-reduced PRP, which is also a 6cc aliquot. Awesome. Thank you. Those are the questions I see in the chat box. I have a couple of questions here. Well, the first one is for Dr. Schaefer. I guess one of the big advantages here is this is an office-based procedure, I'm guessing, and you don't have to go through the process of scheduling the patients in the OR. What kind of anesthesia did you use? Is this simply local anesthesia? What kind of anesthesia is it? And do you have any data on outcomes? Yeah, great question. So we use local anesthesia on all of our patients. And in reviewing the literature, I believe that that's the most common route in people that have undergone this procedure. We, unfortunately, did not look at outcomes in this. We were strictly looking at if there were any clinical complications in this trial. And from your understanding, were patients mostly able to tolerate the procedure during local anesthesia, with local anesthesia? Yes, in my understanding, they were. In my understanding, it's a pretty well-tolerated procedure. Let me see if there's another question here before I go to the next question. So I think, again, Dr. Kirshner, there are a couple of questions for you. I'll ask mine first and then ask one here. I wonder if you, as you know, there's still a debate on whether hyaluronic acid actually is efficacious in treating hypertension. Is it effective in treating hypertension? I wonder if you, as you know, there's still a debate on whether hyaluronic acid actually is efficacious. And the same applies to PRP as well in any kind of a way, let alone, let alone a way. So although you compared those two groups, I wonder if there was any talk to either considering another arm with corticosteroids or a placebo group? That's a terrific point. I mean, there's certainly a placebo effect anytime you insert a needle into a joint. Previous studies looking at hyaluronic acid versus placebo found that both groups actually did statistically better than their baseline, but there wasn't a significant difference between groups. And so we found a similar result. So perhaps, you know, could it be placebo effect? Ideally, we would have either a third arm with placebo or a fourth arm with steroid, you know, in order to improve recruitment, I sort of wanted to offer two active treatment groups and not have a placebo. And again, for cost considerations, we wanted to keep everything under budget. So we certainly need more work, and that would be a great way to design that study with larger patients in multiple series. If you look at some of the other body parts, you know, our study isn't that dissimilar to studies looking at both hip and knee osteoarthritis, which in general show that both HA and PRP, you know, provide relief, but similarly, you know, there was a study a few years ago looking at MIOA, and they found that the HA wasn't statistically different. And the argument was that because it was perhaps a placebo effect, both groups did well. And the patients thinking that they possibly could have had PRP overreported the benefit, even when they had HA. So that's definitely a consideration that we took into account. Thank you, Dr. Kirschner. Dr. Krill, we have a question for you. Were you looking at game snap count or snap count played by the athlete? You also mentioned linemen versus other players. Did you stratify this as well? Yeah, absolutely. So for our study, we actually looked at the individual snap count played by each player, thanks to the NFL kind of changing the way the NFL plays. And we looked at the individual snap count played by the athlete. The NFL kind of changing what they publish and track in their game reports. I think it was a 2012 or 2013 where they started doing it. So that's kind of when we started using that. So it's the snap count for the individual player. And then the second part, kind of linemen versus other players. So a couple of things that were, this first study was kind of just like the bird's eye view, looking at everything in general. The next steps are really to kind of do a video analysis where we've actually collected a video of over 150 of these injuries and kind of analyze it and kind of break down whether it's contact, non-contact. And if we have enough of a sample size, including some indirect contact as well. And then the second part would be to actually compare snap counts of the players in the games preceding and leading up to the game of injury, to see if there was a sudden change in how much they were playing. And then of course, when we break it down into those two other variables that are the next two studies, we hope that we'll be able to break it down into specific position groups. The problem is depending on how quickly you kind of plug in and break down that information, you kind of lose your power real quickly. And then I see a follow-up that came in real quickly, just about differences with regards to playing surface, time of day, weather-related etiologies. We also have all of that also recorded kind of in our data that we've collected. So it's really just about prioritizing and trying to work through some of those different variables to get the findings. This was just the first one to see if it was even possible, honestly, to record snap counts for players and find anything. And then just practice looking at the data that we have. Thank you. There is a question for Dr. Schaefer, but Dr. Cushing, there is, I guess, a suggestion on the chat for you to consider buffers in such as dynamo case studies. But Dr. Schaefer, the question is, did you notice a difference between your procedure time in the office versus what it takes in the OR to do a proper tumor release? Yeah, great question. So with our procedure, you know, you don't have the time that is required in the OR for more than local anesthesia. Time mapping out the nerves as well as the arteries makes up for some of that. But overall, I think it's probably a little bit quicker on the verge of about 10 minutes to 15 minutes versus what's required in the OR. And my limited experience in seeing OR cases is probably a bit longer. I see a couple of questions here have been answered by our presenters, but I'll still read them. This is a question for Dr. Kushner about whether when patients are asked about considering the procedure again, are you taking into account the out-of-pocket cost? And you answered that that was not specifically asked. And I guess there is the question of why did so many patients end up having surgery while others did not since outcomes were not different. Maybe I'll let you, Dr. Kushner, speak a little bit about it. Sure. You know, we're doing a subgroup analysis now looking at the severity of arthritis to see if outcomes vary based on that. And so far, we don't believe it has. Most patients had very severe arthritis and were indicated for surgery already. And so overall, a very small percentage, about 20% of them, 25% of the other people went on to surgery. But that wasn't significantly significant between the two groups. So there are many factors why patients decide to have surgery or not. But for those where the pain and function was prohibitive, they decided to do that. You know, I forget. I did not see any kind of rating, either a fail rating or any rating in the severity of the neurological arthritis. And I wonder if there is talk to using this early on as opposed to in more severe arthritis when patients are almost ready for surgery. I wonder if you'd actually see a greater benefit in more milder forms of the disease or moderate forms of the disease that are still symptomatic. That's a terrific point. And it may be that our patients were too far gone and that early intervention would be better. So that's a terrific point. Ideally, we would repeat the study with multiple arms, more patients, be able to stratify based on severity. Absolutely. Okay. Let me see if there's any more questions. I don't believe I'm missing any questions. I think, you know, I'm going to go back to the question for Dr. Song, fairly lengthy. I sort of summarized them. But there was a sub part to that question, what might be your recommendations in terms of improving the photos for initial MSK presentations using an alkalizer? Right. So to, as prescribers as being the first line in treating musculoskeletal issues, yeah, I really think that we're in, we are well equipped to take on that. 90% of sports injuries have been quoted as being non-operative. And I think this is, again, going to be a partnership with our surgeons and a hospital-based or systems-based solution where it can benefit both parties. And I think we're just going to have to continue to demonstrate that value that we can provide value-based and cost-efficient as well as time-efficient care. Okay. We could probably have a round table that lasts for an entire day on this topic. And it's probably not fair to ask you this question, but, you know, I mean, I think this is a, probably more senior colleagues in PM&R who can help with a strategy on how to address this. I think this is something that as PM&R specialty has evolved, that we are all, you know, grappling with and trying to wrap our heads around. There is, I guess, a suggestion or a question for Dr. Krell, which is, did you look at cleat type and if not, that might be something you might want to consider? Absolutely. It's a great suggestion. I know there's some great research, you know, coming out really looking at kind of soccer cleats and kind of the interface between different grass, different turfs, different, just looking at all those variables. I do think in our kind of study where we're looking at, it may be challenging to get, but it's definitely something that we're considering if we can figure it out how to. And I have a question for Dr. Harper here. Any guidelines on for wheelchair athletes wearing helmets? Are there any guidelines? We can't hear you, Dr. Harper. I think you're muted. You're still muted, sir. No, we can't hear you. Okay. I think Dr. Harper is having some technical issues here. He'll type the answer out. And we are almost towards the end of our session. We might have time for one more question. Let me see if there's any more questions. There's no further questions that are coming from the audience here. You know, there's again the question of, you know, playing surface, time or day, weather-related ideologies for the NFL study by Dr. Krell. I think these are all great points. I'm going to say, I'm not sure if you have a particular answer there, Dr. Krell. I think you're muted, Dr. Krell. You can hear me now? Okay. So yeah, there's definitely a ton of different studies out there. And I know that, you know, we do collect all the variables. It's just kind of from our standpoint, just right now a priority for which ones we're able to test first. But of course, when we get time and we have the ability, we're always looking into as many variables as we can. I think we're almost out of time. I would really like to thank all of the speakers, as well as all of the audience for this session. I know this is a challenging time and a challenging to do these presentations. But thank you again, everybody, and to the Academy staff for making this so seamless. Thank you all. Thank you. Thank you very much.

musculoskeletal

sports medicine

ultrasound-guided carpal tunnel releases

complications

musculoskeletal ambulatory care visits

orthopedic surgeons

concussion management

wheelchair athletes

glenohumeral osteoarthritis