I'll be the moderator today for session 1912 Research Spotlight Musculoskeletal and Sports Medicine. Just a little housekeeping, we'll be introducing the speakers one by one as they come up for their presentations, and we'll take questions only at the end when everybody's finished speaking. That'll be available by raising your hand or by chat box. These presentations represent the best of the best for musculoskeletal and sports medicine, chosen out of over 700 submissions and peer-reviewed by other academy members. We'll start off today with Anuj Bharate from Baylor College of Medicine. He is a fourth-year medical student, and he will discuss a comprehensive characterization of leukocyte-rich PRP, a controlled laboratory study. Hi, everyone. Thank you for the introduction. Before I get started, I just want to thank my mentor, Dr. Pratap Jayaram, for all his help and guidance with this project, and also Dr. Brendan Lee's lab for funding this project. We're also excited to share that this project has been accepted for publication at the Journal of Arthroscopy, Sports Medicine, and Rehabilitation. Next slide, and I will get started. All right, so the background. Platelet-rich plasma is a commonly utilized regenerative therapy for many musculoskeletal applications. It is an autologous peripheral product that is made by centrifuging and concentrating platelets. Currently, there's a lack of comprehensive descriptive profiles of PRP, especially for leukocyte-rich PRP, with respect to the leukocyte subtype compositions. So as such, it is possible that patients may have varying responses to these products based on their individual biologic profiles. So the purpose of this study for us was to comprehensively characterize leukocyte-rich PRP, or LRPRP, and compare it to whole blood by quantitatively assessing platelet and white blood cell subtype concentrations in each. In this study, we used blood samples from 12 healthy men, and we did this to characterize PRP in a healthy and homogeneous population, free of any confounding variables. So as seen in the figure on our left, PRP had about a seven times higher concentration of platelets compared to whole blood. Next slide, please. All right, for the white blood cell subtype comparison, what we found was that in whole blood, neutrophils were the predominant white blood cell type. But in LRPRP, lymphocytes were the predominant white blood cell type. So this is interesting because in most literature, we characterize neutrophils, and even in some of the classification systems, however, lymphocytes tend not to be characterized, even though they're the most predominant white blood cell subtype in PRP. So again, as I mentioned before, there was a seven-fold increase in platelet concentrations going from whole blood to LRPRP. And when comparing white blood cell subtype concentrations in whole blood and LRPRP, we found significant differences between all the subtypes, except for the eosinophils. And we have a table for this in the next slide, which I'll get to in a second. So in whole blood, the mean cumulative percentage of granulocytes was 60%, and agranulocytes was 40%. Whereas in LRPRP, the mean cumulative percentage of granulocytes was 23%, and agranulocytes was 77%. Granulocytes included neutrophils, eosinophils, and basophils, while agranulocytes included lymphocytes, monocytes, and large unstained cells. And the figure on the left shows a pie chart of these breakdowns, again showing that neutrophils are the predominant in whole blood and lymphocytes in LRPRP. Next slide. Oh, sorry. Can you go back to the discussion, please? Yeah. The discussion. There we go. So to wrap everything up, in this study, we were able to delineate different white blood cell subtypes that are found in LRPRP, in addition to neutrophils and lymphocytes. We found that all cell types, except eosinophils, had higher concentrations in LRPRP, and this can be seen on the table on the left. When comparing whole blood and LRPRP, we had a significantly lower percentage of granulocytes and significantly higher percentage of agranulocytes, demonstrating again that LRPRP is predominantly lymphocyte-rich with notable other concentrations. So these findings are important because white blood cell subtypes are not routinely reported in literature. Now, without data to compare patient outcomes and cell concentrations, it's difficult to delineate which of these white blood cells participate in modulating some of the dysregulated processes in musculoskeletal disease. Now, if this could be precisely determined, it's possible that in the future, PRP products could be custom-made for the injury that we are trying to treat. For instance, tendons versus muscle or skin versus dentition, things like that. And so finally, one contributing effort that could be made in the future to bridge this gap and bring us closer to this goal will be to comprehensively quantify all white blood cell subtypes in clinical trials moving forward. Thank you so much for listening to my talk today. If you have any questions, I'll be happy to answer them at the end of our section. Really good job, Anuj. Really, really good job. Thanks. Thanks for presenting that. Our next speaker is David Bacall. He is a fourth-year resident at Stanford University program, and he's currently applying for sports medicine fellowships. He's going to give a discussion about does a team's average acute to chronic workload ratio correlate with injury risk, a study performed in a Division I NCAA men's soccer team. Dr. Bacall. Thank you, Dr. Ellen. Go to the next slide and one more. Great. So soccer fans over the last five years or so probably noticed that players, both professional and now collegiate, wear these training vests. They started off more as a way to track performance, but in the last five years or so, they've been used as a tool to track injury risk. So specifically, the acute chronic workload ratio allows clinicians to compare an individual and the team's training load during a recent period, the acute period in relation to a chronic period. From this prior research, we know that specifically elevations in the acute chronic workload ratio correlate with injury in multiple sports, including soccer, rugby, and Australian rules football. However, in these team environments, using this data from 25 different players who are all practicing together, trying to tailor training sessions, each player's ratio has been found to be challenging. So we aim to establish the more feasible method of utilizing this data for injury prevention in team sports. Please click one more bullet point to see whether changes in the team's average acute chronic workload correlate with injury throughout the competitive NCAA men's soccer season. Please click. So how did we do this? So we had five workload variables that we were measuring. We measured total distance, high speed distance, acceleration, player load, and average velocity. Moving your attention to the right, I know it's a busy slide, and unfortunately you guys can't see my mouse, but the acute period was three days. So for example, so you can look at the orange squares at the bottom. So if day zero was, you know, today, we're trying to calculate someone's acute ratio. It includes the previous three days, whereas the chronic ratio includes the previous four weeks. So calculating the acute chronic workload ratio, we're looking at the average daily, for example, for distance, the average daily distance over those three days divided by the average daily distance over the last month. If those two values are equal, your acute chronic workload ratio is equal to one, whereas if the acute period is more than the chronic period, then your ratio is higher than one. Next slide, please. Busy slide. I'm sorry. I thought I could control animations on this. If we please click. So we're comparing sessions where somebody got injured versus sessions where nobody got injured to kind of compare the workload between those two different types of sessions. So please click. So starting with the acute workload. So click twice. So looking at total distance. So sessions with injury, the team averaged about 15 kilometers versus sessions without injury. The team averaged about 12 kilometers. Main point for this is that sessions with injury, the acute workload over those three days was higher than sessions without injury. Please click twice. So looking at chronic workload. Again, this is the last month. Click twice, please. So the total distance, we saw the opposite trend here. So sessions with injury, the total distance was lower than sessions without injury. The same held true for the other workload variables. The thought behind this perhaps, and again, I'll get to this a little bit more towards the end, but over that chronic period, if you are not getting enough total distance, you are more prone to injury during the acute period because your body is less likely to handle those spikes in workload. So now looking at the acute chronic workload ratio, please click twice and just leave it here. So looking at total distance, and again, a ratio of 1.0 means that the workload in the acute period equals the workload in the chronic period. So we saw that sessions with injury, looking at distance, the acute chronic workload ratio was about 1.4 versus sessions without injury. It was about 1.2. The difference was statistically significant, and the same held true kind of for the other workload variables. And again, the thought behind this is that sessions with injury, there's something where the team was working more during those three days than they had in the past month, and that causes people to be more prone to get injured. Please click twice. So again, we're comparing sessions with injury to sessions without injury, and this included both games and training sessions, but we know that players were more likely to run more and more likely to get injured in games compared to trainings. So we wanted to create a final multivariable model that accounted for whether we were analyzing a game or a training session. So please click. So we created a final model where we looked at the odds ratio of injury, where we're controlling for game versus training. The two variables that really were significantly different were having an acute chronic workload ratio for accelerations greater than 1.4, which is kind of a agreed upon value for a very high acute chronic workload ratio. So when that ratio got above 1.4, the risk of injury was four times greater. And then the second one was having a low chronic total distance. So when the team's total distance over that 28 day chronic period was one standard deviation below their mean, the risk of injury was seven times greater. So we can go to the next slide and I'll kind of explain the findings a bit more. Perfect. So, um, injury risk was greater. We had two main points. One was when the team's total accumulated distance over the chronic period was one standard deviation below their baseline. In this case, you know, with our team specifically, when they had run an average of less than 81.2 kilometers in that chronic period, their risk of injury was over seven times greater. And this is correlating with other studies that could look at this on the individual level, that there's something protective about having run a lot during the chronic period. It gives your body kind of the tools to mitigate, uh, injury risk, you know, when you have acute spikes in your workload, whereas if you have not, you know, run a certain amount during that chronic period, you're more likely to get injured. So that was one of the points that we saw. The other one was looking at that acute chronic workload ratio for acceleration. We saw that when it was elevated over 1.4, the risk of injury was significantly higher. This also correlates with, um, findings that have been seen in English Premier League soccer players, specifically looking at accelerations and this ratio. Um, you know, when you're accelerating more during those three days than you have built up in the last month, you're more likely to get injured. Um, but again, this is the first time this has ever been done on the whole team level. Um, so the overarching point though, is that future research that looks at multiple teams over multiple seasons is going to give us an information more about the generalizability of these findings and, uh, you know, the feasibility of doing an interventional study, um, using this data to try and lower injury risk. Thanks Dr. Bacall, really, really well done. Appreciate the, uh, the information that was very well done. Our next speaker, uh, comes from the other side of the country. Uh, she is Jiaqing Chen. Dr. Chen is a PGY-4 at the Spalding, uh, hospital, a Harvard medical school affiliate, and she will be performing a pain medicine, uh, sorry, you know, pain medicine fellowship next year at, I believe, at UC Davis. Dr. Chen. Thank you. Thank you to AAPMR for having us today. Um, it is my pleasure to present our research study on behalf of my research collaborators. Next slide, please. As you know, the COVID-19 pandemic has affected us all in so many ways. For musculoskeletal ultrasound education in PMR, the restriction of in-person large group teaching has especially challenged us to be creative. Many are trying to incorporate virtual teaching platforms into the traditional MSK ultrasound curriculum. As this is, uh, as this is a new way of teaching musculoskeletal ultrasound in PMR, we have decided to study the feasibility and potential efficacy of virtual teaching platform on our own residency program. Specifically, our objective was to evaluate the feasibility of using virtual teaching and resident-led small groups on residents' confidence and knowledge retention in performing MSK ultrasound. To do this, we conducted a prospective study of 21 PMR residents at one single academic center. The residents received a series of voluntary surveys to assess their confidence and knowledge scores over the 2020 to 2021 academic year. Out of all the joint workshops, the knee and wrist workshops were specifically chosen based on the availability of the equipment needed at the time to enable the virtual teaching platform. During these two workshops, 10 residents were assigned to an in-person MSK ultrasound demonstration by our sports medicine faculty, and the other 11 were assigned to a real-time virtual demonstration over Zoom. The same residents stayed in the same teaching group throughout. Figure 1a and 1b on the left side of this slide are showing our virtual setup. We used a video capture device to connect the ultrasound machine to the computer, and the ultrasound video live stream was displayed using the 4k utility capture software through Zoom. The final virtual output is demonstrated by figure 1c in the left lower corner on this slide, showing the ultrasound pool placement as well as the ultrasound video stream simultaneously. During this, during and after each workshop, six senior residents who serve as ultrasound trainers were also available to offer in-person teaching small groups of three residents. Both the virtual and in-person teaching groups were expected to receive the same amount of small group teaching for at least one hour every one and a half months. Next slide please. So we have two primary outcome measures. First, the residents confidence scores measuring five-point linkage scale were obtained before and after each workshop. Second, residents' knowledge change and knowledge retention for risk MSK ultrasound were also assessed with a six question quiz at pre-workshop, within two weeks post-workshop, and at two months time. Based on resident feedback, the need knowledge was not tested to reduce survey fatigue. Statistically, the pre- and post-workshop confidence scores within each group were compared using paired t-tests. Between group comparisons were performed using unpaired t-tests. For our results, we found that there was no significant difference in the baseline confidence scores between the two groups at the start. In the top left figure, we see that the y-axis is the median confidence score and the x-axis is the time from baseline date to each joint workshop date. The red triangle represents virtual group and the blue axis represents in-person group. We found that after the knee joint workshop, both the virtual and the in-person teaching groups significantly increased their confidence in performing a skilled skeletal ultrasound. The same result is also true for the RIS workshop as shown in the middle figure. Interestingly, the amount of increase in confidence was not significantly different between the two groups for either workshop. Secondly, the result of the RIS test scores is shown on the lowest left figure, with test score in percentages displayed on the y-axis and the number of weeks between tests on the x-axis. The resident's mean knowledge score also increased over time for both virtual and non-virtual groups without significant difference between the two groups. The mean knowledge score was also retained at two months for both workshops, sorry, the RIS workshop. Next slide, please. In summary, it is feasible to teach MSK ultrasound through a combination of virtual platform and resident-led small groups, and this hybrid teaching model may potentially provide significant improvement in confidence as well as higher knowledge skills in MSK ultrasound. Our experiences show that in order to implement an effective virtual teaching platform, it is important to optimize several technical factors. Lastly, we recognize that our study design is limited by small sample size at a single institution. Future multi-site study will be needed to further evaluate the efficacy of virtual teaching approach in MSK ultrasound education. We hope that our study can serve as an example for other residency programs to incorporate virtual teaching technology into their curriculum. This is the end of my presentation. I want to thank all the residents of my program and my research collaborators. To you all, thank you so much for your attention and interest. Happy to answer any questions at the end of this session. Thank you. Thank you, Dr. Chen. Really, really well done. That's just really fantastic. Our next presenter is Ana Ortiz-Santiago. She is a pediatric fellow at the Shirley Ryan Ability Lab in Chicago. Her discussion is on Puerto Rican-Spanish cross-cultural adaptation, sorry, and measurement properties of the anterior cruciate ligament returned to sport after injury scale. Hi, thank you. Thank you so much. Good morning, everyone. As it was mentioned earlier, I will be talking about my research project in residency that was performed alongside Dr. Rios, Dr. Echavarria, Dr. William Micheo, and Dr. Fernando Sepulveda. The anterior cruciate ligament injury is one of the most studied severe injuries in physical medicine. Approximately 45% of all athletes are unable to return to play at their pre-injury performance level, highlighting the need to consider various interconnected aspects in the recovery process. The patient-athlete psychological readiness is a crucial factor in successful reconstruction and rehabilitation outcome. The ACL return to sport after injury, or ACLRSI scale for short, was developed as a tool to measure psychological readiness to return to sport after ACL injury and reconstruction. It is a unidimensional 12-item scale that measures three types of responses associated with the resumption of sport following athletic injury, including emotions, confidence in performance, and risk appraisal. And the primary purpose of this study was to perform a preliminary cross-cultural adaptation and validation of the ACLRSI Spanish scale into Puerto Rican Spanish, which is a culturally diverse population. Eleven amateur or semi-professional athletes participating in competitive sports pre-injury who underwent their first ACL reconstruction were recruited during routine visits by the sports medicine clinics within our residency program. The inclusion criteria were as follows, age between 16 to 40 years, pre-injury sport participation in their sport for at least three times a week, the ability to read and write in Spanish, and having experienced their first ACL injury status post-surgical intervention. Exclusion criteria included patients with partial or contralateral ACL tears, tears associated with other ligamentous injuries requiring surgical treatment, and grade three or four chondral damage or post-operative complications. The ACLRSI Spanish scale by Sala Barat was adapted into Puerto Rican Spanish with the original Spanish author's permission. To adopt this version, the objectives of the study, the term football was replaced by sport, and the original Spanish and Puerto Rican adopted questionnaires were evaluated by two Puerto Rican Spanish-speaking professional athletes living in Spain and determined there was no language difficulty in understanding the adaptation. The participants of the study also referred no difficulty in understanding the adaptations, and the final version was approved by the authors. The current pilot study was conducted with participants answering the ACLRSI Puerto Rican Spanish questionnaire on two separate occasions, on average three to 12 weeks apart. There were 11 participants in the pilot study, and table one depicts the demographic and clinical characteristics of the participants. On average, they were 20.5 years of age, with the highest number of patients being basketball players. Mechanism of injury for most of the patients was non-contact in etiology with pivot injuries, and only 54 percent reported having returned to their pre-injury level of performance. In table two, we have Cronbach's alpha of 0.9 was obtained for the 11 items of the adapted ACLRSI Puerto Rican scale. The corrected item total correlation ranged from 0.167 to 0.89, and the instrument's alpha increased to greater than 0.911 if two of the 12 items, question six and question seven, specific for fear and insecurity, were removed. Meanwhile, the test correlation coefficient of temporal stability was high with 0.9. In table three, we can see the rotated factor structure of the ACLRSI Puerto Rican Spanish version. The items present factorial loads greater than 0.5 in their corresponding factors. The Kaiser criterion of eigenvalues greater than one showed a factorial structure configured by three significant factors, which overall were able to explain 83.9 percent of the variance. The factor one of the three explains 53.5 percent of the variance and has been labeled as participants having confidence in their performance. Factor two is labeled as fear and explains 19.2 percent of the variance and has the highest factorial loads in items two and six. Then factor three is labeled as insecurity and performance and explains 11.2 percent of the variance. Conclusions of this study is that even though it is a small sample size and the data collected at different times and circumstances during the participant's rehab phases and the fact that the scale's discriminatory capacity cannot be accurately assessed, this study still provides preliminary evidence that the ACLRSI Puerto Rican Spanish questionnaire could be able to represent a comparable and reliable instrument with satisfactory psychometric properties like those obtained by the authors in the original Spanish version and adaptations to other languages like in French, German, or English. The questionnaire had good internal consistency and reliability with a convex alpha of 0.9 comparable to previously validated instruments as I mentioned before and its exploratory factor analysis showed a factorial structure that configured of three factors which overall represented 83 percent of the variance. It is well known by the authors and myself that further scale adaptation may address cultural variations within the Spanish language facilitating the accurate assessment of the psychological and emotional factors that may surround ACL rehabilitation in Puerto Rican athletes and we are hoping that we could continue with this study with a greater number of subjects so that we can have more powerful data and results. Thank you and I'll be able to answer questions in the end. Excellent job Dr. Ortiz-Santiago, really well done. Thank you. Our next presenter is Dr. Malia Cali. She is at the University of Colorado School of Medicine. She's a PGY-4 there, also applying for a sports medicine fellowship actively. She will be discussing short-term effects of triamcinolone acetonide injection on serum testosterone, luteinizing hormone, and follicle stimulating hormone levels in male veterans. It's a prospective pilot study. Dr. Cali. Thank you Dr. Ellen for the introduction and thanks to all of the people who worked on this study with me, particularly Dr. Sohi who was my mentor for this study. So intra-articular corticosteroid injections have been a common intervention in the treatment of intra-articular shoulder pathology since they were first introduced around 1951 by Hollander, but unlike the well-established side effects of systemic corticosteroids including the inhaled, the intravenous, and the oral forms, little is known about the effect of locally injected corticosteroids on the HPG axis. So our study, the aim of our study was to determine the short-term effects of a locally injected glenohumeral corticosteroid injection on serum testosterone, LH, and FSH levels, particularly in a cohort of male veterans. We also aimed to assess patient-reported outcomes of shoulder pain and disability using the SPOTI questionnaire, which is the shoulder pain and disability index, and then we also looked at patient-reported outcomes of androgen deficiency using the Q-ADAM questionnaire, which stands for the Quantitative Androgen Deficiency in the Aging Male Questionnaire, which is much harder to say. So in the design of our study, it was a prospective pilot study, and it included 31 male veterans ages 21 to 70. Exclusion criteria for our study included any steroid injection or persistent use of inhaled topical or oral form of steroid in the three months leading up to the injection, as well as any use of exogenous testosterone or drugs known to affect the HPG axis, and then the last exclusion criteria was a hemoglobin A1c greater than nine. So each participant in our study received an ultrasound-guided glenohumeral joint injection, including a mixture of 40 milligrams of triamcinolone, acetanide, or Kenalog, which is one mil, and three milliliters of one percent lidocaine. All of the participants also participated in a therapy program, either a formal PT or a home therapy program with guided exercises as a part of the intervention. Subsequent lab draws were then taken on each individual at both one and four weeks post-injection, and then they were done at about the same time of day, give or take an hour, in order to control for the diurnal variation of testosterone, and it's pretty well known that testosterone has peak levels occurring early in the morning hours, with the trough levels occurring for individuals about 12 hours after that peak, so we needed to do the testing at the same time each draw. And so the primary outcome of our study was the change in testosterone levels at both one and four weeks post-injection, compared to the baseline levels that were taken prior to injection. And then our secondary outcomes, as mentioned before, were changes in LH levels, FSH levels, and then the SPOTI and the Q-ATOM questionnaires. Of note, just for completeness, the SPOTI questionnaire contains 13 items, five are focused on pain and eight are focused on function, with higher scores correlating to greater pain and disability, whereas the Q-ATOM questionnaire is 10 items where the lower scores correlate to greater symptoms of androgen deficiency. So the results of our study, as indicated in the chart on the poster there, included a significant reduction in serum testosterone levels at one week post-injection, as shown in the first column of the table, with an average decline of 56.8 in testosterone. Not included in the table is actually the mean baseline testosterone that we had in our cohort, which was 353 nanograms per deciliter, and that dropped to an average of 298, so that was that change there. We also saw a significant recovery in serum testosterone to baseline levels at four weeks post-injection, which is indicated by the lack of significant change in testosterone from the baseline to four-week mark, as shown in the middle column, and this is also indicated by the significant increase in testosterone from that one-week mark to the four-week mark, as indicated in the far column on the chart. Additional significant results that we found in our study were spotty scores did show a reduction in pain and disability at both one and four weeks post-injection, but it was a slightly more significant reduction at one week compared to four weeks. And then there was a very modest change in LH at one week, but with no significant change when comparing one to four weeks or baseline to four weeks, so the clinical significance of the change in LH is really unclear. And then there was no significant change in the FSH levels or the Q-atom scores at one or four weeks post-injection. So our study shows that a single glenohumeral corticosteroid injection is effective at reducing pain and disability, but it also results in a temporary suppression of the male HPG axis. But despite this decrease in testosterone that we were seeing in our study, none of our participants were actually reporting symptoms of androgen deficiency, as indicated by the lack of change in the Q-atom scores after the injection. I think it's important to note that to date there's only a single other study that was looking at human subjects particularly and the effect of steroids on the HPG axis, and that was done by Whitehoft et al. in 2008, and they were looking specifically at women with rheumatoid arthritis, and they also found significant decreases in testosterone, DHEAS, and estradiol levels within the first week after injection with full recovery to baseline at even two weeks. And this is consistent with the findings that we were we're seeing in our study with testosterone. And I also think it's important to point out the limitations of our study. It was a very small sample size, which was partially due to difficulty enrolling participants in our study during the COVID-19 pandemic, and we also only analyzed or only looking at a single joint, so the effects that we're seeing aren't generalizable to all joints in the body. So I do look forward to future studies including a larger sample size with a more diverse patient population, and then including multiple peripheral joints in the studies. And one of the things that I think that this study as well as future studies have the potential to affect clinical decision making is specifically in the athletic population when we're trying to determine the timing of a corticosteroid injection prior to competition. So that's all I have today. Thank you all for your time and being here, and I look forward to any questions you have at the end of the session. Thank you, Dr. Cowley. Really excellent job. Very, very good. You know, we've got a little bit of time. Our next presenter will be George Raum. He is an intern at the UPMC in a combined program, and he will be speaking today of Spinning to the ER, an Inventory of Exercise, Bike, and Spin Class-Related Injuries. Dr. Raum. Hello, everybody. I'd like to thank the AAPMNR for the opportunity to present today, as well as for all of you all for taking time out of your afternoon. So spin bikes were first invented in 1991 when a South American cyclist teamed up with an entrepreneur to mass produce the exercise equipment. Spin classes quickly rose to popularity. Now boutique cycle classes, such as SoulCycle and CycleBar, have opened up across the country, as well as other classes and commercial gyms across the world. Home cycling products, such as the Peloton, have also sharply increased in popularity since the beginning of the pandemic, as many of our colleagues in rehab are well aware, as identified if you scroll through your Twitter feed. Partially driven by the pandemic, Peloton device sales tripled from the fourth quarter in 2019 to the opening quarter of 2021. And if you could see that down on the figure down in the lower left hand of the screen, there was a sharp increase in the revenue that Peloton was experiencing. With the rise in popularity of the equipment, we decided to observe the injury patterns presenting to the emergency department, resulting from stationary bike use. To do this, we completed a retrospective analysis of injuries reported in the National Electric Injury Surveillance System, or the NEISS database. The NEISS database is a public health research tool utilizing data from 100 EDs across the US. These EDs are selected as a probability sample of over 5,000 US hospitals with emergency departments in the US. We took a look at injuries from the years 2015 to 2019, and all cases involving patients older than 18 years old that mentioned stationary bikes, exercise bikes, spin bikes, cycling classes, or spinning classes were evaluated in the data set. The data was analyzed using the categorization of injuries listed in the NEISS database. Some of the categories that we looked at were the body part injured, the eventual diagnosis, the setting of that the injury occurred in, and the disposition of the patient. We ended up identifying 754 total injuries between the years of 2015 and 2019. The average age of patients injured was 57.4%, and the average age of patients requiring eventual hospitalization was 64.4%. As you can see in the two graphs on the upper right of your screen, those two histograms presenting the age distribution of injuries and hospitalizations. 52% of the sample was identified as female in the data set. The most common setting of the injury was actually the patient's home, accounting for 22.7% of injuries in the database. 18.9% of the injuries evaluated were related to spin classes. The number of cases trended upwards from 107 injuries in 2015 to 160 injuries in 2019, along with the number of injuries related to spin classes increasing from 13 in 2015 to 32 in 2019 over the five-year span. Patients who were injured during spin class had a slightly large proportion of injuries requiring hospitalization than injuries that occurred in the patient's home. This can be seen on the bar chart in the bottom center of the screen. 23 cases of rhabdomyolysis were identified in the sample, and 19 of these cases were a result of spin class, or 82.9% of the total cases of rhabdo in the data set. Interestingly, 22% of the injuries resulted from a fall off or a fall into the bike in the patient's home. The most common diagnoses identified were strains and sprains, and the most commonly affected body parts were the lower back, the knee, and the lower leg. As you can see in the injury breakdown of the figure of the cyclist in the center of your screen. Following the boom in spin studios and home cycling options, injuries may increase from these activities in the coming years. Serious conditions such as rhabdo may result from riding, therefore, a patient should be educated on exercise tolerance or if they're interested in partaking in this exercise. A large proportion of injuries resulted on falls off or into the bike. Therefore, elderly patients who plan on having this exercise equipment in the home should be educated on fall protection and fall prevention strategies and place the bike in a safe location in their household. There are limitations to this data. The injuries presented here were all injuries presented to the ED. These injuries may skew away from the injuries presenting to the outpatient MSK practitioner. These injuries probably most likely represent an increased proportion of acute injuries and less acute on chronic or chronic overuse injuries that the outpatient MSK practitioner may come across. There are also limitations in the way that the NEIS classifies injuries. Some of the categories are missing data and the case descriptions vary in detail depending on the case analyzed. Traditioning road cycling injuries such as Achilles and patellar tendinopathies and spine pathology happen to deduce partially to repetitive motion with poor form or improper bike positioning. The frame geometry, handlebar shape, saddle, and pedal system are selected based on the desired body position and function. Improper body position on the bicycle can contribute to a number of overuse ailments in the traditional cycling. It would be interesting in the future to determine if these same factors may be relevant from mitigating injury risk on the stationary bike. Future directions for the study can focus on injuries presenting to the MSK physician in the outpatient setting, as well as factors that increase the likelihood of these injuries. While the injury prevention strategies that are relevant for traumatic injuries such as helmet use for road cycling are not relevant for spin cycling, the other factors may be relevant. Thank you for your time and your attention and enjoy the rest of the conference. Thanks, Dr. Rahm. Okay, a nice virtual round of applause for all of our presenters today who are all in training at some level. Just a super job by all of you. You are our future, and these are some pretty sophisticated things that you've all been presenting to us, and we're very appreciative of you doing this for us. So questions are starting to roll in. The first comes from Frank's phone, and he asked a question to Dr. Calley, which testosterone was measured? Was it pre-bound or total? Yes, we were measuring, yeah, I'm unmuted. We were measuring total testosterone in the study, and I can also, I read the second question as well, so I can go ahead and address that. He was asking about the kind of wide range in testosterone that seemed rather low, the decrease, and then as well as the lack of changes in LH and FSH, which really indicates the HPG axis. I'll kind of start and go through all of those. Without a change. Yeah, so the lack of the change, I agree. So that is something we're working with our endocrinology colleagues and have been discussing that as well. So I think that's something to further look at in future studies, because we were seeing changes, but they weren't significant, and so I think we do need larger studies, and there have been prior studies that were seeing that. So I do, in our study, maybe it is more that local effect, but we are seeing that just significant decrease in testosterone, and then as far as the baseline levels go, the age range in our study was very variable. It was 21 to 70, and so I think that had a lot to do with the wide range in levels, and we also, we controlled for diurnal variation by doing the blood draws at the same time each day on return, but we did have patients coming both in the morning and in the evening, and so we know that testosterone levels, like it is recommended that when you get testosterone levels drawn, you get them in the morning. So that's something we could do too, is like maybe just limit the study to doing morning, but it still shows that every patient served as their own control, and so if they were an evening patient, they remained in the evening. So that could be contributing to some of those lower levels and also the wide variation. I hope that answers the question. Yeah, nice job, Edka. That was good. Next, back to Dr. Raum and the spin cycling. Were the falls from spin exercise analyzed by age? Were the people who fell regular cyclists? As an older cyclist, I wonder if the bike has an effect or was it age-related? Yeah, I think when we complete our more complete analysis of the data, we will definitely look at the trajectory of whether age had an impact on fall risk. Unfortunately, the way that the NEIS lists the data, it's a very brief analysis of the injury that presented to the ED. It'll say like what they were doing at the time and what the injury is. Sometimes you don't even get a diagnosis, unfortunately, so it's hard to tell how athletic some of the patients were that experienced these injuries, but I think that would be a great future direction for the study as well, is to look at some of these cases more in depth and get some more background story of what actually happened. Well, I think what you'll find is in most ERs, they're great at saving your lives, and they're not great sports medicine docs, and they're not meant to be. So you get what you get, and you're not gonna get the best clarity on what the real injury was going through a retrospective study, but so good job. Our next question is from Dr. Cordobine. He's back to you, Dr. Cowley. The transient decline is interesting, but fortunately, short-term thoughts on clinical relevance, and is this something to add to informed consent if you're doing a shoulder injection? Yeah, so I totally agree, and I think I just did a little bit at the end. So the lack of the symptoms does question a little bit the clinical significance, but I think where this comes into play is, if we're gonna see a decline in testosterone that may be affecting patients at all, I think it's more relevant in our athlete population, specifically in those harder-hitting, bigger sports, so like football, not that it would, maybe it doesn't affect performance, but I think if you talk to patients, maybe we can optimize performance if you're considering doing an injection, knowing that like, okay, maybe we do it at least 10 to 12 days out, knowing that that decline is going to occur. So that is my thoughts on the clinical relevance in the future and what we might see, and then I do think it's probably something that if larger studies are done and we do continue to see this, it will be added to consent forms, but with the caveat that we should let patients know that it's probably not gonna cause any symptoms and it is gonna return as soon as, and we know by the four-week mark, possibly as early as the two-week mark, and just something that we're informing patients about. Well, here's the thing about that. So now we have numbers, but are the numbers clinically relevant? And that's what's gonna have to be determined because you can't take somebody out of their season and say, you know, this is gonna drop for a little bit, but you're gonna miss this game if I inject you. Usually we're injecting them so they can play the game. And it's a completely different thought process when you're in season and you're getting paid a fair amount of money and your career is tiny in real length. So it's interesting, but I think the next part to go is how clinically relevant is that? And you took all comers, you know, you took between what, 21 and 70? And as you get larger numbers, you're gonna have to figure out where you are age range, and then you're not using athletes and athletes are built differently. And maybe the athletes testosterone levels are much, much higher than these people who you're looking at through the VA, with a VA study, right? So not to disparage our warriors or veterans, you know, I worked in the VA for a long time. You have to look at what you have and it's very hard to correlate that and make a direct correlation to sports and athletics and what's clinically relevant. And that's the trick is you're at the very beginning of the pilot study, it's great research. I beg that you continue doing this and you should do this for the rest of your career because this is something that's gonna take 20 or 30 years probably. And then as you get more numbers, you'll be able to figure it out and come up with an answer, but it's far too early to make a decision about I'm gonna inject based on what their testosterone level is or other levels in their body at this point. So, but really, really good baseline work. And I thank you for that. Yeah, absolutely. But you'll find this out next year as a fellow. It's got a long way to go, but it is like, I think it's good that we're looking at it and kind of seeing what could come in the future. But I definitely agree with, I think it was Dr. Cordine that, you know, the clinical relevance at this point is a little bit unclear. And then Dr. Tenney, I agree with the Paralympic athletes with lower testosterone baseline levels. And I think that's probably some of the next steps is instead of doing an all-commerce study, doing specific populations, but a wide variety. Because right now we're only looking at males, we're only looking at veterans. So just maybe narrowing that down, but we'll need more participants as well, so. Yes. So I have a question for Dr. Ortiz-Santiago. So your scale is basically a psychometric scale. And how would that compare, if that's true, how would that compare to a physical scale, how we've been testing patients coming back for return to play physically? Yeah, excellent question. I think that not necessarily would compare, I think it just adds value to our evaluation of these patients and how we're incorporating not only their physical, and for example, endurance, physical response after a surgery through their rehab phases, but how they are responding emotionally and with their insecurities, and how they feel they are responding emotionally, like I said before, and how we can assess with neuropsychology, with sports psychology, and just add more members of the team in this patient's rehab process. So I think it's more of an addition, a readily available scale, a very short one that we can use in our clinics. And I believe it can have a great value when it comes to the rehab and their return to sport. Thank you. Very good. Dr. Bacall, I have a question about, you looked at soccer team and the soccer team only. Is he still on the line? Correct, yeah. So it was a NCAA men's soccer team. So it's similar to when we talk about base and distance runners, that your soccer players also have to have their base up or otherwise you're gonna have increased injuries. It looks like it's almost in every other sport that you lose these ingrams that you have built up over time if you're not regularly playing. Exactly, yeah. And what our data showed, I know what's kind of neat about these GPS tests is that you can actually get an exact kilometer distance over a month. And if you're running under that, your risk of injury seems to go up. So it's the kind of thing that maybe before preseason, the players should be trying to get that distance in so they're less likely to get injured once it starts. And it's up to the coaches to kind of make sure that they keep that baseline throughout the season. Well, yeah, because that always seemed to be the way when we were playing that you had a workout during the summer for your fall sport or you were so far behind. And the other thing I saw as a team physician was that if there was a blowout and putting the third or the fourth string got the play, there was a much higher anecdotally incident of accident rate or injury rate from these kids that never got the play. They'd have much higher rates of injury rather than the starters. That actually was something we found as well. I didn't have the time to include in here, but something about NCAA soccer as well is it's kind of free-flowing substitutions. You have people who are thrown into this intense game for seven minutes and taken out, and those seem to be the ones who got injured. So I definitely agree with what you were saying. Well done, well done. And for Dr. Murata, I have a question for you. So has your study helped to determine are we supposed to be going leukocyte-rich, leukocyte-poor, or what, with our PRP injections? Which way would you lead to based upon what you found out so far? Yeah, absolutely. So I would say based on our study, we can't really make that differentiation. So we kind of just looked at leukocyte-rich in our study to characterize what types of cells were also in there. I think the main difference that we saw compared to what we know now is that leukocyte-rich PRP is predominantly lymphocyte-rich and a lot of our classification systems kind of utilize neutrophil counts and neutrophil classifications. So I think that was kind of like a key highlight that we thought was interesting is that maybe we need to report all of these different subtypes in order to figure out what, maybe there's a certain cell type that's beneficial to patients more than others. But we didn't really directly compare leukocyte-rich versus leukocyte-poor. Okay, thank you. And one last question for Dr. Chen. So you found out that it works well to have a video or a televideo, telehealth learning. What's your next step? So our next step is to try to do with all the sessions possible. And with the simple site, we think that if we can do it at different institutions, we'll also be great. We know that there's a lot of variability in terms of the equipment you can have at a PMR program. So if we can somehow try to standardize our equipment and do a study on a larger scale, then we can better assess the efficacy because I think our research did a good job showing how it is feasible. But it does take a lot of work and preparation time to set everything up for it to run smoothly over all the workshops. Thank you. And unfortunately, we're out of time. I had a whole bunch of questions and it almost seems that we don't need to have a residency anymore if you guys can do all this stuff by telehealth and stuff. But thank you very much for everybody coming. This was the best of the best of our Musculoskeletal and Sports Medicine Abstracts this year. And I'm grateful to the presenters. They're all very young and early in their careers. And we give you a large round of virtual applause, a standing virtual applause to all of you and hope that you will present again in the future. And we look forward to your future submissions. Again, you're chosen that as over 700 abstracts sent in this year and looked at by your peers. And again, thank you very much. And this will conclude our session for this year. Thank you.

presenters

research

insights

platelet-rich plasma injections

exercise-related injuries

corticosteroid injections

hormone levels

biologic profiles

fall prevention strategies