Well, welcome everybody. It's 1245, we'll get started. This is Nitin Jain. Welcome to this session of Research Spotlight of Musculoskeletal and Sports Medicine. Our first presenter for this session will be Dr. Nolan Gall. And he's presenting on veteran information retention and expectations of a platelet-rich plasma periprocedural protocol. Dr. Gall. Great, thank you. So hello everyone, I'm Nolan Gall and I'm gonna talk a little bit about a project we recently conducted, took place at the Palo Alto Veterans Hospital. But first, I just wanna provide a little context behind the inspiration behind this project. As many of you may know, platelet-rich plasma continues to emerge as an effective interventional treatment for musculoskeletal conditions. And it continues to have more and more level one evidence supporting its use for certain indications. However, there are a few investigations that disclose the specific details behind the periprocedural protocol, including details like PRP volume, the PRP content, provided patient education, post-intervention rehab instructions, as well as measured adherence to those instructions. Because the PRP quality has been found to rely on healthy platelet function and can be affected by commonly used over-the-counter non-steroidal anti-inflammatory medications, adherence to those instructions, as well as the periprocedural protocol is likely vital to help optimize its effectiveness. However, little evidence exists investigating this. So in order for us to get a better sense of the degree of difficulty patients have with protocol instructions, as well as their patient, as well as their expectations for the interventional treatment, the purpose of our study was solely to assess their information retention and expectations of our periprocedural protocol. So I'll transition to talk a little bit about the methods. And this project took place from patients who were self-referred or referred from our PNR colleagues or our orthopedic surgery colleagues for an ultrasound guided PRP injection. And they were surveyed after their PRP patient education and their injection. Prior to the procedure day, the patients were notified of their injection appointment and they were told to stop taking a non-steroidal anti-inflammatory medication seven days prior. And then on the day of this procedure, the patients were given a verbal periprocedural protocol education with details, including how PRP promotes healing, the importance of stopping NSAIDs seven days prior, as well as the importance of taking Tylenol and not over-the-counter anti-inflammatory medications for analgesia post-procedure. Additionally, there were also counseled that their analgesia will likely take many months for improvement. Transitioning to our results, we had 23 respondents, most of which were middle-aged men. The most common indication for the procedure was knee osteoarthritis. I've included a QR code here, linking some supplemental data that was more so related to patient expectations. And we'll talk more about some of the highlights that we found at the survey now. Despite being told that recovery will take time, nine of the 23 respondents expected pain relief in four weeks or less. Only six of 23 correctly identified the correct timeframe they should have stopped taking their NSAIDs prior to the procedure. When it came to correctly identifying Tylenol as the most appropriate post-procedure analgesic medication, that was amongst a list of other NSAIDs. Only 15 of 23 correctly did so. 16 of 23 strongly agreed that they understand why to refrain from taking post-procedure NSAIDs. However, only six of those, or six of those 16 people failed to identify the correct time they should have stopped taking the NSAIDs. Despite our findings, our study certainly has limitations. Cervic fatigue could have played a component. Larger sample size clearly would be most beneficial. The study was only conducted at one site and solely assessed veterans, which is not exactly representative of a normal patient population. And lastly, verbal education is not always the preferred type of education to optimize information retention. However, despite the limitations, our study places somewhat of a spotlight on the importance of periprocedural information retention. We found a portion of responders have high expectations for rapid pain relief and had difficulty retaining protocol knowledge and instructions vital to help foster PRP's physiologic mechanism. Looking ahead, more work is definitely needed to find the most effective way to optimize periprocedural protocol information retention, protocol adherence, as well as the effect of full protocol adherence on these clinical outcomes. So with that, that concludes my presentation and I'll hand the baton back to Dr. Jain and we'll take questions at the end of all of the presentations, I believe. Thank you, Dr. Gawal. You finished right on time. I didn't even have to give a one minute warning. So thank you again. Just for the audience, please feel free to put your questions down in the chat box. We will take them at the end of the three presentations or you can wait. I think chat box will be the best, but if you need to just verbally ask your question, if we still have time after addressing all the questions in the chat, we'll take it there after. Our next presenter is Dr. Donald Kasidana and he will be presenting on factors associated with extended return to play after concussion in college and athletes. Dr. Kasidana. Thank you, Dr. Jain. If we could advance to my poster. Yes, so my name is Donald Kasidana. I'm currently an assistant professor at UT Southwestern and this is some research I completed last year during fellowship at Stanford. I'd first like to thank my coauthors, Eric Wong, Calvin Wong, Jeff Abrams, Andy Koosman. And as Dr. Jain mentioned my title, looking at return to play in concussion collegiate athletes. Now looking specifically at giving some background, concussions are very common among athletes and have received much attention due to concerns about the long-term impact they may have on cognitive function. Prognosticating recovery times for individual athletes with concussion remains a challenge for healthcare providers. And it's often much more time sensitive, especially in the athlete population due to missed time from sport and external pressures. Several pre-injury and post-injury factors have been proposed to be predictive of prolonged return to play times, but the data in this area is still really sparse. So we had three major aims in the study. The first was to identify which risk factors are associated with prolonged return to play. Second was to assess whether these risk factors are additive and the third aim was to determine which are the most predictive and prolonged return to play times in head-to-head comparisons. Our study design was a retrospective case series. We performed a chart review and looked at all concussions from September, 2017 through August, 2020 at a single NCAA Division I institution so three academic years. Pre-injury modifiers that we focused on included age, sex, sport, prior concussion history and past medical problems including stuff like ADHD. Post-injury modifiers we looked at included initial and follow-up SCAT-5 results, vestibular evaluations performed by trained PTs and eye tracking results using EyeSync which is like an FDA approved assessment tool for abnormal eye movements. And then finally we did some descriptive statistics then followed by individual multilevel regression models to find variables associated with prolonged return to play times and then the variables that were significantly associated with prolonged return to play were subsequently added to a multivariable regression model to do the head-to-head comparisons. All these analysis were done in the software RStudio. So if we can go up to the results, for the results overall we had 159 athletes representing 187 concussion cases included some general demographics, 54% of the athletes were male, 46% were female in the study and the median number of missed days was 16. We did have one outlier who missed 158 days from sport but our sample size is big enough where I don't think that affected the numbers too much. These athletes represented in table two, these athletes represented 20 different sports at our institution. The one that was most represented was actually football. That's kind of to be expected not only because there's a lot of head trauma within football but also it was just our largest team. If we look at table three further down, here we look at our pre-injury variables and their effect on return to play. There were three that were statistically significant and from here on I'll just say significant meaning statistically significant. These pre-injury variables included being involved in an individual versus a team sport, a history of migraines as well as a history of prior concussions. Interestingly in the pre-injury variables we often ask for ADHD whenever we do evaluation for concussion but we actually didn't find a strong or statistically significant relationship between the history of ADHD and prolonged return to play in our athletes. Now, if we move on to table four further up. Thank you. So here we look at the symptoms and effect on return to play. Overall total symptoms score as well as total number of symptoms did significantly affect a prolonged return to play. And specifically the individual symptoms that seem to have the strongest correlation included balance problems, difficulty concentrating, light sensitivity, drowsiness, fatigue and low energy as well as difficulty remembering. If we scroll down to table five, other post-injury variables that we looked at included the eye tracking variables as well as clinical variables like the BESS exam. And these did not have any significant relationship to prolonged return to play. Finally, our last table is table six and seven. So table six, we looked at VOMS testing. We did see that abnormal VOMS did relate to a longer recovery time from concussion. And the bottom six specific variables within the VOMS testing had the strongest correlations. Finally, table seven was kind of the money table where we looked at everything that was statistically significant and then did head-to-head comparisons. And the three factors that really associated with prolonged return to play included number of prior concussions, the vertical saccades on VOMS, and then as well as being involved in the individual versus team sport. So in terms of discussion conclusions, in terms of pre-injury factors, the history of migraines and history of prior concussion were correlated with prolonged recovery times. And this was very consistent with conclusions drawn by multiple prior studies and systematic reviews. The athletes who participated in individual sports were more likely to have prolonged return to play when compared to those in team sports. This is not something I saw too much in the literature, so I think this is more of a novel finding. Some of the things we postulated whether this might be the case is because there might be a little bit more external pressure with these team sports than there are the individual sports. And then in terms of post-injury factors, the study results are consistent with previous research showing that the total number of symptoms and total symptom score were correlated with prolonged return to play. One thing we did find that was pretty new was that the number and severity of symptoms were additive in a dose-dependent fashion. So for example, each additional symptom resulted in an average of 0.7 longer days of recovery time, and then each additional severity point resulted in a 0.2 addition of recovery time. So for example, if somebody had 20 symptoms compared to someone with 10 symptoms, usually they would take about seven days for them to come back to sport. The three factors we found to be most predictive were prior history of concussion, vertical saccades and bomb testing, and participation in individual sport versus a team sport. So the history of concussion was the most statistically significant, and the participation in individual sports had the largest effect, meaning it resulted in about almost 20 days longer compared to those involved in team sports. This information provides clinicians with a valuable tool in prognosticating and estimating recovery times for athletes, which is a big challenge when working with the elite athlete population. One of the limitations we had is this is a very specific population, so not sure if this can be really generalized to everyone. A lot of these athletes saw multiple specialists, so that's one thing to keep in mind. Future research, I think, should seek to replicate the results of the study by valuing the effects of multiple pre- and post-injury risk factors on return to play. Another interesting thing is that we could investigate whether early targeted interventions would be effective at reducing prolonged return to play in response to these specific risk factors. And that is all I had today, so thank you for your time, and I'll take questions later. Well, thank you, Dr. Kasidana. Moving on to the last presentation, this is by Dr. Ann Kuwabara on perceptions of performance-enhancing medications, benzodiazepines, beta blockers, and cannabinoids. Thank you, Dr. Jain. We can advance to the next slide. So thank you, everyone, for joining us in our research spotlight. My name is Ann Kuwabara, as Dr. Jain mentioned. I'm currently a Stanford Sports Medicine Fellow, and today I'll be discussing perceptions of performance-enhancing medications, specifically benzodiazepines, beta blockers, and cannabinoids. This is a project that I worked on with Dr. Jeremy Stanek and a prior fellow, Dr. Emily Olson at Stanford. So just for some background, Music Performance Anxiety, abbreviated MPA, is defined as a social anxiety disorder, specifically during performances only by the DSM-5. Its prevalence is about 70 to 90 percent in performers, with 15 to 25 percent being severe. Notably, Frederic Chopin was known to suffer from MPA, and its specific definition is greater than six months of consistent symptoms in domains of affect, cognition, behavior, and physiology. Specifically in physiology, tremors are a negative issue that affects certain musicians. So the objective of our study was to evaluate the perceptions, acquisition, and use of potentially performance-enhancing medications to, in the performance artist community specifically, to clarify the use of these medications and to improve our patient counseling and patient safety. So the design, moving on to design, we performed a cross-sectional survey using Stanford's REDCap platform, and we included any professional performing artists who are active members in the following institutions, American Federation of Musicians, National Association of Schools of Music, and International Conference of Symphony and Opera Musicians. And again, the specific outcome measures were perceptions, acquisition, and use of these three classes of medications. Moving on to our results section, we ended up getting 311 participants, 146 women, 161 men, four other from December 2020 to February 2021. Our main results for beta blockers included that professional musicians and teachers have heard of or were more familiar and use beta blockers more so than students, and students generally believe that taking beta blockers is more unethical than professionals and teachers. For benzodiazepines, female musicians have heard of alprazolam and clonazepam more so than male musicians. Students and teachers are more familiar with oxazepam than professionals, and students and teachers believe that taking benzodiazepines were more unethical at a higher rate than the professional community. And last class, cannabinoids professionals and students use cannabis at auditions, performances, and rehearsals more often than teachers, and students were more likely to believe that cannabis had a positive effect on their playing. And we also opened up in this survey to an ethical discussion. So for most of the comments, our participants did not think that there was any issue with taking these medications because they're still not a substitute for talent or preparedness for an audition. And of the medications, beta blockers were found to be most widely used in the music world and best tolerated for music performance anxiety specifically, whereas benzodiazepines were more used for general anxiety. And some people stated that these medications may level the playing field as people who are affected with physiologic tremors may be able to play their instruments better and show more of their true talent. And some worry about musicians obtaining these drugs illegally or potentially developing a dependence. So moving on to our discussion section. So seeing these trends in our results, it did lead us to questions including should professional musicians be held to the same standards as professional athletes because beta blockers are technically prohibited in sports such as archery? And do these medications confer an unfair advantage or not? And due to fairly frequent use in the community, should these performance anxiety treatment options be discussed more openly and routinely in the community? So in conclusion, the results of our study demonstrate current use patterns of beta blockers, benzodiazepines, and cannabinoid products in the professional musician community. Beta blockers were the most well tolerated and most frequently used for music performance anxiety specifically. That concludes my presentation and now I'd like to open the floor to our Q&A section. Well, thank you, Dr. Kuwabara. Again, I did not have to give you a one-minute warning. So thanks again for staying on time. We do have a few questions in the chat box. So let's first go over those questions before I turn it to the audience. I have a couple of questions and a comment from Dr. Kathleen Bell. I think the comment is with regards to there being literature on informed consent and education in patients. But our first question is for Dr. Kasidana, which is if any analysis was done of potential treatment and treatment adherence in this group of athletes and it's possible correlation with prolonged period to return to play. Yeah, great question, Dr. Bell. So within our analysis, we didn't actually look into like whether there is treatment adherence in terms of potential treatment. I would say the athletes with this specific institution kind of get the, you know, everything thrown at them for the most part. Everyone's seen by the team physician as well as in like a concussion specialist who is a neurosurgeon. And then all of them get like evaluation by physical therapy. They see neuro optometrists, pretty much anything you could get for a support team for a concussion relief. So that was one of the limitations I mentioned in terms of, you know, I don't know if that's generalizable to everyone getting that kind of treatment, even at the athlete level. And then treatment adherence, I would say with so many eyes on them, most of the athletes themselves typically are adherent to the treatment, but unfortunately we didn't do anything specifically to try to, I guess, take that out of any of the analysis. Thank you. The next question is for our first PRP study from Dr. Kortemian. And the note is any, if there's any correlation of this data to outcomes slash pain relief, and if there's any data on actual medications, example, NSAIDs, acetaminophen taken post PRP. Dr. Goel. Yeah, the short answer is no, we didn't obtain or track that data. It's the next step with the project, but it does put emphasis on important points of the periprocedural protocol and perhaps finding the most ideal regimen post injection, things like range of motion exercises, isometric strengthening, weight bearing, as well as medications taken throughout the periprocedural protocol to optimize those outcomes. Thank you. Just to keep it even, I'm going to skip a couple of questions and pose a question for Dr. Kuwabara. This is again from Dr. Bell and she says, I'm having a difficult time equating orchestral musicians with competitive athletes. Hard to imagine what the competitive advantage would be except in auditions. So if you had any comments on that, Dr. Kuwabara. Thanks for the question, Dr. Bell. Yeah, so I do think it is specifically in auditions and in the professional musician society, it does seem like there is a very high degree of pressure during auditions, similar to competitive sports. And specifically, we did look into archery and some of the wind instruments like violin, because the physiologic tremors could impair playing. Potentially in a similar fashion to archery. Well, thank you. The next question is from Dr. Marks. If there are any future directions for investigating ADHD's correlation with prolonged return to play, this question is for Dr. Krasudin. Yeah, thanks for your question, Dr. Marks. So yeah, I think there have been plenty of sites, because we typically think ADHD, difficulty concentrating, that it would naturally lead to a prolonged return to play. That's what was kind of hypothesized before. But there's been really mixed results in all of these studies that have been done over the years looking at this. So in terms of future directions, I think it's been investigated pretty thoroughly at this point. And there have been a lot of studies with large sample sizes. So I'm not sure if there's any way to really pin down. I think right now, it's still like some studies say yes, some studies say no. So I would say it's pretty equivocal at this point. Thank you. Again, I'm going to skip a question to go back to Dr. Krasudin. This question is from Dr. Krasudin. In reference to Performance Anxiety Survey, do you have an estimate of total and individuals across those several organizations to get sense of response rates and more responses from particular type of artists? Yeah, so I do think the total number of musicians in those organizations are probably on the order of around 2,000. So we did only get 311 responses. So it definitely was a smaller response rate. And actually, our highest responders were violinists. Thank you. The next question is from Dr. Cash to Dr. Krasudin. And he notes that it's interesting that team sports showed shorter return to play, despite many of these being thought of as higher impact example, football, soccer. Do you think those in individual sports feel less pressure to come back? Or do you think there was less pressure on team medical providers to send the athletes back early or a combination of both? Yeah, thanks, Dr. Cash. So it's a great question as well. I think it's more the former than the latter, or at least the optimistic person in me thinks that's more the former than the latter, since we try to see everybody very objectively in terms of clearing them again. Part of this, I think, with the team sports, the athletes themselves usually try to push to come back very quickly. And I think football is a prime example where there's a lot of media coverage. So you'll hear a lot more about a star football player missing time versus if our star rower misses some time. So they have a little bit more external pressure to try to get there. And I think that's what explains it. But there's no way to really figure that out at this time. Thank you. So it's 1.12. We have three more minutes for questions. And at this point, since there are no more questions in the chat box, I'm going to ask Carla to unmute whoever has a question from the audience. So does anybody in the audience have a question they would like to ask? Yeah, you can raise your hand in the reaction box at the bottom of your Zoom chat. So if you raise your hand, Carla can unmute you. Hello. Thank you so much for your presentations and for taking my question. So I wanted to clarify the question that I asked earlier about investigating ADHD's correlation with prolonged return to play. So I guess to be more specific, maybe I should have worded it a little better, but not necessarily just the correlation, but the why behind the correlation. I guess that's what I was really wanting to know if anybody was looking into why it's associated with prolonged return to play. Thanks for clarifying. Yeah, so I didn't see anything out there that people were looking for the why. I think people hypothesize it's because the people who diagnosed with ADHD naturally have difficulty concentrating. So whether that would lead to, if they started with that, whether it would lead to lingering symptoms. And I guess off the top of my head, I can't think of a great way to really figure out the why. I think the why in a lot of these studies is a difficult part. You can always find correlations, but the why is the difficult part to figure out. I see. It almost makes me wonder if, I mean, I don't know what means for your study that they were using to test players' readiness to come back, whether it was something like the impact test or something like that. But if maybe attention span was measured and just something that's inherently a part of their disability is having ADHD was not really, I guess, controlled for in terms of testing their readiness to come out or come back, you know, to play. So I'm wondering maybe if that had something to do with it as well. And that's a good point. I would say like our return to play protocol is the pretty standard one for sports. Typically we have them do like make sure that they're asymptomatic. We also do eye tracking, make sure their vestibular, you know, vestibular symptoms are gone. And then once we do that, we kind of progress them in your return to play. Like they do some light cardio activity, a little heavier cardio activity, start doing sports specific activities. So I agree that doesn't necessarily tease out whether any of their ADHD symptoms are kind of residual, but at least that they're asymptomatic in terms of on the athletic field before we clean them. But good. That's a good point. Something maybe we can look at in the future. Thank you. Thank you, everybody. It's 115. I don't see any more hands raised, but in any case, we will have to end this session. So I see that about 137 participants join in. And I think at some point these were about over 140. So I appreciate everybody who came to join in this virtual session. I also thank all the presenters as well as the academy staff for making this so seamless. Thank you again. And we are going to end this session. Thank you. Thanks.

platelet-rich plasma

information retention

concussion

extended return to play

performance-enhancing medications

music performance anxiety