So good morning and or good afternoon, depending on from where you're joining us. I'm Saul Portugal. I'm an interventional spine sports doc at NYU, and I'll be moderating today's session, Research Spotlight Musculoskeletal Sports Medicine. Just a little housekeeping, each presenter, we have seven presenters today, will be giving seven-minute presentations on their work. Please enter your questions in the chat. So depending on the available time, we'll try to address any questions you have. So first up is Dr. Kevin Crippiano from MedStar Georgetown National Rehabilitation Hospital. He will be presenting on effects of early outpatient musculoskeletal exposure on inpatient human heart rotations. Dr. Crippiano. All right, thanks for having me, everybody. You can go to the first slide there. So yeah, as Dr. Portugal alluded to, I'll be talking about the effects of early outpatient PMNR exposure on inpatient PMNR rotations in terms of musculoskeletal exams. So a little bit of background, inpatient and outpatient experiences, caring for individuals with disabilities are essential parts of PMNR residency training. There are currently no guidelines directing how inpatient months should be distributed through PMNR residency training curricula, although most programs assign the majority of their inpatient months to the beginning of PMNR training during the PGY-2 year. The primary objective of our study was to determine if early outpatient musculoskeletal medicine exposure during the PGY-2 year increases resident use of musculoskeletal examination skills in the inpatient setting. Our secondary objectives included determining whether residents interested in pursuing a career in musculoskeletal medicine perform more musculoskeletal exams on inpatient rotations than those residents interested in pursuing a different career path, as well as also identifying barriers as to why residents do not perform more frequent musculoskeletal exams on inpatient rotations. Musculoskeletal complaints are very common for our patient population, even in acute inpatient rehabilitation settings, where other needs may be more on the front of attendings and trainees' minds. One study showed 79% of TBI patients who underwent an acute rehabilitation stay reported an MSK complaint within the last 30 days. These patients, compared to the other 21%, reported significantly more pain, lower health status, and less functionality. Another study of 212 spinal cord injury patients found that the most common complaints at all phases of the rehabilitation continuum, including acute rehabilitation, was neurogenic and or musculoskeletal pain. In addition to the clear need for the earlier MSK education, two published surveys of PMNR residents showed the number one topic for residents that they would like to learn more about was musculoskeletal medicine. All these factors were the impetus for our study here. In terms of our methodology, our study was a prospective study where residents completed an eight-question multiple-choice survey at the end of each inpatient rotation over the 2020-2021 academic year. Examination frequency was stratified based on the number of months of prior outpatient musculoskeletal medicine experience, and interquartile range and means were calculated and presented on the poster here. In terms of our results, we had a 95% response rate. Residents who completed zero or one month of outpatient musculoskeletal medicine performed an average of 4.6 and 3.6 MSK exams per month, respectively. Residents who completed two, three, four, and five-plus months averaged 7.2, 7.8, 9, and 6.25 exams, respectively, on each month of their inpatient rotation. In most instances, residents reported doing musculoskeletal exams whenever they were indicated. Lack of time and uncertainty of how to perform an MSK exam on a patient with a disability were cited as the most common responses for not performing more frequent MSK exams on their inpatient rotation. Most responses indicated that residents felt they would likely perform more MSK examinations on their inpatient rotations if they had more MSK experience at this point in their career and their training. So, you know, what we learned from this was that residents appear to perform more MSK examinations on their inpatient rotations after their second outpatient MSK month. Most residents in our program specifically complete two months of outpatient experience dedicated to MSK during their PGY-2 year. We found a significant increase in exams performed when comparing residents who had less than two months of experience versus those who had two or more. Interestingly, we observed a slight dip in exams from zero months of experience to one month of experience, and we believe this is due to residents overestimating the number of exams they're performing before they have had any dedicated outpatient MSK experience and may not realize what entails a complete exam and may not realize the limitations of their knowledge of certain aspects of the exam, such as how to correctly perform certain special tests. We also noted that almost all responses in individuals with three or less months of experience indicated they would perform more exams if they had more experience. Preferred career path in MSK and sports medicine did not seem to lend itself to residents performing more MSK exams, however, which we initially hypothesized. In terms of our limitations for the study, we had a potential recall bias in completing surveys at the end of the resident's inpatient months, as well as our inability to track progress over time for individual residents as we made the responses to the survey anonymous. Future considerations as we plan to use this data to look further into the quality of the exams that are being performed and implementing direct feedback, as well as looking at differences in patient outcomes with length of stay, decreased pain scores, patient satisfaction, et cetera. We also plan to study how this can be implemented throughout physiatry training and if similarly focusing on specific skill sets early in residency can be helpful and applicable to other specialties. Overall, in conclusion, we believe the early outpatient MSK experience during PGY2 year increases resident use of MSK exam skills in the inpatient setting. This supports residents in learning how to provide comprehensive physiatric care to individuals with disability. Early outpatient MSK experience in Pima Residency and a greater focus on teaching MSK exam skills on inpatient populations with disabilities can benefit trainees and positively impact patient care. Thank you. Excellent, thank you. So next up is Dr. Areeb Chander from a resident physician from the University of Michigan who will be presenting on headache during supervised exercise following sports-related concussion. Thank you for the introduction, Dr. Portugal. And so I will be talking about headache during supervised exercise during sports-related concussion. Could we move on to the next slide here? And I would like to also thank my mentors, Dr. Eckner and Dr. Popovich, who are through the Neurosport Department at the University of Michigan. For why we wanted to look at this research study, in terms of some background, the CDC estimates that as many as 3.8 million mild traumatic brain injuries due to sports-related concussion occur annually in the U.S. And with how prevalent these concussions are, along with the fact that headaches are the most common symptom following a mild traumatic brain injury, they're also the most common limiting factor to return to play or to return to work. And despite the prevalence of these concussions and the headaches following concussions, the evolution of post-concussion headache has limited characterization through the recovery period and under impact return to play. And so in terms of our study objectives, I'm going to jump ahead to this next part here. We had two primary objectives. Our aim one objective was to explore factors that were associated with a new and or worsening headache during supervised exercise following a sports-related concussion. So these are athletes that didn't have any headache before and developed one or had some baseline headache that got worse with exercise. And then aim two, we're looking at how these factors, you know, how these changes in headache, along with the other factors are associated with a delayed recovery following sports-related concussion. And we hypothesize that, you know, the presence of a new and or worsening headache during supervised exercise is associated with a slower recovery following sports-related concussion. So for our study, we utilized a retrospective observational chart review methodology. We had a number of patients who sustained a sports-related concussion and were seen at the NeuroSport Clinic. We excluded patients who didn't move on to sports, to supervised exercise, who were cleared at the first visit and those who were seen more than 30 days after their injury. The supervised exercise sessions utilized a consistent approach that included one or more types of aerobic and dynamic exercise where their symptoms were recorded on a two-minute interval. Additionally, also heart rate and rating of perceived exertion were also recorded in two-minute intervals. For aim one, our dependent variable was looking at new or worsening headache during that first supervised exercise and independent variables included a multitude from demographic factors like age and sex, premorbid conditions, concussion history, prior history of depression, ADHD, learning disability history, family history of migraines, headache, was there a loss of consciousness at the time of injury, findings at that first clinic visit such as the SCAT scores, VOMS findings, and cervical exams findings, how long did it take to get to that first supervised exercise, and then the intensity of that exercise in maximal heart rate and RPE. And we utilized a univariate binary logistic regression for aim one and we utilized Benjamini-Hochberg false discovery rate correction due to how many variables we're looking at. For aim two, our dependent variable was concussion recovery, which we measured by days until they were clear to return to play, and independent variables included the presence of a new or worsening headache, which was the dependent variable on aim one, a new headache versus a worsening headache in supervised exercise, the absolute headache rating increase, so did it go from a three to a seven or a three to a four, and then all the independent variables from aim one. And for this, we utilized a backward stepwise multivariate Cox regression analysis. In terms of our patient population, the ages ranged from eight to 34 with a median of about 15 and a half. We had a slight majority of male patients. The race had a predominant Caucasian, about 86%. About half had a prior history of concussion, about half had a prior history of headache and migraine, and about 18% had a prior history of depression slash anxiety or ADHD and learning disability. In terms of the sports these athletes came from, they came from a multitude of different sports, but the largest number came from football, followed by ice hockey, soccer, basketball, et cetera. So we had a nice variety of different sports represented in our patient population here. In terms of our aim one results, I have a table here that details the ones that have a P of less than 0.05, but the ones with asterisks here were found to be statistically significant even after false discovery rate correction. And so these included SCAT symptom score and total symptom severity score, presence of VOMS findings and cervical exams findings at the first clinic visit, and peak heart rate at the first supervised exercise. So for peak heart rate, the higher heart rate you were able to achieve, the less likely you were to have a new or worsening headache, while the other ones, the higher score you achieved, or if you had presence of these findings, the VOMS findings or cervical exams, you were more likely to have the headache during that first supervised exercise. Interestingly, you know, things that you might expect to also be associated, we didn't really find to be statistically significant, such as, you know, prior history of concussion, was there loss of consciousness, history of depression, et cetera. In terms of our aim two results, we first performed a univariate Cox regression analysis and plotted one minus survival plots. And so this one here, I found to be quite interesting. This is, so the y-axis is the proportion that were cleared to return to play. And the x-axis is those who were, or this x-axis is how many days until they cleared the return to play protocol. And so I know it's kind of small, but the blue line on top is if they didn't have a new or worsening headache, and a green line is if they did have a new or worsening headache with that first supervised exercise. And so you can see there's a pretty significant difference between the two groups. And so we took the results of our univariate analysis. We took the variables that had P of less than 0.1 and didn't have overlap with other variables. For example, we didn't include both of the SCAT scores. We only included one of them. And we took those into our stepwise multivariate analysis through which we found four variables that were still found to be statistically significant in terms of having, statistically significant in relation to return to play. And so these included days from concussion to the first supervised exercise. And so the lower number of days meant that they recovered faster. SCAT total symptom severity score, the lower score, recovered faster. A new or worsening headache at that first supervised exercise. So no new or worsening headache recovered faster. And a prior history of concussions. So if they didn't have a prior history of concussions, these athletes also returned, recovered faster. In terms of our study, we did have some limitations that are important to note. We were utilizing observational data and these weren't recorded at consistent post-injury time points. Though we did try to account for this in our aim two multivariate analysis in which we included days from concussion to that first supervised exercise in our model. We additionally did have a relatively small sample size and that our neurosport patient population may not represent the general patient population that undergoes sport-related concussion. Though these may be similar to the patients you would see in clinic. So our significance for aim one included that we were able to determine some factors that were associated with neuroworsening headache. And it's also interesting of the ones that weren't found to be statistically significant. And aim two significance included that development of neuroworsening headache, symptom burden, and prior concussion history were associated with a slower recovery even after accounting for time of that supervised exercise. And hopefully these findings can inform management and prognosis of athletes with sports-related concussion. Thank you. All right, thank you. So next up is Dr. Heather Vincent, Associate Professor at the University of Florida who will be presenting on Psychological Outlook Changes and Impact on Quality of Life Before and After Rehabilitation in Injured Runners Implications for Rehabilitation Programs. All right. Thank you very much. If we could forward to the next slide, please. Thank you so much everyone for attending. We're very excited to share the results of this first part of our study. We have spent the last few years trying to determine how we can improve the medical care of our athletes that come in with rather devastating injuries. And so after a collection of anecdotal evidence, as well as reviewing the published but limited evidence in the literature, runners who present a clinic with either a chronic injury or acute injury experience changes in psychological outlook that compare to those individuals who present an orthopedic trauma base with severe orthopedic injury. So these types of psychological distresses change mood state and also can severely impact quality of life. What remains unclear, however, is the actual qualities of these domains psychologically that are changing in the magnitude and the time course of these various factors. And so during the return to run period, it becomes very important to understand what these patterns actually are so that we can improve the structure of our rehabilitation programs to not just focus on the physical aspects but also help these injured athletes return back to their level of activity at which they're excited to participate in. So the purpose of this study was to quantify changes in the psychological outlook and the injury effects on quality of life at the time of initial diagnosis and presentation to the laboratory to the time point of recovery at which the athletes felt most comfortable with among recreational runners. So this was a prospective observational study initially enrolled 42 people and completed 22 with 20 who dropped out due to a loss of interest in running which related to their psychological outlook or loss to follow-up. These individuals were approximately 36 years of age and about 77 percent female. They ran approximately 35 kilometers a week with a long run distance of approximately 13 to 14 kilometers. We collected at the time of enrollment several measures of psychological outlook as well as quality of life including days of sleep disruption and the impact of pain on physical activities. These were collected at baseline and monthly until the participants self-reported that they were back to the performance that they wanted. We also collected a battery of health-related quality of life surveys and state trait inventory for anxiety, the Tampa scale of kinesiophobia, positive and negative affect schedule to look at changes in mood over time, as well as some self-reported functional measures such as the lower extremity functional scale and the relatively new University of Wisconsin running injury and recovery index. In addition, we also provided for the athletes an opportunity to have a 3D motion analysis at the time of the initial diagnosis to get a starting point of how far back their performance was. So we captured running measurements using 3D motion as well as high-speed film at the beginning and at the time of return back to performance. We use repeated measures analysis of variance co-variant for specific patient factors. If we look at table one, we are presenting here the running injury characteristics, which shows the true spectrum of the type of injuries that we see in the University of Florida running medicine clinic. These injuries were predominantly in the ankle and the foot and in the knee. And all of these were considered to be overuse related, which includes the onset of stress fractures. There were some related to pelvic, hip and thigh, as well as lower leg. And the injury side depended on the individual. Only 13% reported injuries in both sides of the lower extremity. Table one shows the variation in injury sites and table two shows the baseline and follow-up survey responses. And what I want to show is we have consistent and unanimous change across these survey instruments from the time of baseline and injury to the actual follow-up time of recovery, which indicates to us an improvement in the state trait and the state anxiety levels from baseline to follow-up. There was a shift in the PANAS positive to show an improved mood and reduction in the negative portions of the mood profile. The University of Wisconsin running injury index improved significantly, in fact, over double the score. And also other physical function measures such as the LEPs also showed improved function. The fear of re-injury due to pain was significantly reduced with the Tampa scale of kinesiophobia. And we were also delighted to see that the days disrupted by pain nearly vanished at the time of recovery and the days of sleep disrupted by pain were cut by half by time of recovery. In addition, if we look at table three, we see positive changes in how runners adopted their running strategy. So, they were able to improve their running velocity and also make compensatory changes with gains in cadence and reductions in center of gravity vertical displacement. And this was also concurrent with reductions in step length. Interestingly, we did not see any changes with kinetic features associated with injury, which include ground reaction forces and impact loading rate. So, if we put these data together, what do these numbers tell us? First, as practitioners who might be listening and caring for this injured population, injured runners experience quite profound psychological distress that does impact into several domains of life, including quality of days experienced without pain, sleep, as well as mood. And that we need to take this into consideration when we are developing our plans with therapists to structure rehabilitation activities, which could help cope with reduced running volume over time. So, this could include reframing the situation at hand, daily goal setting with each rehabilitation visit, focusing on controllable parts of performance, also focusing on the technical aspects of running when they do run during the return to run phase and less on the volume. And then finally, modifying the view on what actually constitutes running. So, perhaps encouraging runners to adopt interval strategies or changing up volume and intermixing with other non-impact loading activities. Thank you so much for your time. Excellent talk. Thank you. Next up, we have Ms. Amy Height. She is a medical student from the Open University William Beaumont School of Medicine. She'll be presenting on reporting of concussion symptoms in high school age athletes. Hi everyone. Thank you so much for having me. Like Dr. Portugal said, I am Amy Height. I'm from Oakland University and I will be presenting on concussion symptoms. So, as a high school and collegiate athlete myself, I saw a lot of my best friends and teammates fall victim to sustaining concussions. While some of my teammates were able to return to play quite quickly, I saw others delay telling our athletic trainer about their symptoms, return to play too quickly, and others whose concussions seemed to last for months. 8.9% of all high school athletic injuries are concussions. So, concussions continue to remain a concern due to long-term neuropsychological effects such as attention deficits and poor academic performance. Current literature focuses on diagnosed concussion and lacks studies that focus on isolated concussion symptoms. So, my study aimed to ascertain the prevalence of concussion symptoms as well as the pervasiveness of continuing to play while experiencing symptoms and not telling a supervising adult while experiencing these symptoms. So, this study was a retrospective survey of Oakland University students which inquired about their experiences playing a high school sport. In order to meet the inclusion criteria, participants were required to be currently enrolled at Oakland University and to have played a sport in high school. This survey asked students if they had experienced any of the five major measures of concussion symptomology, dizziness, headache, confusion, nausea, and blackouts while playing a sport. They then were asked if they reported any of these symptoms or if they continue to play while experiencing symptoms. Of the 433 total participants, 299 participants reported experiencing one or more concussion symptoms. In order of most to least frequent, students reported experiencing headaches, then dizziness, then nausea, then confusion, then blackouts. Of these symptoms, 37% were not reporting to a supervising adult and 76% of the time students continued to play while they were experiencing symptoms. As the figure on the top of the second or the third section shows here, the rates of continuing to play were quite high for symptoms like headache, dizziness, and nausea. What creates more concern is the number of students that are continuing to play and not reporting symptoms like confusion and blackouts, which are fairly specific for concussions. This study demonstrates an overt lack of reporting of concussion symptoms as well as a severe problem with student athletes continuing to compete while experiencing concussion symptoms. So there are a few limitations of our study. The original intent of our study was to survey actual current high school students, but of course with needing parental permission and needing parental signatures, that wasn't really feasible for us to be able to go to high schools and get all these things done while still getting the number of participants we wanted to have. So we determined that we could get a larger pool of participants, So to conclude, with increasing education about concussion for high school athletes, there should be increasing awareness. However, our study indicates that high school students and supervising adults underestimate that an isolated symptom may be indicating a concussion. Although the cause of the under-reporting of concussion symptoms is not known, may be indicating a concussion. Although the cause of the under-reporting of concussion symptoms and continuation of play while experiencing symptoms is not well delineated by our study, the likelihood is that it's caused by a combination of athletes failing to recognize their concussion symptoms, failing to report their symptoms, and being allowed to play while experiencing symptoms. The under-reporting of concussion symptoms indicates the need for multifaceted education programs for high school student-athletes and supervising adults on basic concussion knowledge and concussion symptom recognition. Thank you. Thank you, Dr. Portugal. As Dr. Portugal alerted to, I will be presenting on early skeletal muscle changes in patients with spinal cord injury. Next slide, please. Next slide, please. So as an introduction, the image on the top right shows an MRI of a cross-section of the thigh muscles of an able body male. This is in contrast to the picture below of a patient with chronic SCI, where an MRI cross-section shows reduced cross-sectional area of muscles, which are highly atrophied. So we know that individuals with complete SCI experience chronic muscle loss below the level of SCI, and this is important because muscle loss is associated with decreased strength and gait ability. This finding of muscle loss has been well reported in patients with chronic SCI many years after the injury. However, we do not know if these muscle changes already start after the acute injury, especially when these patients are undergoing rehabilitation. Now, this is relevant to rehab providers because being able to know muscle changes can help us understand physiological adaptations in response to exercise-based rehab. The standard method of measuring muscle has always been through the use of MRI, which has been a gold standard for many years. Although it's often used in the research setting, it may not be feasible in the clinical setting due to various reasons. This includes cost, transportation, equipment requirements, and the fact that many patients would have had recent surgical instrumentation after the SCI, which can be incompatible with MRI. On the other hand, ultrasound of the muscle has been proven to be a relatively inexpensive, quicker, and safer technology with comparative reliability, and most importantly, can be used at the bedside. Therefore, our study aim was to investigate ultrasound changes in muscle thickness and echo intensity of the lower limbs over four weeks in patients with complete, auto-complete spinal cord injury. Next slide, please. For materials and methods, this was a prospective observational study of 20 patients. We recruited auto-complete patients with the majority classified as Asia B. Most of these patients had either falls or motor vehicle accidents, and the average age of our study population was 60 years old. We chose to evaluate the rectus femoris and the medial gastrocnemius, as these are primary muscles involved in anti-gravity movement. Muscle measurements were performed within two weeks of SCI and four weeks after initial measurement. So the picture on the right illustrates our measurement techniques. We used a linear array transducer. The top right-hand picture illustrates our measurement of the medial gastrocnemius muscle, where we derive the muscle thickness, which reflects muscle cross-sectional area. Below, the images show how we derive the muscle echo intensity by analyzing specific regions. The image on the bottom left shows normal echo intensity of the muscle, whereas the image on the bottom right shows increased echo intensity of the muscle, which reflects increased fibrosis and fatty infiltration of the muscle. Next slide, please. Our main findings showed changes in the rectus femoris muscle. Specifically, we found that there was a reduction of nearly 20% in the muscle thickness over four weeks. We also found an increase in the echo intensity of the muscle over four weeks. However, we did not find significant difference for the medial gastrocnemius muscle. Therefore, we conclude that in patients with motor complete spinal cord injury, there are muscle changes in the rectus femoris, which are proven on ultrasound, even during the first few weeks after acute rehabilitation. We also conclude that the measures of muscle mass and quality can be useful to determine muscle response, which may guide rehab interventions. We note, though, that these are preliminary findings due to the small sample size of the study. Additionally, further larger studies are required to determine if these findings are applicable to patients with incomplete SCI. You also need to study if there are potentially modifiable risk factors, which can attenuate this acute deterioration in muscle loss. I thank you all for your time. I can step in and introduce our next speaker. It is Dr. Agala Hussain from Albert Einstein Alexandria University presenting on the incidence of diabetes mellitus type 2 and prediabetes among shoulder impingement syndrome patients and related modifying factors epidemiological study. Yes, thank you for having me. I'm assistant professor at Albert Einstein College of Medicine, New York, as well as professor in Alexandria University, Egypt. This study is done in the United States. Thank you so much, Dr. Portugal, for having me. The title of the study is the incidence of diabetes mellitus type 2 and prediabetes among shoulder impingement syndrome patients and related modifying factors. It's an epidemiological study. Next slide, please. As an introduction, the diabetes mellitus is well known to affect the musculoskeletal system by multiple complications secondary to the affection of the connective tissue related to the diabetes. And one of the complications in the shoulder is shoulder impingement syndrome. It is estimated that the shoulder impingement syndrome occurs three times more in diabetic patients rather than in non-diabetic. So, the aim of the study was to measure the incidence of diabetes mellitus among patients with shoulder impingement syndrome or rotator cuff injury or sorry, rotator cuff tendinopathy and the factors that can modify this disease. This was a prospective outpatient study. 412 patients presented with unilateral or bilateral shoulder pain, suspecting of shoulder impingement syndrome or rotator cuff tendinopathy were included in the study and the exclusion criteria for those having manifestations suggesting of cervical radiculopathy or shoulder trauma history. As far as for the intervention, each of the included patient was subjected to a full demographic data collection, including body mass index, occupation, as well as sex and detailed medical history, including the history of diabetes mellitus, shoulder exam, including impingement, provocative tests, mainly the Hocken and Neer and neck exam, including full neurological examination, including also spurling test and the last was full neurological examination. Next slide, please. As for the main outcome measures, there was a measurement for the diabetes through the glycosylated hemoglobin or gluco, hemoglobin gluco A1C and the liver and kidney function test as well as shoulder MRI if possible. And the results that the mean age was 59 year old and all the patient were right-handed and most of them was, majority of them were manual worker actually. The female was 37, the male was 37% while the female was 62%. There was no significant relationship between shoulder impingement and the sex, but there was significant relationship between the shoulder impingement and the body mass index as well as the age. As regarding the incidence among the diabetic, the hemoglobin A1C with the result of less than 5.5 showed the lowest number of patients and there was no significant relation and there was a rising incidence of shoulder impingement among the rising categories of the hemoglobin A1C was the highest above seven. There are still high incidence or significant incidence among the pre-diabetic status or which is the hemoglobin A1C basically from 5.7 up to six in the pre-diabetes. They're still significantly affected as well as the bilaterality was very high and significant among patients with hemoglobin A1C above seven. Can you have the next slide please? And in conclusion, we concluded that there is a high incidence of diabetes mellitus as well as pre-diabetes among shoulder impingement syndrome patients and the level of hemoglobin A1C significantly proportional to the incident as well as the bilaterality because we found significant bilateral shoulder impingement syndrome in patients with hemoglobin A1C above seven. And this suggests that it is part of the musculoskeletal complication of diabetes that can evidently occur with pre-diabetes status and the body mass index and the sex do not affect the, actually the body mass index affect but the sex do not affect the incidence of the shoulder impingement syndrome. The explanation that was suggested in the literature that the shoulder impingement syndrome as a complication of diabetes, it happened due to the glycosylation of the connective tissue with accumulation of the end product of, end glycation product as well as accumulation of the calcium hydroxyapatite among the tendons or mainly the supraspinatus tendons. And the secondary effect will be the changes in the microvasculature as well as the nerves. So those was a suggestive mechanism in the literature why there is affection of high incidence of shoulder related problem mainly the impingement syndrome among diabetic. And thank you for having me. Your presentations, thank you everyone. So hopefully my audio has been fixed. Please let me know if not but if you have any questions feel free to enter it into the chat or you can raise your hand. So question from Dr. Hearn. So this question is for Dr. Tay. Great use of ultrasound as accessible tests to learn more about how atrophy evolves in this group. I'm curious, any hypothesis on why rectus femoris is more involved than gastroc? Could it be possibly related to more oxidative versus glycolytic nature of these fibers? Thank you for a great question. Actually there's not much literature published on why these two muscles have changes. The rectus femoris and gastrocnemius are normally chosen because these are prime muscles involved in gait. One possibility could be that the rectus femoris muscle is larger than the gastrocnemius muscle and therefore the changes are more acute and more significant compared to the gastrocnemius muscle. Otherwise, it's just hypothesis. I think we really need to do more research to find out what's the reason. Thanks. Dr. Hussain, I just had a question. Oh, I'll jump in and then actually let's go to Dr. Guilford's question. Or could it be related to gastroc is more likely to have spasticity preserving the muscle? Your thoughts on that, Dr. Tay. Yeah, so yeah, that's a great question. Actually we did look at the MAS level of each of the muscles, but we were unable to, when we did the adjustments, we did not find that the MAS actually affected the changes in terms of echo intensity or thickness. But that's a great point because there's a common thought that spasticity will actually preserve the muscle thickness as well as the quality of the muscles, but we did not find such a correlation in our study. So a question or more of a comment, and I'm just going to share from Dr. Hearn. Dr. Capriano, I'm excited to see this work as musculoskeletal exam skills are so foundational in our field, and you picked an outcome here that actually measures application of skills. For me as a PD, this adds value. Would be interesting to look further to see any impact by graduation, presumably if the number of MSK months in the residency is held constant. Early MSK exposure could mean less MSK exposure later. Would be interesting to explore impact here on skill acquisition by graduation. Yeah, and to comment on that, it's thought that three months of outpatient MSK exposure is when you can gain mastery on that. And what we found was that it kind of plateaus after you're getting about three or four months where it kind of levels off. So it seems that that is kind of where that cutoff, two or three months, seems to be where people are doing the majority of their exams, but then after that, it kind of levels off and there isn't as much gain in terms of what they're doing on inpatient. To further add to that, I was just curious in terms of, I was just looking into the poster regarding indications for maybe a factor, right, in terms of whether or not to do a musculoskeletal exam, if it's appropriate or not. What are your thoughts on that? It's like almost, do you find that the residents were more like actively pursuing opportunities to do the exam, or a lot of the musculoskeletal complaints were being triaged to another service? Yeah, I think what we want to look into further is now the quality of the exams, and like you indicated, like the indications if the exams were necessary, and then potentially the outcomes. So I think all three of those could answer that question. If it's being done with the attending in the room, which majority of the time it was on rounds with the attending, so they could comment on the appropriateness of the exam, most likely, and the quality, and then hopefully down the line, we can look at these people who are getting more of the exams done, does that lead to less pain scores, or earlier discharge, or more involvement in their inpatient therapy, and things like that. Dr. Hussain, I just had a question, if you were looking at the duration of, since, I guess, onset of diabetes as a potential factor. For the duration, the target actually for those actually, even with pre-diabetes status, which were not diagnosed as diabetes, most of the patient attending the clinic, usually they even say that, oh, I'm not diabetic. So, and when you do the hemoglobin A1c, you find that they are in the borderline status, and usually there is a big difference between our consideration as diabetic versus the primary care physician. So the primary care physician, when the hemoglobin A1c is six, they tell them, well, it's okay, you are okay. And we found that there is a very high incidence of the shoulder impingement syndrome among those categories. So basically, we cannot calculate exactly, because we are the first people to tell them, because usually the primary care doctor do not pay attention to this and say, okay, that's fine, you don't need medication for this. So the usual response to the patient, surprisingly, is that, no, I'm not diabetic. And you find a shoulder impingement syndrome, and then when you go retrograde to the hemoglobin A1c, you find that it's in the pre-diabetes categories, which are being modified now by the American Association of Diabetes. And now, and then you will tell the patient, okay, no, I think you are pre-diabetes. And in my opinion, to tell the patient you are pre-diabetic, it's better to tell the patient you are diabetic to make him much more worry about himself, rather than to assure him and tell him you are pre-diabetic. That's my opinion. But so I couldn't calculate exactly, except for those who was well-defined as diabetes, but it was not in the statistics. But for those very big amount of patients who are running in the pre-diabetic status, which we found that there is a high incidence among them significant, we cannot calculate exactly when they are, because we usually are the first one to tell them in the clinic. That's surprising. But for the other of those diagnosed, I didn't include it actually in the statistics for the existing duration. In my opinion, personally, I believe it will be worsened by the duration. I'm not sure what you agree with this, Dr. Portugal, or no. I'm going to be cautious with that one. But clearly your work shows the need to express and educate our patients that glucose control is most important, regardless of when they were diagnosed with diabetes, but clearly higher the A1C, the more likely they're going to develop these types of symptoms, right? Great, thank you for the question. So just to move into the chat, should be recognized that based on this type of data, the relationship between impingement and diabetes is a correlation and not necessarily causation. Need more investigation to evaluate as causation. Well, this is actually not something new. This has been established for many years that the diabetes mellitus itself make changes in the connective tissue. So it's not something that we discovered that's well-established, that it is evidently that microvascular changes happen as well as changes in the connective tissue by the accumulation of the glycation end product, advanced glycation end product, as well as hydroxyapatite, which they found microscopically actually deposited in the supraspinatus tendon and mainly the supraspinatus tendon, but all the rotator cuff tendinopathy in diabetes, they related to this factor. So this is actually well-documented. So if we find high incidence of diabetes, in my opinion, it's likely to be cause-effect relationship rather than coincident. A comment from Dr. Hearn to Dr. Hussain. It seems to be a theme that our patients may be susceptible to impairments that impact function often before we are detecting a threshold for systemic disease. Great window for us as physiatrists to be able to recognize patterns and treat patients accordingly, even if we are still working on evolving the science. I'm totally agree with this. That's a very nice comment. Thank you for the comment. Dr. Chater, it's more of a comment than a question. I was just actually very surprised that prior history of concussion, loss of consciousness, severity of concussion were not as much of a factor in terms of worsening symptoms. Yeah, no, I agree. That was one of the more interesting findings of our research as well, that prior history of concussion, loss of consciousness, et cetera, it wasn't really correlated with, did these patients have a new or worsening headache? And so, I don't know what to make of that exactly. Is it we didn't have enough patients or is it just that maybe we are overlooking other factors that are more associated, more than the severity of the concussion itself? And I guess too, one other thing is we only mainly looked at headaches. We didn't really look at dizziness. We didn't look at neck pain. We didn't look at other symptoms that these patients may have been experiencing. So it's possible that they had other symptoms that also limit them from getting back to sports, but headaches itself, these weren't linked, at least in our study. It's helpful information to how to educate the patients what to expect regarding these symptoms. And in the chat, yes, connect, so now this is going back to Dr. Hussain. Yes, connective tissue effects occur, but impingement is most certainly multifactorial, and it cannot be stated that every patient with diabetes will always have impingement. Agree, of course. That's why when we say the modifying factors, we detected a significant relation with the body mass index, as well as the age. And almost all those patients included in the study was manual worker. So I totally agree that there is a modifying factors for this, not all the diabetic will get impingement because that's why when we add it to the title, the modifying factors, definitely there is a modifying factors that can exaggerate the effect of diabetes. Thank you for the comment. So excellent session, everyone. If there are no further comments, we're going to, or questions, I think we're gonna wrap this one up.

Musculoskeletal Sports Medicine

outpatient musculoskeletal exposure

sports-related concussion

rehabilitation in injured runners

concussion symptoms

skeletal muscle changes

shoulder impingement syndrome

patient care